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Barrera Sánchez M, Royo Villa C, Ruiz de Gopegui Miguelena P, Gutiérrez Ibañes P, Carrillo López A. Factors associated with vasoplegic shock in the postoperative period of cardiac surgery and influence on morbidity and mortality of the use of arginine vasopressin as rescue therapy. Med Intensiva 2024; 48:392-402. [PMID: 38697904 DOI: 10.1016/j.medine.2024.04.003] [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: 01/02/2024] [Accepted: 03/11/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVES Analyzing associated factors with vasoplegic shock in the postoperative period of Cardiac Surgery. Analyzing the influence of vasopressin as rescue therapy to first-line treatment with norepinephrine. DESIGN Cohort, prospective and observational study. SETTING Main hospital Postoperative Cardiac ICU. PATIENTS Patients undergoing cardiac surgery with subsequent ICU admission from January 2021 to December 2022. INTERVENTIONS Record of presurgical, perioperative and ICU discharge clinical variables. MAIN VARIABLES OF INTEREST chronic treatment, presence of vasoplegic shock, need for vasopressin, cardiopulmonary bypass time, mortality. RESULTS 773 patients met the inclusion criteria. The average age was 67.3, with predominance of males (65.7%). Post-CPB vasoplegia was documented in 94 patients (12.2%). In multivariate analysis, vasoplegia was associated with age, female sex, presurgical creatinine levels, cardiopulmonary bypass time, lactate level upon admission to the ICU, and need for prothrombin complex transfusion. Of the patients who developed vasoplegia, 18 (19%) required rescue vasopressin, associated with pre-surgical intake of ACEIs/ARBs, worse Euroscore score and longer cardiopulmonary bypass time. Refractory vasoplegia with vasopressin requirement was associated with increased morbidity and mortality. CONCLUSIONS Postcardiopulmonary bypass vasoplegia is associated with increased mortality and morbidity. Shortening cardiopulmonary bypass times and minimizing products blood transfusion could reduce its development. Removing ACEIs and ARBs prior to surgery could reduce the incidence of refractory vasoplegia requiring rescue with vasopressin. The first-line treatment is norepinephrine and rescue treatment with VSP is a good choice in refractory situations. The first-line treatment of this syndrome is norepinephrine, although rescue with vasopressin is a good complement in refractory situations.
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Sadjadi M, von Groote T, Weiss R, Strauß C, Wempe C, Albert F, Langenkämper M, Landoni G, Bellomo R, Khanna AK, Coulson T, Meersch M, Zarbock A. A Pilot Study of Renin-Guided Angiotensin-II Infusion to Reduce Kidney Stress After Cardiac Surgery. Anesth Analg 2024; 139:165-173. [PMID: 38289858 DOI: 10.1213/ane.0000000000006839] [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: 02/01/2024]
Abstract
BACKGROUND Vasoplegia is common after cardiac surgery, is associated with hyperreninemia, and can lead to acute kidney stress. We aimed to conduct a pilot study to test the hypothesis that, in vasoplegic cardiac surgery patients, angiotensin-II (AT-II) may not increase kidney stress (measured by [TIMP-2]*[IGFBP7]). METHODS We randomly assigned patients with vasoplegia (cardiac index [CI] > 2.1l/min, postoperative hypotension requiring vasopressors) and Δ-renin (4-hour postoperative-preoperative value) ≥3.7 µU/mL, to AT-II or placebo targeting a mean arterial pressure ≥65 mm Hg for 12 hours. The primary end point was the incidence of kidney stress defined as the difference between baseline and 12 hours [TIMP-2]*[IGFBP7] levels. Secondary end points included serious adverse events (SAEs). RESULTS We randomized 64 patients. With 1 being excluded, 31 patients received AT-II, and 32 received placebo. No significant difference was observed between AT-II and placebo groups for kidney stress (Δ-[TIMP-2]*[IGFBP7] 0.06 [ng/mL] 2 /1000 [Q1-Q3, -0.24 to 0.28] vs -0.08 [ng/mL] 2 /1000 [Q1-Q3, -0.35 to 0.14]; P = .19; Hodges-Lehmann estimation of the location shift of 0.12 [ng/mL] 2 /1000 [95% confidence interval, CI, -0.1 to 0.36]). AT-II patients received less fluid during treatment than placebo patients (2946 vs 3341 mL, P = .03), and required lower doses of norepinephrine equivalent (0.19 mg vs 4.18mg, P < .001). SAEs were reported in 38.7% of patients in the AT-II group and in 46.9% of patients in the placebo group. CONCLUSIONS The infusion of AT-II for 12 hours appears feasible and did not lead to an increase in kidney stress in a high-risk cohort of cardiac surgery patients. These findings support the cautious continued investigation of AT-II as a vasopressor in hyperreninemic cardiac surgery patients.
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Affiliation(s)
- Mahan Sadjadi
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Thilo von Groote
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Raphael Weiss
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Strauß
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Carola Wempe
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Felix Albert
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Marie Langenkämper
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Giovanni Landoni
- Department of Intensive Care and Anesthesia, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesia and Intensive Care, School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, North Carolina
| | - Tim Coulson
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Melanie Meersch
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Alexander Zarbock
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
- Outcomes Research Consortium, Cleveland, Ohio
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Yoshida T, Goto A, Shinoda S, Kotani Y, Mihara T. The epidemiology of postoperative dobutamine and phosphodiesterase inhibitors after adult elective cardiac surgery and its impact on the length of hospital stay: a post hoc analysis from the multicenter retrospective observational study. Heart Vessels 2024; 39:438-445. [PMID: 38197915 DOI: 10.1007/s00380-023-02349-3] [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: 08/18/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024]
Abstract
The optimal administration of inotrope after cardiac surgery is unknown. This study aimed to investigate the impact of postoperative inotrope on clinical outcomes in adult elective cardiac surgery patients. Data from the Blood Pressure and Relative Optimal Target after Heart Surgery in Epidemiologic Registry study were analyzed, employing propensity score considering the hospital of admission. The primary outcome was the length of hospital stay evaluated using quantile regression. Secondary outcomes were kidney injury progression, renal replacement therapy, atrial fibrillation, mortality, mechanical ventilation duration, and length of intensive care unit (ICU) stay. Among 870 patients from 14 ICUs in Japan, 535 received inotropes within 24 h of ICU admission, with usage rates ranging from 40 to 100% among facilities. After propensity score matching, 218 patients were included in each group. The inotrope group had a significantly longer hospital stay compared to the control group (16 days vs. 14 days; median difference 1.78 [95% confidence interval [CI] 0.31-3.24]; p = 0.018). However, no significant differences were observed in the secondary outcomes, except for mechanical ventilation duration. The results of the sensitivity analysis using a mixed-effects quantile regression analysis considering the hospital of admission for length of hospital stay in the original cohort were consistent with the results of the propensity analyses (median difference in days, 2.35 [95% CI, 0.35-4.36]; p = 0.022). The use of inotropes within 24 h of ICU admission in adult elective cardiac surgery patients was associated with an extended hospitalization period of approximately 2 days, without offering any prognostic benefit. Clinical trial registration: UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.
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Affiliation(s)
- 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, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi Minato-ku, Tokyo, 105-8471, Japan.
| | - Atsushi Goto
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, 236-0027, Japan
| | - Satoru Shinoda
- Department of Biostatistics, School of Medicine, Yokohama City University, Yokohama City, Kanagawa, 236-0004, Japan
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
- Department of Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan, Italy
| | - Takahiro Mihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, 236-0027, Japan
- Department of Anesthesiology, Yokohama City University School of Medicine, Yokohama, Japan
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Hwang KY, Phoon PHY, Hwang NC. Adverse Clinical Effects Associated With Non-catecholamine Pharmacologic Agents for Treatment of Vasoplegic Syndrome in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:802-819. [PMID: 38218651 DOI: 10.1053/j.jvca.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 01/15/2024]
Abstract
Vasoplegic syndrome is a relatively common complication that can happen during and after major adult cardiac surgery. It is associated with a higher rate of complications, including postoperative renal failure, longer duration of mechanical ventilation, and intensive care unit stay, as well as increased mortality. The underlying pathophysiology of vasoplegic syndrome is that of profound vascular hyporesponsiveness, and involves a complex interplay among inflammatory cytokines, cellular surface receptors, and nitric oxide (NO) production. The pharmacotherapy approaches for the treatment of vasoplegia include medications that increase vascular smooth muscle contraction via increasing cytosolic calcium in myocytes, reduce the vascular effects of NO and inflammation, and increase the biosynthesis of and vascular response to norepinephrine. Clinical trials have demonstrated the clinical efficacy of non-catecholamine pharmacologic agents in the treatment of vasoplegic syndrome. With an increase in their use today, it is important for clinicians to understand the adverse clinical outcomes and patient risk profiles associated with these agents, which will allow better-tailored medical therapy.
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Affiliation(s)
- Kai Yin Hwang
- Department of Anaesthesiology, National University Hospital, Singapore
| | - Priscilla Hui Yi Phoon
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
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Chen DX, Wang TH, Xiong XL, Shi J, Zhou L. Incidence, factors, and prognostic analyses of challenging cardiopulmonary bypass separation in Chinese cardiac surgical populations. Minerva Anestesiol 2024; 90:144-153. [PMID: 38127467 DOI: 10.23736/s0375-9393.23.17727-3] [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: 12/23/2023]
Abstract
BACKGROUND Challenging separation from cardiopulmonary bypass (CPB) has been associated with multiple medical adversities, while its incidence, associated factors, and prognosis among cardiac surgery populations are substantially understudied. METHODS Adult cardiac surgical patients in two medical centers were retrospectively analyzed. Separation from CPB was stratified as easy, difficult, or complex, based on the use of pharmacologic assistance agents and mechanical supports. The various in-hospital adverse outcomes (e.g., mortality, common complications) were assessed. RESULTS The incidence of difficult and complex separation from CPB was 21.9% (1159 cases, 95% CI 20.8% to 23.1%), and 6.1% (320 cases, 95% CI 5.4% to 6.7%), respectively. High age, the presence of pulmonary hypertension or unstable angina, decreased ejection fraction, and emergency surgery were more frequently associated with challenging separation from CPB. Patients who experienced challenging separation from CPB had an elevated risk of adverse outcomes, including in-hospital mortality (complex: odds ratio [OR] 2.85), composite infection events (difficult: OR=1.82; complex: OR=1.88), major adverse cardiac events (difficult: OR=1.40; complex: OR=1.57), pulmonary complications (difficult: OR=1.31; complex: OR=1.20), acute kidney injury (difficult: OR=1.75; complex: OR=2.64), and prolonged postoperative hospital stays. CONCLUSIONS We depicted the incidence of challenging separation from CPB among cardiac surgery population. Additionally, results of influential factors and various adverse outcome analyses emphasize the potential of interventions aimed at preventing difficult or complex separation from CPB and reducing associated adverse outcomes.
