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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [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: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Chai T, Zhuang X, Tian M, Yang X, Qiu Z, Xu S, Cai M, Lin Y, Chen L. Meta-Analysis: Shouldn't Prophylactic Corticosteroids be Administered During Cardiac Surgery with Cardiopulmonary Bypass? Front Surg 2022; 9:832205. [PMID: 35722531 PMCID: PMC9198450 DOI: 10.3389/fsurg.2022.832205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/02/2022] [Indexed: 12/04/2022] Open
Abstract
Background Corticosteroids can effectively inhibit systemic inflammation induced by cardiopulmonary bypass. Recently clinical trials and meta-analyses and current guidelines for cardiac surgery do not support corticosteroids prophylaxis during cardiac surgery because of an increase in myocardial infarction and no benefit for patients. The aim of this study is to determine whether specific corticosteroids dose ranges might provide clinical benefits without increasing myocardial infarction. Methods The PubMed, Web of Science, Embase, Clinical Trials, and Cochrane databases were searched for randomized controlled trials (RCTs) published before August 1, 2021. Results 88 RCTs with 18,416 patients (17,067 adults and 1,349 children) were identified. Relative to placebo and high-dose corticosteroids, low-dose corticosteroids (≤20 mg/kg hydrocortisone) during adult cardiac surgery did not increase the risks of myocardial infarction (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.43-2.17; p = 0.93). However, low-dose corticosteroids were associated with lower risks of atrial fibrillation (OR: 0.58, 95% CI: 0.44-0.76; p < 0.0001) and kidney injury (OR: 0.29, 95% CI: 0.09-0.96; p = 0.04). Furthermore, low-dose corticosteroids significantly shortened the mechanical ventilation times (mean difference [MD]: -2.74 h, 95% CI: -4.14, -1.33; p = 0.0001), intensive care unit (ICU) stay (MD: -1.48 days, 95% CI: -2.73, -0.22; p = 0.02), and hospital stay (MD: -2.29 days, 95% CI: -4.51, -0.07; p = 0.04). Conclusion Low-dose corticosteroids prophylaxis during cardiac surgery provided significant benefits for adult patients, without increasing the risks of myocardial infarction and other complications.
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Affiliation(s)
- Tianci Chai
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Department of anesthesiology, Xinyi People’s Hospital, Xuzhou, China
| | - Xinghui Zhuang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Mengyue Tian
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Xiaojie Yang
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhihuang Qiu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Shurong Xu
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Meiling Cai
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanjuan Lin
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
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3
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Ng KT, Van Paassen J, Langan C, Sarode DP, Arbous MS, Alston RP, Dekkers OM. The efficacy and safety of prophylactic corticosteroids for the prevention of adverse outcomes in patients undergoing heart surgery using cardiopulmonary bypass: a systematic review and meta-analysis of randomized controlled trials. Eur J Cardiothorac Surg 2020; 57:620-627. [DOI: 10.1093/ejcts/ezz325] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
Corticosteroids are often administered prophylactically to attenuate the inflammatory response associated with cardiac surgery using cardiopulmonary bypass (CPB). However, the efficacy and safety profile of corticosteroids remain uncertain. The primary aim of this systematic review and meta-analysis was to investigate the effect of corticosteroids on mortality in adult cardiac surgery using CPB. Secondary aims were to examine the effect of corticosteroids on myocardial adverse events, pulmonary adverse events, atrial fibrillation, surgical site infection, gastrointestinal bleeding and duration of stay in the intensive care unit and hospital. Randomized controlled trials (RCTs) were systematically searched in electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science) from their inception until March 2019. Observational studies, case reports, case series and literature reviews were excluded. Sixty-two studies (n = 16 457 patients) were included in this meta-analysis. There was no significant difference in mortality between the corticosteroid and placebo groups [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.81–1.14; P = 0.65, participants = 14 693, studies = 24, evidence of certainty: moderate]. Compared to those receiving a placebo, patients who were given corticosteroids had a significantly higher incidence of myocardial adverse events (OR 1.17, 95% CI 1.03–1.33; P = 0.01, participants = 14 512, studies = 23) and a lower incidence of pulmonary adverse events (OR 0.86, 95% CI 0.75–0.98; P = 0.02, participants = 13 426, studies = 17). The incidences of atrial fibrillation (OR 0.87, 95% CI 0.81–0.94; P < 0.001, participants = 14 148, studies = 24) and surgical site infection (OR 0.81, 95% CI 0.73–0.90; P < 0.001, participants = 13 946; studies = 22) were all lower in patients who were given corticosteroids. In the present meta-analysis of 62 RCTs (16 457 patients), including the 2 major RCTs (SIRS and DECS trials: 12 001 patients), we found that prophylactic corticosteroids in cardiac surgery did not reduce mortality. The clinical significance of an increase in myocardial adverse events remains unclear as the definition of a relevant myocardial end point following cardiac surgery varied greatly between RCTs.
