Association between high dose catecholamine support and liver dysfunction following cardiac surgery

The Effects of Different Doses of Sufentanil on Intraoperative Cardiovascular Response and Postoperative Recovery in Patients Undergoing Cardiac Surgery: A Retrospective Cohort Study

Objective

To investigate the correlation between the amount of sufentanil used during anesthesia and intraoperative hemodynamic fluctuation and postoperative recovery in patients undergoing cardiopulmonary bypass (CPB).

Materials and Methods

A retrospective analysis was performed on 454 patients undergoing elective heart surgery under CPB. Patients were divided into two groups according to the amount of sufentanil used during anesthesia: Group L (induced sufentanil 0.4-0.6 ug /kg, maintained sufentanil 0.01-0.02 ug/kg/min, n = 223) and Group H (induced sufentanil 4-6 ug/kg, maintained sufentanil 0.02-0.03 ug/kg/min, n = 231). Propensity score matching (PSM) was used at a 1:1 nearest-neighbor ratio to compare the two groups. Intraoperative use of vasoactive drugs, spontaneous heart rebound, secondary endotracheal intubation, postoperative mechanical ventilation time, the length of stay (LOS) in ICU, postoperative LOS in hospital, postoperative in-hospital mortality were analyzed.

Results

After matching, a total of 144 patients were included (72 patients in Group L, and 72 patients in Group H). Multivariate logistic regression analysis showed that the dosage of sufentanil during anesthesia was significantly correlated with the utilization rate of intraoperative vasoactive drugs (P < 0.001) and the success rate of spontaneous heart rebound (p = 0.001). The utilization rate of vasoactive drugs decreased significantly in Group H (OR, 0.062; 95% CI, 0.019-0.200) compared to that of Group L. The success rate of spontaneous heart rebound (OR, 0.187; 95% CI, 0.071-0.491) was higher in Group H. There were no differences on postoperative recovery outcomes between the two groups.

Conclusion

On the basis of our data, the use of high-dose sufentanil is beneficial to keep the cardiovascular response of patients in a stable state, but there is no significant effect on the quality of early postoperative recovery.

Association of nonalcoholic fatty liver disease with acute cholangitis: a nationwide propensity-matched analysis from the United States

Background

Nonalcoholic fatty liver disease (NAFLD) has previously been linked to several disease states with an impact on patient outcomes. However, clinical evidence on the association between NAFLD and acute cholangitis (AC) remains scarce. We aimed to evaluate the potential association between NAFLD and AC.

Methods

We conducted a retrospective cohort study using the US National Inpatient Sample database from 2016 to 2019 to analyze primary AC hospitalizations with NAFLD compared to non-NAFLD in a 1:1 propensity-matched population.

Results

A total of 1550 AC patients with NAFLD were matched to 1550 AC patients without NAFLD. NAFLD had a higher association with AC when compared to patients without NAFLD, with an odds ratio of 2.33 (95% CI [1.81-3.0], P < 0.001). The length of stay was higher in NAFLD than in non-NAFLD (4 vs 3 days, P < 0.001). The median inpatient charges in NAFLD were also higher than in the non-NAFLD cohort ($36,182 vs $35,244, P < 0.001). Inpatient mortality was higher in NAFLD compared to non-NAFLD (1.6% vs 0%, P < 0.001). There was an increased prevalence of portal vein thrombosis (3.2% vs 0%), acute kidney injury (24.2% vs 17.7%), sepsis (3.2% vs 1.6%), mechanical ventilation (3.2% vs 0%), and percutaneous cholecystostomy tube insertion (3.2% vs 1.6%) in NAFLD compared to non-NAFLD (P < 0.05). NAFLD also had a higher association with acute cholecystitis, with an odds ratio of 3.70 (95% CI [3.19-4.29], P < 0.001).

Conclusions

This study showed an association between NALFD and AC, resulting in increased length of stay, hospital charges, and inpatient mortality. Underlying NAFLD also increases acute complications of AC.