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Affiliation(s)
- Dong X Chen
- Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China
| | - Tian H Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xing L Xiong
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Jing Shi
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Leng Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China -
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Kong L, Lv M, Qiao CL, Sun XX, Du WY, Li Q. The effect of pituitrin on postoperative outcomes in patients with pulmonary hypertension undergoing cardiac surgery: a study protocol for a randomized controlled trial. Front Cardiovasc Med 2024; 10:1269624. [PMID: 38235292 PMCID: PMC10792051 DOI: 10.3389/fcvm.2023.1269624] [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: 07/30/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024] Open
Abstract
Background The vasoplegic syndrome is one of the major consequences of cardiac surgery. If pulmonary hypertension is additionally involved with vasoplegic syndrome, circulation management becomes much more complicated. According to previous studies, pituitrin (a substitute for vasopressin, which contains vasopressin and oxytocin) not only constricts systemic circulation vessels and increases systemic circulation pressure but also likely decreases pulmonary artery pressure and pulmonary vascular resistance. The aim of this study is to investigate whether pituitrin is beneficial for the postoperative outcomes in patients with pulmonary hypertension undergoing cardiac surgery. Methods and analysis The randomized controlled trial will include an intervention group continuously infused with 0.04 U/(kg h) of pituitrin and a control group. Adult patients with pulmonary hypertension undergoing elective cardiac surgery will be included in this study. Patients who meet the conditions and give their consent will be randomly assigned to the intervention group or the control group. The primary outcome is the composite endpoint of all-cause mortality within 30 days after surgery or common complications after cardiac surgery. Secondary outcomes include the incidence of other postoperative complications, length of hospital stay, and so on. Discussion Pituitrin constricts systemic circulation vessels, increases systemic circulation pressure, and may reduce pulmonary artery pressure and pulmonary vascular resistance, which makes it a potentially promising vasopressor during the perioperative period in patients with pulmonary hypertension. Therefore, evidence from randomized controlled trials is necessary to elucidate whether pituitrin influences outcomes in patients with pulmonary hypertension following cardiac surgery.
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Affiliation(s)
- Lingchen Kong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering Research Center for Health Transplant and Material, Jinan, Shangdong Province, China
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Meng Lv
- Anesthesiology Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Chang-long Qiao
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Xia-xuan Sun
- Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Wen-ya Du
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Quan Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering Research Center for Health Transplant and Material, Jinan, Shangdong Province, China
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7
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Johnson AJ, Tidwell W, McRae A, Henson CP, Hernandez A. Angiotensin-II for vasoplegia following cardiac surgery. Perfusion 2023:2676591231215920. [PMID: 37955639 DOI: 10.1177/02676591231215920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The objective of this study was to describe the implementation and outcomes of a protocol outlining angiotensin-II utilization for vasoplegia following cardiac surgery. METHODS This was a retrospective chart review at a single-center university hospital. Included patients received angiotensin-II for vasoplegia refractory to standard interventions, including norepinephrine 20 mcg/min and vasopressin 0.04 units/min, following cardiac surgery between April 2021 and April 2022. RESULTS 30 patients received angiotensin-II for refractory vasoplegia. Adjunctive agents at angiotensin-II initiation included corticosteroids (26 patients; 87%), epinephrine (26 patients; 87%), dobutamine (17 patients; 57%), dopamine (9 patients; 30%), milrinone (2 patients; 7%), and hydroxocobalamin (4 patients; 13%). At 3 hours, the median mean arterial pressure increased from baseline (70 vs 61.5 mmHg, p = .0006). Median norepinephrine doses at angiotensin-II initiation, 1 hour, 3 hours, and angiotensin-II discontinuation were 0.22, 0.16 (p = .0023), 0.10 (p < .0001), and 0.07 (p < .0001) mcg/kg/min. Median dobutamine doses decreased throughout angiotensin-II infusion from eight to six mcg/kg/min (p = .0313). Other vasoactive medication doses were unchanged. Three patients (10%) subsequently received hydroxocobalamin. Thirteen (43.3%) and five (16.7%) patients experienced mortality by day 28 and venous or arterial thrombosis events, respectively. CONCLUSIONS The administration of angiotensin-II to vasoplegic patients following cardiac surgery was associated with increased mean arterial pressure, reduced norepinephrine dosages, and reduced dobutamine dosages.
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Affiliation(s)
- Andrew J Johnson
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William Tidwell
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew McRae
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Patrick Henson
- Department of Anesthesia, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Antonio Hernandez
- Department of Anesthesia, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Khalil MA, El Tahan MR, Khidr AM, Fallatah S, Abohamar AD, Amer MM, Makhdom F, El Ghoneimy Y, Al Bassam B, Alghamdi T, Abdulfattah D. Effects of norepinephrine infusion during cardiopulmonary bypass on perioperative changes in lactic acid level (Norcal). Perfusion 2023; 38:1584-1599. [PMID: 35994013 DOI: 10.1177/02676591221122350] [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: 11/17/2022]
Abstract
INTRODUCTION Hyperlactatemia, a problem reported in up to 30% of cardiac surgery patients, results from excessive production of or decreased clearance of lactate. It is typically a symptom of tissue hypoperfusion and may be associated with the prevalence of postoperative acute mesenteric ischemia and renal failure, or prolonged intensive care unit (ICU) and hospital stay, and increased 30-day mortality. METHODS AND MEASUREMENTS Eighty cardiac surgery patients using cardiopulmonary bypass (CPB) were randomly assigned into either a placebo (n = 39) or norepinephrine 0.05-0.2 µg/kg/min (n = 41) as well as norepinephrine boluses during CPB to maintain mean arterial blood pressure (MAP) at 65 to 80 mm Hg. Patient assignments were done after receiving ethical approval to proceed. The primary result was the perioperative changes in lactic acid level. Secondary findings were also recorded, including hemodynamic variables, the incidence of vasoplegia, intraoperative hypotension, myocardial ischemia, the need for vasopressor support, postoperative complications, and mortality. RESULTS The peak levels and perioperative changes in blood lactate during the first 24 postoperative hours, the number of patients who experienced early hyperlactatemia on admission to the ICU (Placebo: 46.2%, Norepinephrine: 51.2%, p = .650), vasoplegia, hemodynamic changes, incidences of intraoperative hypotension, myocardial ischemia, postoperative complications, and mortality rates were similar in the two groups. Patients in the norepinephrine group received lower intraoperative rescue norepinephrine boluses to maintain the target MAP (p = .039) and had higher MAP values during the CPB and intraoperative blood loss [mean difference [95% confidence interval]; 177 [20.9-334.3] ml, p = .027]. CONCLUSION norepinephrine and placebo infusions during the CPB with the maintenance of MAP from 65 to 80 mmHg had comparative effects on the changes in blood lactate and incidence of vasoplegia after cardiac surgery. Norepinephrine infusion maintained higher MAP values during the CPB.
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Affiliation(s)
- Mohamed A Khalil
- Consultant, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
- Professor, Anesthesiology Department, College of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed R El Tahan
- Professor, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Alaa M Khidr
- Assistant Professor, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Summayah Fallatah
- Assistant Professor, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Ahmad D Abohamar
- Senior registrar, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
- Lecturer, Anesthesiology Department, College of Medicine, Tanta University, Tanta, Egypt
| | - Mahmoud M Amer
- Senior registrar, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Fahd Makhdom
- Assistant Professor, Department of Surgery Cardiac Surgical Unit, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Yasser El Ghoneimy
- Professor, Department of Surgery Cardiac Surgical Unit, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Bassam Al Bassam
- Demonstrator, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Talal Alghamdi
- Demonstrator, Anesthesiology Department, College of Medicine, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Dalia Abdulfattah
- Clinical Nursing Supervisor Operating Room, Day Surgery, CSSD, Hemodialysis, and PDU, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
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Kim ME, Goldstein SL, Chlebowski MM. Recombinant angiotensin II therapy in a child with cardiac dysfunction and Pandoraea and Candida sepsis. Cardiol Young 2023; 33:2393-2394. [PMID: 37212085 DOI: 10.1017/s1047951123001221] [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] [Indexed: 05/23/2023]
Abstract
Recombinant angiotensin II is an emerging drug therapy for refractory hypotension. Its use is relevant to patients with disruption of the renin-angiotensin-aldosterone system denoted by elevated direct renin levels. We present a child that responded to recombinant angiotensin II in the setting of right ventricular hypertension and multi-organism septic shock.
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Affiliation(s)
- Michael E Kim
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Meghan M Chlebowski
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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Hiruy A, Ciapala S, Donaldson C, Wang L, Hohlfelder B. Hydroxocobalamin Versus Methylene Blue for the Treatment of Vasoplegic Shock Associated With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:2228-2235. [PMID: 37586951 DOI: 10.1053/j.jvca.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/24/2023] [Accepted: 07/14/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To compare changes in vasopressor requirements and hemodynamic responses after hydroxocobalamin or methylene blue administration for vasoplegic shock (VS). DESIGN Retrospective cohort analysis. SETTING Single-center, academic medical center. PATIENTS Cardiothoracic surgery adult patients. INTERVENTIONS Hydroxocobalamin or methylene blue. MEASUREMENTS The primary outcome was a change in vasopressor requirements over the first 24 hours (1, 3, 6, 12, and 24 hours) after hydroxocobalamin or methylene blue initiation. Secondary outcomes included changes in mean arterial pressure (MAP), systemic vascular resistance, and lactate. MAIN RESULTS A total of 120 adult patients who received hydroxocobalamin (n = 77) or methylene blue (n = 43) were included. Vasopressor requirements at baseline were 0.34 µg/kg/min (95% CI 0.28-0.4) norepinephrine equivalent (NEE) in the hydroxocobalamin group, and 0.59 µg/kg/min (95% CI 0.52-0.66) NEE in the methylene blue group; p < 0.001. Vasopressor requirements decreased significantly at each time point within each group (hour 1 mean [95% CI] NEE, hydroxocobalamin 0.27 µg/kg/min [0.21-0.33]; methylene blue 0.44 µg/kg/min [0.38-0.51]; p < 0.001). The mean MAP at baseline was 65 mmHg (95% CI 63-67) in the hydroxocobalamin group, and 57 mmHg (95% CI 54-59) in the methylene blue group; p < 0.001. The mean MAP increased significantly from baseline at each time point within each group (hour 1 mean [95% CI] hydroxocobalamin 73 mmHg [71-75]; methylene blue 67 mmHg [65-70]; p < 0.001). After adjusting for baseline characteristics, a significantly greater reduction in vasopressor requirements and an increase in MAP were noted in the hydroxocobalamin group compared with the methylene blue group. CONCLUSIONS Hydroxocobalamin was associated with a greater reduction in vasopressor requirements than methylene blue in treating VS associated with cardiopulmonary bypass.