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Affiliation(s)
- Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Judith Van Paassen
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Clare Langan
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - Deep Pramod Sarode
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - R Peter Alston
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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Sundaram S, Courtney J, Taggart D, Tweddel A, Martin W, McQuiston A, Wheatley D, Lowe G. Biocompatibility of Cardiopulmonary Bypass: Influence on Blood Compatibility of Device Type, Mode of Blood Flow and Duration of Application. Int J Artif Organs 2018. [DOI: 10.1177/039139889401700210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The biocompatibility of artificial organs is recognised as an area presenting difficulties in terms of the complexity of the situation. The nature of the blood response involving interactions of systems, pattern and extent of change, patient status and the influence of the whole device contribute to the complexity. Recognising these, the profile of the blood response to cardiopulmonary bypass (CPB), with respect to type of device, mode of blood flow, duration of the procedure and patient status, has been evaluated by monitoring contact phase activation [Factor XII-like activity (FXIIA)], fibrinolytic activity [Fibrin degradation products (X-FDP's)], complement activation (C3a, C5a), leucocyte activation [Granulocyte elastase (GE)] and platelet and white cell imaging. FXIIA, X-FDP's, and GE rose gradually during CPB, with levels remaining elevated post-operatively for up to 48 h. In contrast, C3a levels rose sharply with no significant elevation in the post-operative period, while C5a did not show significant changes during bypass. The use of pulsatile perfusion resulted in lesser activation of the parameters, although these were significantly less only for GE. The alterations in FXIIA, X-FDP's, C3a and GE correlated positively with the duration of CPB, with this effect pronounced in the post-operative period for FXIIA, X-FDP's and GE. However, these changes had no apparent influence on clinical outcome and the majority of patients had uncomplicated post-operative recoveries. With respect to the use of bubble/membrane oxygenators, platelet and white cell deposition and the patterns of change for FXIIA and C3a were similar in the two groups. The investigation has enabled a broad perspective of biocompatibility in CPB relevant to the clinical application of biomaterials.
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Affiliation(s)
- S. Sundaram
- Bioengineering Unit, University of Strathclyde, Glasgow
| | - J.M. Courtney
- Bioengineering Unit, University of Strathclyde, Glasgow
| | - D.P. Taggart
- Department of Cardiac Surgery, Royal Infirmary, University of Glasgow, Glasgow
| | - A.C. Tweddel
- Department of Cardiac Surgery, Royal Infirmary, University of Glasgow, Glasgow
| | - W. Martin
- Department of Cardiac Surgery, Royal Infirmary, University of Glasgow, Glasgow
| | - A.M. McQuiston
- Department of Cardiac Surgery, Royal Infirmary, University of Glasgow, Glasgow
| | - D.J. Wheatley
- Department of Cardiac Surgery, Royal Infirmary, University of Glasgow, Glasgow
| | - G.D.O. Lowe
- Department of Medicine, Royal Infirmary, University of Glasgow, Glasgow - U.K
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5
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Mickleborough LL, Arnold G, Chiu RCJ. Complement consumption during cardiopulmonary bypass: bubble versus membrane oxygenators. Perfusion 2016. [DOI: 10.1177/026765918600100405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to compare levels of C3 and C4 during cardiopulmonary bypass, using bubble and membrane oxygenators. In vitro studies were performed using human blood in a simple circuit involving an oxygenator, roller pump and connector tubing. In vivo studies were carried out in two separate institutions using a variety of bubble and membrane oxygenators. Samples were taken throughout the pump run (30-1 20 minutes). Complement levels were corrected for haemodilution. All oxygenators tested caused a rapid decrease in C3 and C4 complement levels on institution of bypass. The magnitude and timing of these decreases were similar in the membrane and bubble groups. Thereafter, complement levels were stable throughout the pump run. These data do not suggest that there is any difference in complement activation during relatively short pump runs using bubble and membrane oxygenators.