The Role of Physical Activity in Nonalcoholic and Metabolic Dysfunction Associated Fatty Liver Disease

Sedentary behavior constitutes a pandemic health threat contributing to the pathophysiology of obesity and type 2 diabetes (T2D). Sedentarism is further associated with liver disease and particularly with nonalcoholic/metabolic dysfunction associated fatty liver disease (NAFLD/MAFLD). Insulin resistance (IR) represents an early pathophysiologic key element of NAFLD/MAFLD, prediabetes and T2D. Current treatment guidelines recommend regular physical activity. There is evidence, that physical exercise has impact on a variety of molecular pathways, such as AMP-activated protein kinase and insulin signaling as well as glucose transporter 4 translocation, modulating insulin action, cellular substrate flow and in particular ectopic lipid and glycogen storage in a positive manner. Therefore, physical exercise can lead to substantial clinical benefit in persons with diabetes and/or NAFLD/MAFLD. However, experience from long term observational studies shows that the patients’ motivation to exercise regularly appears to be a major limitation. Strategies to integrate everyday physical activity (i.e., nonexercise activity thermogenesis) in lifestyle treatment schedules might be a promising approach. This review aggregates evidence on the impact of regular physical activity on selected molecular mechanisms as well as clinical outcomes of patients suffering from IR and NAFLD/MAFLD.

Birkenfeld A, Sponholz C, A. Müller U, von Loeffelholz C. Blood Sugar Targets in Surgical Intensive Care—Management and Special Considerations in Patients With Diabetes

BACKGROUND

30-80% of patients being treated in intensive care units in the perioperative period develop hyperglycemia. This stress hyperglycemia is induced and maintained by inflammatory-endocrine and iatrogenic stimuli and generally requires treatment. There is uncertainty regarding the optimal blood glucose targets for patients with diabetes mellitus.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and Google Scholar.

RESULTS

Patients in intensive care with pre-existing diabetes do not benefit from blood sugar reduction to the same extent as metabolically healthy individuals, but they, too, are exposed to a clinically relevant risk of hypoglycemia. A therapeutic range from 4.4 to 6.1 mmol/L (79-110 mg/dL) cannot be justified for patients with diabetes mellitus. The primary therapeutic strategy in the perioperative setting should be to strictly avoid hypoglycemia. Neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia. Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value. The target range of 7.8-10 mmol/L (140-180 mg/dL) proposed by specialty societies for hospitalized patients with diabetes seems to be the best compromise at present for optimizing clinical outcomes while avoiding hypoglycemia. The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requirng standardized, high-quality monitoring conditions.

CONCLUSION

Optimal blood sugar control for diabetic patients in intensive care meets the dual objectives of avoiding hypoglycemia while keeping the blood glucose concentration under 10 mmol/L (180 mg/dL). Nutrition therapy in accordance with the relevant guidelines is an indispensable pre - requisite.

A Narrative Review on the Role of AMPK on De Novo Lipogenesis in Non-Alcoholic Fatty Liver Disease: Evidence from Human Studies

5′AMP-activated protein kinase (AMPK) is known as metabolic sensor in mammalian cells that becomes activated by an increasing adenosine monophosphate (AMP)/adenosine triphosphate (ATP) ratio. The heterotrimeric AMPK protein comprises three subunits, each of which has multiple phosphorylation sites, playing an important role in the regulation of essential molecular pathways. By phosphorylation of downstream proteins and modulation of gene transcription AMPK functions as a master switch of energy homeostasis in tissues with high metabolic turnover, such as the liver, skeletal muscle, and adipose tissue. Regulation of AMPK under conditions of chronic caloric oversupply emerged as substantial research target to get deeper insight into the pathogenesis of non-alcoholic fatty liver disease (NAFLD). Evidence supporting the role of AMPK in NAFLD is mainly derived from preclinical cell culture and animal studies. Dysbalanced de novo lipogenesis has been identified as one of the key processes in NAFLD pathogenesis. Thus, the scope of this review is to provide an integrative overview of evidence, in particular from clinical studies and human samples, on the role of AMPK in the regulation of primarily de novo lipogenesis in human NAFLD.