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Affiliation(s)
- Aklil Hiruy
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
| | | | - Chase Donaldson
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
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Ferreira LO, Vasconcelos VW, Lima JDS, Vieira Neto JR, da Costa GE, Esteves JDC, de Sousa SC, Moura JA, Santos FRS, Leitão Filho JM, Protásio MR, Araújo PS, Lemos CJDS, Resende KD, Lopes DCF. Biochemical Changes in Cardiopulmonary Bypass in Cardiac Surgery: New Insights. J Pers Med 2023; 13:1506. [PMID: 37888117 PMCID: PMC10608001 DOI: 10.3390/jpm13101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 10/28/2023] Open
Abstract
Patients undergoing coronary revascularization with extracorporeal circulation or cardiopulmonary bypass (CPB) may develop several biochemical changes in the microcirculation that lead to a systemic inflammatory response. Surgical incision, post-CPB reperfusion injury and blood contact with non-endothelial membranes can activate inflammatory signaling pathways that lead to the production and activation of inflammatory cells, with cytokine production and oxidative stress. This inflammatory storm can cause damage to vital organs, especially the heart, and thus lead to complications in the postoperative period. In addition to the organic pathophysiology during and after the period of exposure to extracorporeal circulation, this review addresses new perspectives for intraoperative treatment and management that may lead to a reduction in this inflammatory storm and thereby improve the prognosis and possibly reduce the mortality of these patients.
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Affiliation(s)
- Luan Oliveira Ferreira
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
- Laboratory of Experimental Neuropathology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil
| | - Victoria Winkler Vasconcelos
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Janielle de Sousa Lima
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jaime Rodrigues Vieira Neto
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Giovana Escribano da Costa
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jordana de Castro Esteves
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Sallatiel Cabral de Sousa
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jonathan Almeida Moura
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Felipe Ruda Silva Santos
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - João Monteiro Leitão Filho
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | | | - Pollyana Sousa Araújo
- Department of Cardiovascular Anesthesiology, Hospital Clínicas Gaspar Vianna, Belém 66083-106, Brazil; (P.S.A.); (C.J.d.S.L.)
| | - Cláudio José da Silva Lemos
- Department of Cardiovascular Anesthesiology, Hospital Clínicas Gaspar Vianna, Belém 66083-106, Brazil; (P.S.A.); (C.J.d.S.L.)
| | - Karina Dias Resende
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Dielly Catrina Favacho Lopes
- Laboratory of Experimental Neuropathology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil
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Nesseler N, Mansour A, Cholley B, Coutance G, Bouglé A. Perioperative Management of Heart Transplantation: A Clinical Review. Anesthesiology 2023; 139:493-510. [PMID: 37458995 DOI: 10.1097/aln.0000000000004627] [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: 09/13/2023]
Abstract
In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.
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Affiliation(s)
- Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Metabolism, Cancer Mixed Research Unit, University Hospital Federation Survival Optimization in Organ Transplantation, Rennes, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Research Institute for Environmental and Occupational Health Mixed Research Unit, Rennes, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care Medicine, European Hospital Georges Pompidou, Public Hospitals of Paris, Paris, France; Paris Cité University, National Institute of Health and Medical Research Mixed Research Unit, Paris, France
| | - Guillaume Coutance
- Sorbonne University, Public Hospitals of Paris, Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
| | - Adrien Bouglé
- Sorbonne University, Clinical Research Group in Anesthesia, Resuscitation, and Perioperative Medicine, Public Hospitals of Paris, Department of Anesthesiology and Critical Care, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
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Sommer W, Arif R, Kremer J, Al Maisary S, Verch M, Tochtermann U, Karck M, Meyer AL, Warnecke G. Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery. JTCVS OPEN 2023; 15:252-260. [PMID: 37808068 PMCID: PMC10556953 DOI: 10.1016/j.xjon.2023.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 10/10/2023]
Abstract
Objectives Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle. Methods Preoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed. Results A total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation. Conclusions The combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.
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Affiliation(s)
- Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Jamila Kremer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sameer Al Maisary
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus Verch
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ursula Tochtermann
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anna L. Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
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14
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Gökdemir BN, Çekmen N. Vasoplegic Syndrome and Anaesthesia: A Narrative Review. Turk J Anaesthesiol Reanim 2023; 51:280-289. [PMID: 37587654 PMCID: PMC10440482 DOI: 10.4274/tjar.2023.221093] [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: 10/06/2022] [Accepted: 02/23/2023] [Indexed: 08/18/2023] Open
Abstract
Vasoplegic syndrome (VS) is defined as low systemic vascular resistance, normal or high cardiac output, and resistant hypotension unresponsive to vasopressor agents and intravenous volume. VS is a frequently encountered complication in cardiovascular and transplantation surgery, burns, trauma, pancreatitis, and sepsis. The basis of the pathophysiology is associated with an imbalance of vasodilator and vasoconstrictive structure in vascular smooth muscle cells and is highly complex. The pathogenesis of VS has several mechanisms, including overproduction of iNO, stimulation of ATP-dependent K+ channels and NF-κB, and vasopressin receptor 1A (V1A-receptor) down-regulation. Available treatments involve volume and inotropes administration, vasopressin, methylene blue, hydroxocobalamin, Ca++, vitamin C, and thiamine, and should also restore vascular tone and improve vasoplegia. Other treatments could include angiotensin II, corticosteroids, NF-κB inhibitor, ATP-dependent K+ channel blocker, indigo carmine, and hyperbaric oxygen therapy. Despite modern advances in treatment, the mortality rate is still 30-50%. It is challenging for an anaesthesiologist to consider this syndrome's diagnosis and manage its treatment. Our review aims to review the diagnosis, predisposing factors, pathophysiology, treatment, and anaesthesia approach of VS during anaesthesia and to suggest a treatment algorithm.
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Affiliation(s)
- Begüm Nemika Gökdemir
- Department of Anaesthesiology and Reanimation, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Nedim Çekmen
- Department of Anaesthesiology and Reanimation, Başkent University Faculty of Medicine, Ankara, Turkey
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15
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Bird S, Chand M, Tran TL, Ali S, Awad SS, Cornwell LD, Schutz A, Jimenez E. Evaluation of the Addition of Angiotensin II in Patients With Shock After Cardiac Surgery at a Veterans Affairs Medical Center. Ann Pharmacother 2023; 57:141-147. [PMID: 35658717 DOI: 10.1177/10600280221099928] [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: 01/05/2023] Open
Abstract
BACKGROUND Vasoplegic shock occurs in up to 37% of cardiac surgery patients. We investigated the use of angiotensin II for treating vasoplegic shock in these patients. OBJECTIVES We assessed clinical outcomes and mortality in patients undergoing cardiac surgery at our center between March 1, 2018 and October 31, 2020 who developed vasoplegic shock, comparing those who received angiotensin II with those who did not. METHODS This was a retrospective chart review. Response to angiotensin II was defined as increase in or maintenance of mean arterial pressure (MAP) and decrease in background vasopressor dosage. RESULTS Angiotensin II was administered to 7 patients (postoperatively in 4 patients [57.1%]) with vasoplegic shock and baseline norepinephrine equivalent (NEE) of 0.49 ± 0.08 μg/kg/min; 12 patients with vasoplegic shock did not receive angiotensin II. Within 3 hours of angiotensin II administration, NEE decreased by 38.0 ± 33.1%. Angiotensin patients were more likely to newly require renal replacement therapy (66.7% vs 9.1%, P = 0.03) and had a longer, although not statistically significant, postoperative stay (23.1 vs 14.0 days, P = 0.16). Despite higher NEE requirements at baseline (0.49 vs 0.30, P = 0.03) and over the next 48 hours in the angiotensin group, no between-group differences in 7-day mortality (14.3% vs 0.0%, P = 0.37) or 30-day mortality (28.6% vs 8.3%, P = 0.52) were noted. CONCLUSION AND RELEVANCE In patients who developed vasoplegic shock after cardiac surgery, angiotensin II administration allowed immediate dosage reductions of other vasopressors while maintaining MAP. Despite its small sample size, this study adds to the paucity of data in these patients and highlights future research needs.
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Affiliation(s)
- Stephanie Bird
- Department of Pharmacy, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Section of General Internal Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mastian Chand
- Division of Trauma & Acute Care Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Trung Ly Tran
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
- School of Medicine-Surgery, University of Alabama at Birmingham, Montgomery, AL, USA
| | - Shahid Ali
- Department of Anesthesiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Samir S Awad
- Division of Trauma & Acute Care Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Lorraine D Cornwell
- Division of Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alexander Schutz
- Division of Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Ernesto Jimenez
- Division of Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiothoracic Surgery, Winchester Medical Center, Valley Health Heart and Vascular Center, Winchester, VA, USA
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16
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Hwang NC, Sivathasan C. Review of Postoperative Care for Heart Transplant Recipients. J Cardiothorac Vasc Anesth 2023; 37:112-126. [PMID: 36323595 DOI: 10.1053/j.jvca.2022.09.083] [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: 05/07/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022]
Abstract
The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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17
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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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18
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Ltaief Z, Ben-Hamouda N, Rancati V, Gunga Z, Marcucci C, Kirsch M, Liaudet L. Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. J Clin Med 2022; 11:6407. [PMID: 36362635 PMCID: PMC9658078 DOI: 10.3390/jcm11216407] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 09/13/2023] Open
Abstract
Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (KATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Valentina Rancati
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Ziyad Gunga
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Carlo Marcucci
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
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Smoroda A, Douin D, Morabito J, Lyman M, Prin M, Ahlgren B, Young A, Christensen E, Abrams BA, Weitzel N, Clendenen N. Year in Review 2021: Noteworthy Literature in Cardiothoracic Anesthesia. Semin Cardiothorac Vasc Anesth 2022; 26:107-119. [PMID: 35579926 PMCID: PMC9588253 DOI: 10.1177/10892532221100660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2021, progress in clinical science related to Cardiac Anesthesiology continued, but at a slower rate due to the ongoing pandemic and disruptions to clinical research. Most progress was incremental and addressed persistent questions related to our field. To identify articles for this review, we completed a structured review using our previously reported methods (1). Specifically, we used the search terms: "cardiac anesthesiology and outcomes" (n = 177), "cardiothoracic anesthesiology" (n = 34), "cardiac anesthesia," and "clinical outcomes" (n = 42) filtered on clinical trials and the year 2021 in PubMed. We also reviewed clinical trials from the most prominent clinical journals to identify additional studies for a narrative review. We then selected the most noteworthy publications for inclusion in this review and identified key themes.