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Affiliation(s)
| | - George Arnold
- Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto
| | - Ray C-J Chiu
- Division of Cardiovascular Surgery, Montreal General Hospital, McGill University
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6
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Dieleman JM, van Paassen J, van Dijk D, Arbous MS, Kalkman CJ, Vandenbroucke JP, van der Heijden GJ, Dekkers OM. Prophylactic corticosteroids for cardiopulmonary bypass in adults. Cochrane Database Syst Rev 2011:CD005566. [PMID: 21563145 DOI: 10.1002/14651858.cd005566.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND High-dose prophylactic corticosteroids are often administered during cardiac surgery. Their use, however, remains controversial, as no trials are available that have been sufficiently powered to draw conclusions on their effect on major clinical outcomes. OBJECTIVES The objective of this meta-analysis was to estimate the effect of prophylactic corticosteroids in cardiac surgery on mortality, cardiac and pulmonary complications. SEARCH STRATEGY Major medical databases (CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched for randomised studies assessing the effect of corticosteroids in adult cardiac surgery. Database were searched for the full period covered, up to December 2009. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials comparing corticosteroid treatment to either placebo treatment or no treatment in adult cardiac surgery were selected. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more end-points. DATA COLLECTION AND ANALYSIS The processes of searching and selection for inclusion eligibility were performed independently by two authors. Also, quality assessment and data-extraction of selected studies were independently performed by two authors. The primary endpoints were mortality, cardiac and pulmonary complications. The main effect measure was the Peto odds ratio comparing corticosteroids to no treatment/placebo. MAIN RESULTS Fifty-four randomised studies, mostly of limited quality, were included. Altogether, 3615 patients were included in these studies. The pooled odds ratio for mortality was 1.12 (95% CI 0.65 to 1.92), showing no mortality reduction in patients treated with corticosteroids. The odds ratios for myocardial and pulmonary complications were 0.95, (95% CI 0.57 to 1.60) and 0.83 (95% CI 0.49 to 1.40), respectively. The use of a random effects model did not substantially influence study results. Analyses of secondary endpoints showed a reduction of atrial fibrillation and an increase in gastrointestinal bleeding in the corticosteroids group. AUTHORS' CONCLUSIONS This meta-analysis showed no beneficial effect of corticosteroid use on mortality, cardiac and pulmonary complications in cardiac surgery patients.
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Affiliation(s)
- Jan M Dieleman
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, PO Box 85500, mailstop: Q04.2.313, Utrecht, Netherlands, 3508 GA
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7
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Cappabianca G, Rotunno C, de Luca Tupputi Schinosa L, Ranieri VM, Paparella D. Protective effects of steroids in cardiac surgery: a meta-analysis of randomized double-blind trials. J Cardiothorac Vasc Anesth 2010; 25:156-65. [PMID: 20537923 DOI: 10.1053/j.jvca.2010.03.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Cardiac surgery and cardiopulmonary bypass (CPB) induce an acute inflammatory response contributing to postoperative morbidity. The use of steroids as anti-inflammatory agents in surgery using CPB has been tested in many trials and has been shown to have good anti-inflammatory effects but no clear clinical advantages for the lack of an adequately powered sample size. The aim of this study was to evaluate the effects of steroid treatment on mortality and morbidity after cardiac surgery. DESIGN A systematic meta-analysis of randomized double-blind trials (RDBs). SETTING A university hospital. PARTICIPANTS Adult patients who underwent cardiac surgery. MEASUREMENTS AND MAIN RESULTS A trial search was performed through PubMed and Cochrane databases from 1966 to January 2009. Among 104 clinical trials reviewed, 31 RDB trials (1,974 patients) were considered suitable to be analyzed. A quality assessment of the trials was performed using the Jadad score. The types of steroid used in these trials were methylprednisolone (51.4%), dexamethasone (34.3%), hydrocortisone (5.7%), prednisolone (2.9%), or a combination of methylprednisolone and dexamethasone (5.7%). Steroid prophylaxis provided a protective effect preventing postoperative atrial fibrillation (odds ratio = 0.56; confidence interval [CI] 0.44-0.72, p < 0.0001), reducing postoperative blood loss (mean difference = -204.2 mL; CI from -287.4 to -121 mL; p < 0.0001), and reducing intensive care unit (mean difference = -6.6 hours; CI from -10.5 to -2.7 hours, p = 0.0007) and overall hospital stay (mean difference = -0.8 days; CI from -1.4 to -0.2 days, p = 0.01). Steroid prophylaxis had no effect on postoperative mortality, mechanical ventilation duration, re-exploration for bleeding, and postoperative infection. CONCLUSIONS A systematic review of RDB trials reveals that steroid prophylaxis may reduce morbidity after cardiac surgery and does not increase the risk of postoperative infections.