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Affiliation(s)
- Aaron Smoroda
- University of Colorado School of Medicine, Aurora, CO, USA
| | - David Douin
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Joseph Morabito
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew Lyman
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Meghan Prin
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Bryan Ahlgren
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew Young
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Benjamin A Abrams
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nathaen Weitzel
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nathan Clendenen
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Intraoperative Hypotension and Acute Kidney Injury, Stroke, and Mortality during and outside Cardiopulmonary Bypass: A Retrospective Observational Cohort Study. Anesthesiology 2022; 136:927-939. [PMID: 35188970 DOI: 10.1097/aln.0000000000004175] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In cardiac surgery, the association between hypotension during specific intraoperative phases or vasopressor-inotropes with adverse outcomes remains unclear. This study's hypothesis was that intraoperative hypotension duration throughout the surgery or when separated into hypotension during and outside cardiopulmonary bypass may be associated with postoperative major adverse events. METHODS This retrospective observational cohort study included data for adults who had cardiac surgery between 2008 and 2016 in a tertiary hospital. Intraoperative hypotension was defined as mean arterial pressure of less than 65 mmHg. The total duration of hypotension was divided into three categories based on the fraction of overall hypotension duration that occurred during cardiopulmonary bypass (more than 80%, 80 to 60%, and less than 60%). The primary outcome was a composite of stroke, acute kidney injury, or mortality during the index hospitalization. The association with the composite outcome was evaluated for duration of hypotension during the entire surgery, outside cardiopulmonary bypass, and during cardiopulmonary bypass and the fraction of hypotension during cardiopulmonary bypass adjusting for vasopressor-inotrope dose, milrinone dose, patient, and surgical factors. RESULTS The composite outcome occurred in 256 (5.1%) of 4,984 included patient records; 66 (1.3%) patients suffered stroke, 125 (2.5%) had acute kidney injury, and 109 (2.2%) died. The primary outcome was associated with total duration of hypotension (adjusted odds ratio, 1.05; 95% CI, 1.02 to 1.08; P = 0.032), hypotension outside cardiopulmonary bypass (adjusted odds ratio, 1.06; 95% CI, 1.03 to 1.10; P = 0.001) per 10-min exposure to mean arterial pressure of less than 65 mmHg, and fraction of hypotension duration during cardiopulmonary bypass of less than 60% (reference greater than 80%; adjusted odds ratio, 1.67; 95% CI, 1.10 to 2.60; P = 0.019) but not with each 10-min period hypotension during cardiopulmonary bypass (adjusted odds ratio, 1.04; 95% CI, 0.99 to 1.09; P = 0.118), fraction of hypotension during cardiopulmonary bypass of 60 to 80% (adjusted odds ratio, 1.45; 95% CI, 0.97 to 2.23; P = 0.082), or total vasopressor-inotrope dose (adjusted odds ratio, 1.00; 95% CI, 1.00 to 1.00; P = 0.247). CONCLUSIONS This study confirms previous single-center findings that intraoperative hypotension throughout cardiac surgery is associated with an increased risk of acute kidney injury, mortality, or stroke. EDITOR’S PERSPECTIVE
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21
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Noubiap JJ, Nouthe B, Sia YT, Spaziano M. Effect of preoperative renin-angiotensin system blockade on vasoplegia after cardiac surgery: A systematic review with meta-analysis. World J Cardiol 2022; 14:250-259. [PMID: 35582469 PMCID: PMC9048276 DOI: 10.4330/wjc.v14.i4.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/09/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vasoplegia is a common complication of cardiac surgery but its causal relationship with preoperative use of renin angiotensin system (RAS) blockers [angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB)] is still debated.
AIM To update and summarize data on the effect of preoperative use of RAS blockers on incident vasoplegia.
METHODS All published studies from MEDLINE, EMBASE, and Web of Science providing relevant data through January 13, 2021 were identified. A random-effects meta-analysis method was used to pool estimates, and post-cardiac surgery shock was differentiated from vasoplegia.
RESULTS Ten studies reporting on a pooled population of 15672 patients (none looking at ARBs exclusively) were included in the meta-analysis. All were case-control studies. Use of ACEIs was associated with an increased risk of vasoplegia [pooled adjusted odds ratio (Aor) of 2.06, 95%CI: 1.45-2.93] and increased inotropic/vasopressor support requirement (pooled aOR 1.19, 95%CI: 1.10-1.29). Post-cardiac surgery shock was increased in the presence of left ventricular dysfunction (pooled aOR 2.32, 95%CI: 1.60-3.36; I2 49%) but not increased by the use of beta blockers (pooled aOR 0.78, 95%CI: 0.36-1.69; I2 77%). Two randomized control trials (RCTs), not eligible for the meta-analysis, did not show an association between continuation of RAS blockers and vasoplegia.
CONCLUSION Preoperative continuation of ACEIs is associated with an increased need for inotropic support postoperatively and with an increased risk of vasoplegia in observational studies but not in RCTs. The absence of a consensus definition of vasoplegia should lead to the use of perioperative cardiovascular monitoring when designing RCTs to better understand this discrepancy.
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Affiliation(s)
- Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide 5000, South Australia, Australia
| | - Brice Nouthe
- Department of Medicine, University of British Columbia, Vancouver V6T 1W5, Canada
| | - Ying Tung Sia
- Department of Medicine, Regional Trois-Rivières Hospital (CIUSSS-MCQ), Trois-Rivières 5000, Canada
| | - Marco Spaziano
- Department of Cardiology, McGill University Health Centre, Montréal QC H4A 3J1, Canada
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22
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van Lier D, Beunders R, Kox M, Pickkers P. The value of bioactive adrenomedullin and dipeptidyl peptidase 3 to predict short-term unfavourable outcomes after cardiac surgery: A prospective cohort study. Eur J Anaesthesiol 2022; 39:342-351. [PMID: 35102040 DOI: 10.1097/eja.0000000000001662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Adrenomedullin (ADM) is a key regulator of endothelial barrier function and vascular tone. Dipeptidyl peptidase 3 (DPP3) is a protease involved in the degradation of several cardiovascular mediators. Increased levels of bioactive ADM (bio-ADM) and circulating DPP3 (cDPP3) were found to predict short-term outcome in cardiogenic shock patients. OBJECTIVES To investigate the unknown temporal profiles of bio-ADM and cDPP3 and their association with short-term outcome following cardiac surgery. DESIGN Prospective observational study of 203 adult cardiac surgery patients admitted to the intensive care unit (ICU) postoperatively. Plasma bio-ADM and cDPP3 levels were measured at ICU admission (day 1) and on days 2 and 3. MAIN OUTCOME MEASURES Biomarker prediction of prolonged vasopressor dependency (>3 days), acute kidney injury (AKI) and prolonged ICU length of stay (ICU-LOS) (>3 days). RESULTS bio-ADM and cDPP3 levels displayed distinct temporal profiles following cardiac surgery. cDPP3 levels were highest on day 1 and strongly correlated with surgical complexity and duration but subsequently normalised on day 2 in most patients. In contrast, bio-ADM levels on day 1 were within the normal range but subsequently increased. Day 2 bio-ADM levels were strongly associated with study outcomes: the area under the receiver-operating curves (AUROC) were 0.82 (95% CI, 0.72 to 0.92) for prolonged vasopressor dependency, 0.87 (0.81 to 0.92) for AKI and 0.82 (0.75 to 0.90) for prolonged ICU-LOS (all P < 0.0001). cDPP3 levels on day 2 also predicted these outcomes, albeit to a lesser extent, with AUROCs of 0.73 (95% CI, 0.64 to 0.81) for prolonged vasopressor dependency, 0.69 (0.61 to 0.77) for AKI and 0.70 (0.62 to 0.79) for prolonged ICU-LOS (all P < 0.0001). CONCLUSION Following cardiac surgery, increased bio-ADM levels are strongly associated with unfavourable short-term outcomes, whereas cDPP3 levels are mainly related to surgery complexity and duration. On the basis of these findings, ADM-modulating therapies may have beneficial effects in cardiac surgery patients whereas DPP3-targeted therapies should be reserved for patient categories with higher baseline disease severity.
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Affiliation(s)
- Dirk van Lier
- From the Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
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Jarry S, Halley I, Calderone A, Momeni M, Deschamps A, Richebé P, Beaubien-Souligny W, Denault A, Couture EJ. Impact of Processed Electroencephalography in Cardiac Surgery: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2022; 36:3517-3525. [PMID: 35618594 DOI: 10.1053/j.jvca.2022.03.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/24/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The use of brain function monitoring with processed electroencephalography (pEEG) during cardiac surgery is gaining interest for the optimization of hypnotic agent delivery during the maintenance of anesthesia. The authors sought to determine whether the routine use of pEEG-guided anesthesia is associated with a reduction of hemodynamic instability during cardiopulmonary bypass (CPB) separation and subsequently reduces vasoactive and inotropic requirements in the intensive care unit. DESIGN This is a retrospective cohort study based on an existing database. SETTING A single cardiac surgical center. PARTICIPANTS Three hundred patients undergoing cardiac surgery, under CPB, between December 2013 and March 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred and fifty patients had pEEG-guided anesthesia, and 150 patients did not have a pEEG-guided anesthesia. Multiple logistic regression demonstrated that pEEG-guided anesthesia was not associated with a successful CPB separation (p = 0.12). However, the use of pEEG-guided anesthesia reduced by 57% the odds of being in a higher category for vasoactive inotropic score compared to patients without pEEG (odds ratio = 0.43; 95% confidence interval: 0.26-0.73; p = 0.002). Duration of mechanical ventilation, fluid balance, and blood losses were also reduced in the pEEG anesthesia-guided group (p < 0.003), but there were no differences in organ dysfunction duration and mortality. CONCLUSION During cardiac surgery, pEEG-guided anesthesia allowed a reduction in the use of inotropic or vasoactive agents at arrival in the intensive care unit. However, it did not facilitate weaning from CPB compared to a group where pEEG was unavailable. A pEEG-guided anesthetic management could promote early vasopressor weaning after cardiac surgery.
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Affiliation(s)
- Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Isabelle Halley
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, UC Louvain, Institut de Recherche Expérimentale et Clinique, Brussels, Belgium
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Île de Montréal, Université de Montréal, Montreal, Canada
| | | | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada; Department of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.
| | - Etienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Canada
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Meersch M, Weiss R, Massoth C, Küllmar M, Saadat-Gilani K, Busen M, Chawla L, Landoni G, Bellomo R, Gerss J, Zarbock A. The Association Between Angiotensin II and Renin Kinetics in Patients After Cardiac Surgery. Anesth Analg 2022; 134:1002-1009. [PMID: 35171852 DOI: 10.1213/ane.0000000000005953] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hyperreninemia after cardiac surgery is associated with cardiovascular instability. Angiotensin II (AT-II) could potentially attenuate hyperreninemia while maintaining target blood pressure. This study assesses the association between AT-II usage and renin levels in cardiac surgery patients with postoperative hyperreninemia and vasoplegia. METHODS Between September 2020 and March 2021, we retrospectively identified 40 cardiac surgery patients with high Δ-renin levels (4 hours after cardiopulmonary bypass [CPB] minus preoperative levels) (defined as higher than 3.7 µU/mL) and vasopressor use who received a vasopressor therapy with either AT-II or continued norepinephrine alone. The primary outcome was the renin plasma level at 12 hours after surgery, adjusted by the renin plasma level at 4 hours after surgery. RESULTS Overall, the median renin plasma concentration increased from a baseline with median of 44.3 µU/mL (Q1-Q3, 14.6-155.5) to 188.6 µU/mL (Q1-Q3, 29.8-379.0) 4 hours after CPB. High Δ-renin (difference between postoperation and preoperation) patients (higher than 3.7 µU/mL) were then treated with norepinephrine alone (median dose of 3.25 mg [Q1-Q3, 1.00-4.75]) or with additional AT-II (norepinephrine dose: 1.33 mg [Q1-Q3, 0.78-2.04]; AT-II dose: 0.34 mg [Q1-Q3, 0.29-0.78]). At 12 hours after surgery, AT-II patients had lower renin levels than standard of care patients (71.7 µU/mL [Q1-Q3, 21.9-211.4] vs 130.6 µU/mL [Q1-Q3, 62.9-317.0]; P = .034 adjusting for the renin plasma level at 4 hours after surgery). CONCLUSIONS In cardiac surgery patients with hypotonia and postoperative high Δ-renin levels, AT-II was associated with reduced renin plasma levels for at 12 hours and significantly decreased norepinephrine use, while norepinephrine alone was associated with increased renin levels. Further studies of AT-II in cardiac surgery appear justified.
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Affiliation(s)
- Melanie Meersch
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Raphael Weiss
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christina Massoth
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Mira Küllmar
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Khaschayar Saadat-Gilani
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Manuel Busen
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Lakhmir Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, California
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University
| | - Rinaldo Bellomo
- Department of Critical Care, the University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Alexander Zarbock
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
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Küllmar M, Saadat-Gilani K, Weiss R, Massoth C, Lagan A, Cortés MN, Gerss J, Chawla LS, Fliser D, Meersch M, Zarbock A. Kinetic Changes of Plasma Renin Concentrations Predict Acute Kidney Injury in Cardiac Surgery Patients. Am J Respir Crit Care Med 2021; 203:1119-1126. [PMID: 33320784 DOI: 10.1164/rccm.202005-2050oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: The renin-angiotensin-aldosterone system is a major pathway in regulating blood pressure, glomerular filtration, and fluid homeostasis. During inflammatory diseases, generation of angiotensin II might be disturbed, leading to increased renin concentrations. Cardiac surgery and the use of cardiopulmonary bypass both induce inflammatory response and cardiovascular instability, which can contribute to acute kidney injury (AKI).Objectives: To investigate whether renin concentrations are associated with hypotension and AKI.Methods: This is a single-center, prospective, observational study among patients undergoing cardiac surgery.Measurements and Main Results: The primary endpoint was the occurrence of AKI within 72 hours after cardiac surgery. A total of 197 patients were available for the primary analysis. The median renin serum concentration was 40.2 μU/ml (quartile 1 [Q1]-Q3, 9.3-144.4) at baseline and 51.3 μU/ml (Q1-Q3, 19.1-167.0) 4 hours after cardiac surgery, whereas the difference between postoperation and preoperation concentrations (Δ-renin) was 3.7 μU/ml (Q1-Q3, -22.7 to 50.9). Patients with an elevated Δ-renin developed an AKI significantly more often (43% vs. 12.2%; P < 0.001). High Δ-renin after cardiac surgery was associated with a significantly lower mean arterial pressure, longer time on vasopressors, and longer length of ICU and hospital stay. The area under the curve (AUC) of Δ-renin for the prediction of AKI (AUC, 0.817; 95% confidence interval, 0.747-0.887) was significantly greater compared with the AUC of the postoperative renin concentrations (AUC, 0.702; 95% CI, 0.610-0.793; P = 0.007).Conclusions: Elevated renin concentrations were associated with cardiovascular instability and increased AKI after cardiac surgery. Elevated renin concentrations could be used to identify high-risk patients for cardiovascular instability and AKI who would benefit from timely intervention that could improve their outcomes.
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Affiliation(s)
- Mira Küllmar
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Khaschayar Saadat-Gilani
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Raphael Weiss
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Christina Massoth
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Anas Lagan
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Manuel Núñez Cortés
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | | | - Danilo Fliser
- Department of Internal Medicine 4, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
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Abstract
Rationale: Patients undergoing cardiac surgery often require vasopressor or inotropic ("vasoactive") medications, but patterns of postoperative use are not well described.Objectives: This study aimed to describe vasoactive medication administration throughout hospitalization for cardiac surgery, to identify patient- and hospital-level factors associated with postoperative use, and to quantify variation in treatment patterns among hospitals.Methods: Retrospective study using the Premier Healthcare Database. The cohort included adult patients who underwent coronary artery bypass grafting or open valve repair or replacement (or in combination) from January 1, 2016, to June 30, 2018. Primary outcome was receipt of vasoactive medication(s) on the first postoperative day (POD1). We identified patient- and hospital-level factors associated with receipt of vasoactive medications using multilevel mixed-effects logistic regression modeling. We calculated adjusted median odds ratios to determine the extent to which receipt of vasoactive medications on POD1 was determined by each hospital, then calculated quotients of Akaike Information Criteria to compare the relative contributions of patient and hospital characteristics and individual hospitals with observed variation.Results: Among 104,963 adults in 294 hospitals, 95,992 (92.2%) received vasoactive medication(s) during hospitalization; 30,851 (29.7%) received treatment on POD1, most commonly norepinephrine (n = 11,427, 37.0%). A median of 29.0% (range, 0.0-94.4%) of patients in each hospital received vasoactive drug(s) on POD1. After adjustment, hospital of admission was associated with twofold increased odds of receipt of any vasoactive medication on POD1 (adjusted median odds ratio, 2.07; 95% confidence interval, 1.93-2.21). Admitting hospital contributed more to observed variation in POD1 vasoactive medication use than patient or hospital characteristics (quotients of Akaike Information Criteria 0.58, 0.44, and <0.001, respectively).Conclusions: Nearly all cardiac surgical patients receive vasoactive medications during hospitalization; however, only one-third receive treatment on POD1, with significant variability by institution. Further research is needed to understand the causes of variability across hospitals and whether these differences are associated with outcomes.
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Alam A, Sovic W, Gill J, Ragula N, Salem M, Hughes GJ, Colbert GB, Mooney JL. Angiotensin II: A Review of Current Literature. J Cardiothorac Vasc Anesth 2021; 36:1180-1187. [PMID: 34452817 DOI: 10.1053/j.jvca.2021.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 01/11/2023]
Abstract
Up to one-third of all patients admitted to intensive care units carry a diagnosis of shock. The use of angiotensin II is becoming widespread in all forms of shock, including cardiogenic, after the U.S. Food and Drug Administration's (FDA's) initial approval for vasoplegic shock in 2017. Here, the authors review the literature on angiotensin II's mechanism of action, benefits, and future therapeutic opportunities.
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Affiliation(s)
- Amit Alam
- Baylor University Medical Center, Dallas, TX; Texas A&M University College of Medicine, Bryan, TX.
| | | | | | | | | | | | - Gates B Colbert
- Baylor University Medical Center, Dallas, TX; Texas A&M University College of Medicine, Bryan, TX
| | - Jennifer L Mooney
- Baylor University Medical Center, Dallas, TX; Texas A&M University College of Medicine, Bryan, TX
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Datt V, Wadhhwa R, Sharma V, Virmani S, Minhas HS, Malik S. Vasoplegic syndrome after cardiovascular surgery: A review of pathophysiology and outcome-oriented therapeutic management. J Card Surg 2021; 36:3749-3760. [PMID: 34251716 DOI: 10.1111/jocs.15805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Vasoplegic syndrome (VPS) is defined as systemic hypotension due to profound vasodilatation and loss of systemic vascular resistance (SVR), despite normal or increased cardiac index, and characterized by inadequate response to standard doses of vasopressors, and increased morbidity and mortality. It occurs in 9%-44% of cardiac surgery patients after cardiopulmonary bypass (CPB). The underlying pathophysiology following CPB consists of resistance to vasopressors (inactivation of Ca2+ voltage gated channels) on the one hand and excessive activation of vasodilators (SIRS, iNOS, and low AVP) on the other. Use of angiotensin-converting enzyme inhibitor (ACE-I), calcium channel blockers, amiodarone, heparin, low cardiac reserve (EF < 35%), symptomatic congestive heart failure, and diabetes mellitus are the perioperative risk factors for VPS after cardiac surgery in adults. Till date, there is no consensus about the outcome-oriented therapeutic management of VPS. Vasopressors such as norepinephrine (NE; 0.025-0.2 µg/kg/min) and vasopressin (0.06 U/min or 6 U/h median dose) are the first choice for the treatment. The adjuvant therapy (hydrocortisone, calcium, vitamin C, and thiamine) and rescue therapy (methylene blue [MB] and hydroxocobalamin) are also considered when perfusion goals (meanarterial pressure [MAP] > 60-70 mmHg) are not achieved with nor-epinephrine and/or vasopressin. AIMS The aims of this systematic review are to collect all the clinically relevant data to describe the VPS, its potential risk factors, pathophysiology after CPB, and to assess the efficacy, safety, and outcome of the therapeutic management with catecholamine and non-catecholamine vasopressors employed for refractory vasoplegia after cardiac surgery. Also, to elucidate the current and practical approach for management of VPS after cardiac surgery. MATERIAL AND METHODS "PubMed," "Google," and "Medline" weresearched, and over 150 recent relevant articles including RCTs, clinical studies, meta-analysis, reviews, case reports, case series and Cochrane data were analyzed for this systematic review. The filter was applied specificallyusing key words like VPS after cardiac surgery, perioperative VPS following CPB, morbidity, and mortality in VPS after cardiac surgery, vasopressors for VPS that improve outcomes, VPS after valve surgery, VPS after CABG surgery, VPS following complex congenital cardiac anomalies corrective surgery, rescue therapy for VPS, adjuvant therapy for VPS, definition of VPS, outcome in VPS after cardiac surgery, etiopathology of VPS following CPB. This review did not require any ethical approval or consent from the patients. RESULTS Despite the recent advances in therapy, the mortality remains as high as 30%-50%. NE has been recommended the most frequent used vasopressor for VPS. It restores and maintain the MAP and provides the outcome benefits. Vasopressin rescue therapy is an alternative approach, if catecholamines and fluid infusions fail to improve hemodynamics. It effectively increases vascular tone and lowers CO, and significantly decreases the 30 days mortality. Hence, suggested a first-line vasopressor agent in postcardiac surgery VPS. Terlipressin (1.3μg/kg/h), a longer acting and more specific vasoconstrictor prevents the development of VPS after CPB in patients treated with ACE-I. MB significantly reduces morbidity and mortality of VPS. The Preoperative MB (1%, 2mg/kg/30min, 1h before surgery) administration in high risk (on ACE-I) patients for VPS undergoing CABG surgery, provides 100% protection against VPS, and early of MB significantly reduces operative mortality, and recommended as a rescue therapy for VPS. Hydroxocobalamin (5 g) has been recommended as a rescue agent in VPS refractory to multiple vasopressors. A combination of ascorbic acid (6 g), hydrocortisone (200 mg/day), and thiamine (400 mg/day) as an adjuvant therapy significantly reduces the vasopressors requirement, and provides mortality and morbidity benefits. CONCLUSION Currently, the VPS is frequently encountered (9%-40%) in cardiac surgical patients with predisposing patient-specific risk factors and combined with inflammatory response to CPB. Multidrug therapy (NE, MB, AVP, ATII, terlipressin, hydroxocobalamin) targeting multiple receptor systems is recommended in refractory VPS. A combination of high dosage of ascorbic acid, hydrocortisone and thiamine has been used successfully as adjunctive therapyto restore the MAP. We also advocate for the early use of multiagent vasopressors therapy and catecholamine sparing adjunctive agents to restore the systemic perfusion pressure with a goal of preventing the progressive refractory VPS.
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Affiliation(s)
- Vishnu Datt
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Rachna Wadhhwa
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Varun Sharma
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Sanjula Virmani
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Harpreet S Minhas
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Shardha Malik
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
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Bhat I, Arya VK, Mandal B, Jayant A, Dutta V, Rana SS. Postoperative hemodynamics after high spinal block with or without intrathecal morphine in cardiac surgical patients: a randomized-controlled trial. Can J Anaesth 2021; 68:825-834. [PMID: 33564993 DOI: 10.1007/s12630-021-01937-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE There is some evidence for the use of intrathecal morphine as a means to provide prolonged analgesia in selective cardiac surgical patients; however, the hemodynamic effects of intrathecal morphine are not well defined. This study was designed to study the effect of intrathecal morphine on hemodynamic parameters in cardiac surgery patients. METHODS In a prospective, double-blind study, 100 adult cardiac surgical patients were randomized to receive either intrathecal 40 mg of 0.5% hyperbaric bupivacaine alone (intrathecal bupivacaine [ITB] group, n = 50) or intrathecal 250 µg of morphine added to 40 mg of 0.5% bupivacaine (intrathecal bupivacaine and morphine [ITBM] group, n = 50). Hemodynamic data, pain scores, rescue analgesic use, spirometry, and vasopressor use were recorded every four hours after surgery for 48 hr. The primary outcome was the incidence of vasoplegia in each group, which was defined as a cardiac index > 2.2 L·min-1·m-2 with the requirement of vasopressors to maintain the mean arterial pressure > 60 mmHg with the hemodynamic episode lasting > four hours. RESULTS Eighty-seven patients were analyzed (ITB group, n = 42, and ITBM group, n =45). The incidence of vasoplegia was higher in the ITBM group than in the ITB group [14 (31%) vs 5 (12%), respectively; relative risk, 2.6; 95% confidence interval [CI], 1.0 to 6.6; P = 0.04]. The mean (standard deviation [SD]) duration of vasoplegia was significantly longer in the ITBM group than in the ITB group [8.9 (3.0) hr vs 4.3 (0.4) hr, respectively; difference in means, 4.6; 95% CI, 3.7 to 5.5; P < 0.001]. CONCLUSION Intrathecal morphine added to bupivacaine for high spinal anesthesia increases the incidence and duration of vasoplegia in cardiac surgery patients. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02825056); registered 19 June 2016.
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Affiliation(s)
- Imran Bhat
- Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra K Arya
- Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, St. Boniface Hosptial, Winnipeg, MB, Canada.
| | - Banashree Mandal
- Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aveek Jayant
- Department of Anaesthesiology and Critical Care Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - Vikas Dutta
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, St. Boniface Hosptial, Winnipeg, MB, Canada
| | - Sandeep Singh Rana
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Slomovits M, Neuburger PJ, Rong LQ. Vasoplegia in cardiac surgery: Know your enemy and attack early. J Card Surg 2021; 36:3031-3033. [PMID: 34021630 DOI: 10.1111/jocs.15670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/15/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mark Slomovits
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, USA
| | - Peter J Neuburger
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, USA
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Martin D, Mantziari S, Demartines N, Hübner M. Defining Major Surgery: A Delphi Consensus Among European Surgical Association (ESA) Members. World J Surg 2021; 44:2211-2219. [PMID: 32172309 DOI: 10.1007/s00268-020-05476-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Major surgery is a term frequently used but poorly defined. The aim of the present study was to reach a consensus in the definition of major surgery within a panel of expert surgeons from the European Surgical Association (ESA). METHODS A 3-round Delphi process was performed. All ESA members were invited to participate in the expert panel. In round 1, experts were inquired by open- and closed-ended questions on potential criteria to define major surgery. Results were analyzed and presented back anonymously to the panel within next rounds. Closed-ended questions in round 2 and 3 were either binary or statements to be rated on a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). Participants were sent 3 reminders at 2-week intervals for each round. 70% of agreement was considered to indicate consensus. RESULTS Out of 305 ESA members, 67 (22%) answered all the 3 rounds. Significant comorbidities were the only preoperative factor retained to define major surgery (78%). Vascular clampage or organ ischemia (92%), high intraoperative blood loss (90%), high noradrenalin requirements (77%), long operative time (73%) and perioperative blood transfusion (70%) were procedure-related factors that reached consensus. Regarding postoperative factors, systemic inflammatory response (76%) and the need for intensive or intermediate care (88%) reached consensus. Consequences of major surgery were high morbidity (>30% overall) and mortality (>2%). CONCLUSION ESA experts defined major surgery according to extent and complexity of the procedure, its pathophysiological consequences and consecutive clinical outcomes.
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Affiliation(s)
- David Martin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Bartholmes F, M. Malewicz N, Ebel M, K. Zahn P, H. Meyer-Frießem C. Pupillometric Monitoring of Nociception in Cardiac Anesthesia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:833-840. [PMID: 33593477 PMCID: PMC8021968 DOI: 10.3238/arztebl.2020.0833] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 12/19/2019] [Accepted: 05/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND High-dose opioids are conventionally used for cardiac anesthesia, but without monitoring of nociception. In non-cardiac surgical procedures the intra - operative dose of opioids can be individualized and reduced with pupillometric monitoring of the pupillary pain index (PPI; scale 1-9). A randomized controlled trial was carried out to explore whether pupillometry can be used for nociception monitoring in cardiac anesthesia and whether it leads to opioid reduction. METHODS A sample of 57 cardiac surgery patients receiving continuously administered sufentanil (initial dosage 0.7 μg*kg-¹*h-¹) was divided into a PPI group (sufentanil reduction if PPI<3 up to a minimum of 0.15 μg*kg-¹*h-¹, n=32) and a control group (standard anesthesia; n = 25). The primary outcome was the time from the end of anesthesia to extubation. The secondary outcomes were total intraoperative dose of sufentanil/noradrenaline, postoperative pain intensity (numeric rating scale [NRS] 0-10) and intraoperative awareness. German Clinical Trials Registry no. DRKS 00012329. RESULTS The primary outcome, extubation time, did not differ between the two groups (1.14 h, 95% confidence interval [-0.99; 3.27], p = 0.592). Compared with the control patients (68% male, age 70 ± 10.4 years, PPI 1.1 ± 0.2), the mean sufentanil infusion rate in the PPI patients (81% male, age 68 ± 10.3 years, PPI 1.1 ± 0.2) decreased by 81.8% (-0.68 μg*kg-¹*h-¹ [-0,7; -0.67], p<0.001) to the predetermined minimum level, without intraoperative awareness. Moreover, the noradrenaline dose was reduced by 56% (1235.51 μg [321.91; 2149.12], p = 0.005) and the postoperative pain intensity by 45% (2.11 NRS [0.93; 3.3] after 24 h, p = 0.003). CONCLUSION Pupillometry is appropriate for nociception monitoring in cardiac anesthesia. Thereby a considerable reduction of intraoperative opioids as well as increased intraoperative hemodynamic stability was achieved and postoperative opioid-induced hyperalgesia was prevented. The consistently low PPI scores, indicating adequate analgesia, suggest that further reduction of opioid doses is feasible.
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Affiliation(s)
- Felix Bartholmes
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
| | - Nathalie M. Malewicz
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
| | - Melanie Ebel
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
| | - Peter K. Zahn
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
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Klijian A, Khanna AK, Reddy VS, Friedman B, Ortoleva J, Evans AS, Panwar R, Kroll S, Greenfeld CR, Chatterjee S. Treatment With Angiotensin II Is Associated With Rapid Blood Pressure Response and Vasopressor Sparing in Patients With Vasoplegia After Cardiac Surgery: A Post-Hoc Analysis of Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) Study. J Cardiothorac Vasc Anesth 2020; 35:51-58. [PMID: 32868152 DOI: 10.1053/j.jvca.2020.08.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/29/2020] [Accepted: 08/02/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The present study investigated outcomes in patients with vasoplegia after cardiac surgery treated with angiotensin II plus standard-of-care vasopressors. Vasoplegia is a common complication in cardiac surgery with cardiopulmonary bypass and is associated with significant morbidity and mortality. Approximately 250,000 cardiac surgeries with cardiopulmonary bypass are performed in the United States annually, with vasoplegia occurring in 20%to-27% of patients. DESIGN Post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) study. SETTING Multicenter, multinational study. PARTICIPANTS Sixteen patients with vasoplegia after cardiac surgery with cardiopulmonary bypass were enrolled. INTERVENTIONS Angiotensin II plus standard-of-care vasopressors (n = 9) compared with placebo plus standard-of-care vasopressors (n = 7). MEASUREMENTS AND MAIN RESULTS The primary endpoint was mean arterial pressure response (mean arterial pressure ≥75 mmHg or an increase from baseline of ≥10 mmHg at hour 3 without an increase in the dose of standard-of-care vasopressors). Vasopressor sparing and safety also were assessed. Mean arterial pressure response was achieved in 8 (88.9%) patients in the angiotensin II group compared with 0 (0%) patients in the placebo group (p = 0.0021). At hour 12, the median standard-of-care vasopressor dose had decreased from baseline by 76.5% in the angiotensin II group compared with an increase of 7.8% in the placebo group (p = 0.0013). No venous or arterial thrombotic events were reported. CONCLUSION Patients with vasoplegia after cardiac surgery with cardiopulmonary bypass rapidly responded to angiotensin II, permitting significant vasopressor sparing.
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Affiliation(s)
- Ara Klijian
- Department of Cardiothoracic Surgery, Sharp and Scripps Healthcare, San Diego, CA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC; Outcomes Research Consortium, Cleveland, OH
| | | | | | - Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | | | - Rakshit Panwar
- John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Stew Kroll
- La Jolla Pharmaceutical Company, San Diego, CA
| | | | - Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX.
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Barnes TJ, Hockstein MA, Jabaley CS. Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies. SAGE Open Med 2020; 8:2050312120935466. [PMID: 32647575 PMCID: PMC7328055 DOI: 10.1177/2050312120935466] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/21/2020] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular disease remains the leading cause of death in the United States,
and cardiopulmonary bypass is a cornerstone in the surgical management of many
related disease states. Pathophysiologic changes associated both with
extracorporeal circulation and shock can beget a syndrome of low systemic
vascular resistance paired with relatively preserved cardiac output, termed
vasoplegia. While increased vasopressor requirements accompany vasoplegia,
related pathophysiologic mechanisms may also lead to true catecholamine
resistance, which is associated with further heightened mortality. The
introduction of a second non-catecholamine vasopressor, angiotensin II, and
non-specific nitric oxide scavengers offers potential means by which to manage
this challenging phenomenon. This narrative review addresses both the
definition, risk factors, and pathophysiology of vasoplegia and potential
therapeutic interventions.
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Affiliation(s)
- Theresa J Barnes
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - Craig S Jabaley
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
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Cengic S, Zuberi M, Bansal V, Ratzlaff R, Rodrigues E, Festic E. Hypotension after intensive care unit drop-off in adult cardiac surgery patients. World J Crit Care Med 2020; 9:20-30. [PMID: 32577413 PMCID: PMC7298587 DOI: 10.5492/wjccm.v9.i2.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension is a frequent complication in the intensive care unit (ICU) after adult cardiac surgery.
AIM To describe frequency of hypotension in the ICU following adult cardiac surgery and its relation to the hospital outcomes.
METHODS A retrospective study of post-cardiac adult surgical patients at a tertiary academic medical center in a two-year period. We abstracted baseline demographics, comorbidities, and all pertinent clinical variables. The primary predictor variable was the development of hypotension within the first 30 min upon arrival to the ICU from the operating room (OR). The primary outcome was hospital mortality, and other outcomes included duration of mechanical ventilation (MV) in hours, and ICU and hospital length of stay in days.
RESULTS Of 417 patients, more than half (54%) experienced hypotension within 30 min upon arrival to the ICU. Presence of OR hypotension immediately prior to ICU transfer was significantly associated with ICU hypotension (odds ratio = 1.9; 95% confidence interval: 1.21-2.98; P < 0.006). ICU hypotensive patients had longer MV, 5 (interquartile ranges 3, 15) vs 4 h (interquartile ranges 3, 6), P = 0.012. The patients who received vasopressor boluses (n = 212) were more likely to experience ICU drop-off hypotension (odds ratio = 1.45, 95% confidence interval: 0.98-2.13; P = 0.062), and they experienced longer MV, ICU and hospital length of stay (P < 0.001, for all).
CONCLUSION Hypotension upon anesthesia-to-ICU drop-off is more frequent than previously reported and may be associated with adverse clinical outcomes.
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Affiliation(s)
- Sabina Cengic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of General Surgery, Stadtspital Triemli, Zurich 8063, Switzerland
| | - Muhammad Zuberi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Robert Ratzlaff
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Eduardo Rodrigues
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Emir Festic
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, United States
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36
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Sommerfeld O, von Loeffelholz C, Diab M, Kiessling S, Doenst T, Bauer M, Sponholz C. Association between high dose catecholamine support and liver dysfunction following cardiac surgery. J Card Surg 2020; 35:1228-1236. [PMID: 32333454 DOI: 10.1111/jocs.14555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cardiac surgery using cardiopulmonary bypass is a well-established procedure. However, up to 20% to 30% of patients require high dose vasopressor or inotropic support following surgery, enhancing the risk of organ dysfunction and impacting mortality. Nonalcoholic fatty liver disease (NAFLD) is a frequent finding in these patients and may be involved in the pathophysiology of vasoplegia and cardiac failure. METHODS Retrospective analysis of 463 patients undergoing elective cardiac surgery in 2014 at our institution. NAFLD was defined using the NAFLD fibrosis score and the vasoactive-inotropy score was used to determine postoperative vasopressor and inotropic dependency. RESULTS Patients with NAFLD more often presented with high vasopressor or inotropic support compared to patients without NAFLD, resulting in significant differences after 6 hours (n = 20 [27.0%] of 74 patients), 12 hours (n = 20 [27.0%] of 74 patients), and on the first postoperative day (n = 12 [16.4%] of 73 patients) of intensive care unit (ICU) treatment. Multivariate analysis revealed time of catecholamine application (P = .001), preoperative left ventricular ejection fraction (P = .001), type of surgery (P = .001), model of endstage liver disease on hospital admission (P = .002), pre-existing pulmonary hypertension (P = .004) and NAFLD-time interaction (P = .05) as independent predictors of high vasopressor and inotropic support. Patients with NAFLD had higher degrees of extrahepatic organ dysfunction, were more dependent on hemodialysis, spent more days in the ICU and within the hospital. Patients with NAFLD and high catecholamine support had the highest mortality rates among the study population. CONCLUSIONS NAFLD is a common finding in elective cardiac surgery patients. Anesthesiologists and intensivists should be sensitive for the specific risk profile of this population.
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Affiliation(s)
- Oliver Sommerfeld
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | | | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Stefan Kiessling
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Christoph Sponholz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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Busse LW, Barker N, Petersen C. Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:36. [PMID: 32019600 PMCID: PMC7001322 DOI: 10.1186/s13054-020-2743-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Vasoplegic syndrome is a common occurrence following cardiothoracic surgery and is characterized as a high-output shock state with poor systemic vascular resistance. The pathophysiology is complex and includes dysregulation of vasodilatory and vasoconstrictive properties of smooth vascular muscle cells. Specific bypass machine and patient factors play key roles in occurrence. Research into treatment of this syndrome is limited and extrapolated primarily from that pertaining to septic shock, but is evolving with the expanded use of catecholamine-sparing agents. Recent reports demonstrate potential benefit in novel treatment options, but large clinical trials are needed to confirm.
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Affiliation(s)
- Laurence W Busse
- Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA. .,Emory Johns Creek Hospital, 6325 Hospital Parkway, Johns Creek, GA, 30097, USA.
| | - Nicholas Barker
- Department of Pharmacy, Emory St. Joseph's Hospital, Atlanta, GA, USA
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Terbeck S, Heinisch PP, Lenz A, Friess JO, Guensch D, Carrel T, Eberle B, Erdoes G. Levosimendan and systemic vascular resistance in cardiac surgery patients: a systematic review and meta-analysis. Sci Rep 2019; 9:20343. [PMID: 31889123 PMCID: PMC6937247 DOI: 10.1038/s41598-019-56831-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022] Open
Abstract
AbstractLevosimendan is a potent non-adrenergic inodilator agent. The net effect of hemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. We conducted a systematic review and meta-analysis assessing hemodynamics in cardiac surgery patients treated with levosimendan. English-language literature was searched systematically from 2006 until October 2018, including randomized controlled trials and case-matched or retrospective studies providing at least two sequentially measured hemodynamic variables in adult patients who underwent cardiac surgery with cardiopulmonary bypass and were treated with levosimendan in comparison to alternative drugs or devices. Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardized mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference at baseline by a multivariate mixed effects meta-analysis model. With this correction for baseline differences, other hemodynamic variables including systemic vascular resistance did not significantly differ until POD 1 [−0.17 (−0.64 to 0.30), p = 0.48] and POD 7 [−0.13 (−0.61 to 0.34), p = 0.58] between the levosimendan and the comparator group. Levosimendan increases cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome.
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39
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Imperiali CE, Lopez-Delgado JC, Dastis-Arias M, Sanchez-Navarro L. Evaluation of the delta of immature platelet fraction as a predictive biomarker of inflammatory response after cardiac surgery. J Clin Pathol 2019; 73:335-340. [PMID: 31732619 DOI: 10.1136/jclinpath-2019-206068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 12/23/2022]
Abstract
AIMS Cardiac surgery (CS) can induce an inflammatory response (IR) that is associated with poorer outcomes. Immature platelets are among the factors that may be associated with IR development. We aimed to evaluate whether immature platelet fraction (IPF) could be a predictive biomarker for IR and whether IPF could improve the prognosis assessment of IR for Acute Physiologic and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) following CS. METHODS Three-hundred and twenty-seven (327) patients who underwent CS were enrolled during the study period. IR was defined according to the need for vasopressor support (>48 hours). Perioperative variables and outcomes were registered in our database. IPF was measured immediately following CS and at 24 hours by Sysmex XN analyzer and the difference between both measurements (ΔIPF) was calculated. To assess the relationship between ΔIPF and IR, univariate and multivariate logistic regression were performed. To analyse the additive value of ΔIPF in APACHE II and SOFA scores in predicting IR, an area under the receiver operating characteristic (AUROC) curve was calculated. RESULTS Among 327 patients included, 60 patients (18.3%) developed IR. Multivariate analysis showed ΔIPF was significantly associated with IR (OR: 1.26; 95% CI: 1.01 to 1.56; p=0.038). The combination of ΔIPF with scores improved the AUROC for IR prediction: 0.629 vs 0.728 (p=0.010) for APACHE II and 0.676 vs 0.715 (p=0.106) for SOFA. CONCLUSION These findings suggested that ΔIPF may be a useful and low-cost biomarker for the early identification of patients at risk of IR development.
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Affiliation(s)
- Claudia Elizabeth Imperiali
- Clinical Laboratory, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain .,Biochemistry and Molecular Biology Department, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Macarena Dastis-Arias
- Clinical Laboratory, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lourdes Sanchez-Navarro
- Clinical Laboratory, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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40
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Patel JJ, Venegas-Borsellino C, Willoughby R, Freed JK. High-Dose Vitamin B12 in Vasodilatory Shock: A Narrative Review. Nutr Clin Pract 2019; 34:514-520. [PMID: 31187494 DOI: 10.1002/ncp.10327] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Vasodilatory shock, as observed in postoperative states and sepsis, is hallmarked by low systemic vascular resistance and low blood pressure compensated by increased cardiac output. Gasotransmitters, such as nitric oxide and hydrogen sulfide, are implicated in the development and perpetuation of vasodilatory shock. Established therapies do not target these physiologic drivers of vasodilation. Due to their nontoxic and pleotropic effects, micronutrients are being used as rescue therapy in postoperative vasoplegia and septic shock. Here, we outline the pathophysiology of vasodilatory shock, describe the rationale for vitamin B12 (hydroxocobalamin) in vasodilatory shock, and identify literature evaluating its use in vasoplegic states.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Rodney Willoughby
- Division of Pediatric Infectious Disease, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julie K Freed
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Cardiac Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Dayan V, Cal R, Giangrossi F. Risk factors for vasoplegia after cardiac surgery: a meta-analysis. Interact Cardiovasc Thorac Surg 2019; 28:838-844. [DOI: 10.1093/icvts/ivy352] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Victor Dayan
- Centro Cardiovascular Universitario, Hospital de Clinicas, Montevideo, Uruguay
- Instituto Nacional de Cirugía Cardiaca, Montevideo, Uruguay
| | - Rosana Cal
- Instituto Nacional de Cirugía Cardiaca, Montevideo, Uruguay
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Orozco Vinasco DM, Triana Schoonewolff CA, Orozco Vinasco AC. Vasoplegic syndrome in cardiac surgery: Definitions, pathophysiology, diagnostic approach and management. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:277-287. [PMID: 30736984 DOI: 10.1016/j.redar.2018.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/22/2018] [Accepted: 12/24/2018] [Indexed: 06/09/2023]
Abstract
Vasoplegic syndrome is a state of vasopressor resistant systemic vasodilation in the presence of a normal cardiac output. Its definition, pathophysiology, risk factors, diagnosis and therapeutic approach will be reviewed in this paper. It occurs frequently during cardiac surgery and is associated with high morbidity and mortality. A search in the LILACS, MEDLINE, and GOOGLE SCHOLAR databases was conducted to find the most relevant papers during the last 18 years. Prompt identification and diagnosis of patients at risk must be undertaken in order to implement an optimal therapeutic approach. This latter includes early treatment with vasopressors with different mechanisms of action.
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Affiliation(s)
- D M Orozco Vinasco
- Departamento de Anestesia cardiovascular, Clínica Colsubsidio Calle 100, Instituto del Corazón de Bucaramanga sede Bogotá, Bogotá, Colombia.
| | - C A Triana Schoonewolff
- Departamento de Anestesia cardiovascular, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - A C Orozco Vinasco
- Departamento de Anestesia, Hospital Universitario Severo Ochoa, Leganés Madrid, España
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Sponholz C, Schuwirth C, Koenig L, Hoyer H, Coldewey SM, Schelenz C, Doenst T, Kortgen A, Bauer M. Intraoperative reduction of vasopressors using processed electroencephalographic monitoring in patients undergoing elective cardiac surgery: a randomized clinical trial. J Clin Monit Comput 2019; 34:71-80. [PMID: 30784008 DOI: 10.1007/s10877-019-00284-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/13/2019] [Indexed: 01/13/2023]
Abstract
Intraoperative vasopressor and fluid application are common strategies against hypotension. Use of processed electroencephalographic monitoring (pEEG) may reduce vasopressor application, a known risk factor for organ dysfunction, in elective cardiac surgery patients. Randomized single-centre clinical trial at Jena University Hospital. Adult patients operated on cardiopulmonary bypass or off-pump coronary artery bypass grafting were randomised to receive anesthesia with visible or blinded pEEG using Narcotrend™. In blinded-Narcotrend (NT) depth of anesthesia was extrapolated from clinical signs, hemodynamic response and anesthetic concentration, supplemented by target indices between 37 and 64 in the visible-NT group. Intraoperative norepinephrine requirement (primary endpoint), fluid balance, extubation time, delirium occurrence and adverse events were evaluated. Patients of the intent-to-treat population (visible-NT: n = 123, blinded-NT: n = 122) had similar patient and procedural characteristics. Adjusted for type of surgery intraoperative Norepinephrine application was significantly reduced in visible-NT (n = 120, robust mean of cumulative dose 4.71 µg/kg bodyweight) compared to blinded-NT patients (n = 119, 6.14 µg/kg bodyweight) (adjusted robust mean difference 1.71 (95% CI 0.33-3.10) µg/kg bodyweight). Although reduction in patients operated on cardiopulmonary bypass was higher the interaction was not significant in post-hoc subgroup analysis. Intraoperative fluid balance was similar among both groups and strata. Extubation time was non-significantly lower in visible than in blinded-NT group. Overall postoperative delirium risk was 16.4% without differences among the groups. Adverse events-sudden movement/coughing, perspiration or hypertension-occurred more often with visible-NT, while one blinded-NT patient experienced intraoperative awareness. Titration of depth of anesthesia in elective cardiac surgery patients using pEEG allows to reduce application of norepinephrine.
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Affiliation(s)
- C Sponholz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
| | - C Schuwirth
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - L Koenig
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - H Hoyer
- Institute of Medical Statistics, Computer Sciences and Data Sciences, Jena University Hospital, Jena, Germany
| | - S M Coldewey
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.,ZIK Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - C Schelenz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - T Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - A Kortgen
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - M Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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de Waal EEC, van Zaane B, van der Schoot MM, Huisman A, Ramjankhan F, van Klei WA, Marczin N. Vasoplegia after implantation of a continuous flow left ventricular assist device: incidence, outcomes and predictors. BMC Anesthesiol 2018; 18:185. [PMID: 30526494 PMCID: PMC6286572 DOI: 10.1186/s12871-018-0645-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/22/2018] [Indexed: 12/14/2022] Open
Abstract
Background Vasoplegia after routine cardiac surgery is associated with severe postoperative complications and increased mortality. It is also prevalent in patients undergoing implantation of pulsatile flow left ventricular assist devices (LVAD). However, less is known regarding vasoplegia after implantation of newer generations of continuous flow LVADs (cfLVAD). We aim to report the incidence, impact on outcome and predictors of vasoplegia in these patients. Methods Adult patients scheduled for primary cfLVAD implantation were enrolled into a derivation cohort (n = 118, 2006–2013) and a temporal validation cohort (n = 73, 2014–2016). Vasoplegia was defined taking into consideration low mean arterial pressure and/or low systemic vascular resistance, preserved cardiac index and high vasopressor support. Vasoplegia was considered after bypass and the first 48 h of ICU stay lasting at least three consecutive hours. This concept of vasoplegia was compared to older definitions reported in the literature in terms of the incidence of postoperative vasoplegia and its association with adverse outcomes. Logistic regression was used to identify independent predictors. Their ability to discriminate patients with vasoplegia was quantified by the area under the receiver operating characteristic curve (AUC). Results The incidence of vasoplegia was 33.1% using the unified definition of vasoplegia. Vasoplegia was associated with increased ICU length-of-stay (10.5 [6.9–20.8] vs 6.1 [4.6–10.4] p = 0.002), increased ICU-mortality (OR 5.8, 95% CI 1.9–18.2) and one-year-mortality (OR 3.9, 95% CI 1.5–10.2), and a higher incidence of renal failure (OR 4.3, 95% CI 1.8–10.4). Multivariable analysis identified previous cardiothoracic surgery, preoperative dopamine administration, preoperative bilirubin levels and preoperative creatinine clearance as independent preoperative predictors of vasoplegia. The resultant prediction model exhibited a good discriminative ability (AUC 0.80, 95% CI 0.71–0.89, p < 0.01). Temporal validation resulted in an AUC of 0.74 (95% CI 0.61–0.87, p < 0.01). Conclusions In the era of the new generation of cfLVADs, vasoplegia remains a prevalent (33%) and critical condition with worse short-term outcomes and survival. We identified previous cardiothoracic surgery, preoperative treatment with dopamine, preoperative bilirubin levels and preoperative creatinine clearance as independent predictors. Electronic supplementary material The online version of this article (10.1186/s12871-018-0645-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eric E C de Waal
- Department of Anesthesiology, University Medical Centre Utrecht, Mailstop Q04.2.317, Post Office Box 85500, 3508 GA, Utrecht, Netherlands.
| | - Bas van Zaane
- Department of Anesthesiology, University Medical Centre Utrecht, Mailstop Q04.2.317, Post Office Box 85500, 3508 GA, Utrecht, Netherlands
| | | | - Albert Huisman
- Clinical chemist, Department of Clinical Chemistry and Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Faiz Ramjankhan
- Cardiothoracic surgeon, Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Centre Utrecht, Mailstop Q04.2.317, Post Office Box 85500, 3508 GA, Utrecht, Netherlands
| | - Nandor Marczin
- Anaesthesiologist, Section of Anaesthesia, Pain Medicine and Intensive Care, Imperial College, London, UK.,Department of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
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Vasoplegia After Surgical Left Ventricular Restoration: 2-Year Follow-Up. Ann Thorac Surg 2018; 106:1371-1378. [DOI: 10.1016/j.athoracsur.2018.06.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 06/06/2018] [Accepted: 06/25/2018] [Indexed: 12/28/2022]
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Dünser MW, Bouvet O, Knotzer H, Arulkumaran N, Hajjar LA, Ulmer H, Hasibeder WR. Vasopressin in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2018; 32:2225-2232. [DOI: 10.1053/j.jvca.2018.04.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Indexed: 01/29/2023]
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Bolliger D, Erb JM. Vasopressin—Magic Bullet in Vasoplegia Syndrome After Cardiac Surgery? J Cardiothorac Vasc Anesth 2018; 32:2233-2235. [DOI: 10.1053/j.jvca.2018.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Indexed: 12/31/2022]
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Shaefi S, Mittel A, Klick J, Evans A, Ivascu NS, Gutsche J, Augoustides JG. Vasoplegia After Cardiovascular Procedures—Pathophysiology and Targeted Therapy. J Cardiothorac Vasc Anesth 2018; 32:1013-1022. [DOI: 10.1053/j.jvca.2017.10.032] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Indexed: 11/11/2022]
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Characterizing Predictors and Severity of Vasoplegia Syndrome After Heart Transplantation. Ann Thorac Surg 2018; 105:770-777. [DOI: 10.1016/j.athoracsur.2017.09.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/27/2017] [Accepted: 09/22/2017] [Indexed: 01/19/2023]
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Nemeth E, Kovacs E, Racz K, Soltesz A, Szigeti S, Kiss N, Csikos G, Koritsanszky KB, Berzsenyi V, Trembickij G, Fabry S, Prohaszka Z, Merkely B, Gal J. Impact of intraoperative cytokine adsorption on outcome of patients undergoing orthotopic heart transplantation-an observational study. Clin Transplant 2018; 32:e13211. [PMID: 29377282 DOI: 10.1111/ctr.13211] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2018] [Indexed: 12/13/2022]
Abstract
AIM The aim of this study was to assess the influence of intraoperative cytokine adsorption on the perioperative vasoplegia, inflammatory response and outcome during orthotopic heart transplantation (OHT). METHODS Eighty-four OHT patients were separated into the cytokine adsorption (CA)-treated group or controls. Vasopressor demand, inflammatory response described by procalcitonin and C-reactive protein, and postoperative outcome were assessed performing propensity score matching. RESULTS In the 16 matched pairs, the median noradrenaline requirement was significantly less in the CA-treated patients than in the controls on the first and second postoperative days (0.14 vs 0.3 μg*kg-1 *min-1 , P = .039 and 0.06 vs 0.32 μg*kg-1 *min-1 , P = .047). The inflammatory responses were similar in the two groups. There was a trend toward shorter length of mechanical ventilation and intensive care unit (ICU) stay in the CA-treated group compared to the controls. No difference in adverse events was observed between the two groups. The frequency of renal replacement therapy was less in the CA‐treated patients than in the controls. CONCLUSIONS Intraoperative CA treatment was associated with reduced vasopressor demand with a favorable tendency in length of mechanical ventilation, ICU stay and renal replacement therapy. CA treatment was not linked to higher rates of adverse events.
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Affiliation(s)
- Endre Nemeth
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Eniko Kovacs
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Kristof Racz
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Adam Soltesz
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Szabolcs Szigeti
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Nikolett Kiss
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gergely Csikos
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Kinga B Koritsanszky
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Viktor Berzsenyi
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gabor Trembickij
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Szabolcs Fabry
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Zoltan Prohaszka
- 3rd Department of Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Janos Gal
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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