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Affiliation(s)
- Giangiuseppe Cappabianca
- Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari, Bari, Italy
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8
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Carvalho EMF, Gabriel EA, Salerno TA. Pulmonary protection during cardiac surgery: systematic literature review. Asian Cardiovasc Thorac Ann 2009; 16:503-7. [PMID: 18984765 DOI: 10.1177/021849230801600617] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ischemia-reperfusion injury occurs during heart surgery in which cardiopulmonary bypass is used. Current knowledge of the factors contributing to postoperative pulmonary dysfunction and the measures to avoid it are reviewed.
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Affiliation(s)
- Enisa M F Carvalho
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida 33136, USA
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9
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Whitlock RP, Rubens FD, Young E, Teoh KH. Pro: Steroids should be used for cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2005; 19:250-4. [PMID: 15868539 DOI: 10.1053/j.jvca.2005.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Richard P Whitlock
- Division of Cardiac Surgery, McMaster University, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada.
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10
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Chong AJ, Hampton CR, Verrier ED. Microvascular Inflammatory Response in Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2003. [DOI: 10.1177/108925320300700308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac surgical procedures, with or without cardiopulmonary bypass, elicit a systemic inflammatory response in patients that induces the elaboration of multiple cytokines, chemokines, adhesion molecules, and destructive enzymes. This inflammatory reaction involves multiple interdependent and redundant cell types and humoral cascades, which allows for amplification and positive feedback at numerous steps. This systemic inflammatory response ultimately results in a broad spectrum of clinical manifestations, with multiple organ failure being the most severe form. Investigative efforts have focused on understanding the mechanism of this systemic inflammatory response syndrome in order to develop potential therapeutic targets to inhibit it, thereby possibly decreasing postoperative morbidity and mortality. Multiple therapeutic methods have been investigated, including pharmacologic inhibitors and modifications of surgical technique and the cardiopulmonary bypass circuit. Although studies have demonstrated that the use of these therapies in experimental and clinical settings has attenuated the systemic inflammatory response, they have failed to conclusively show clinical benefit from these therapies. These therapies may be too specific to minimize the deleterious effects of a systemic inflammatory response that results from the activation of multiple, interdependent, and redundant inflammatory cascades and cell types. Hence, further studies that investigate the molecular and cellular events underlying the systemic inflammatory response syndrome and the resultant effects of anti-inflammatory therapies are warranted to ultimately achieve improvements in clinical outcome after cardiac surgical procedures.
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Affiliation(s)
| | | | - Edward D. Verrier
- Division of Cardiothoracic Surgery, The University of Washington, Seattle, Washington
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11
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Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications. J Am Coll Surg 2002; 195:694-712. [PMID: 12437261 DOI: 10.1016/s1072-7515(02)01491-6] [Citation(s) in RCA: 290] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Kathrine Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, Denmark
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12
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Abstract
Postoperative lung injury is one of the most frequent complications of cardiac surgery that impacts significantly on health-care expenditures and largely has been believed to result from the use of cardiopulmonary bypass (CPB). However, recent comparative studies between conventional and off-pump coronary artery bypass grafting have indicated that CPB itself may not be the major contributor to the development of postoperative pulmonary dysfunction. In our study, we review the associated physiologic, biochemical, and histologic changes, with particular reference to the current understanding of underlying mechanisms. Intraoperative modifications aiming at limiting lung injury are discussed. The potential benefits of maintaining ventilation and pulmonary artery perfusion during CPB warrant further investigation.
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Affiliation(s)
- Calvin S H Ng
- Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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13
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Abstract
Traditionally, corticosteroids have been administered to patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) to ward off detrimental physiologic alterations associated with activation of the systemic inflammatory response, yet few well-controlled investigations exist, and use of these drugs in this setting remains controversial. This review article critically examines the results of clinical investigations in this area, and certain conclusions are suggested. The constellation of findings indicate that corticosteroids offer no clinical benefits to patients undergoing cardiac surgery with CPB and in fact may be detrimental. Further directions for clinical research in this area are also suggested.
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Affiliation(s)
- Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA.
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14
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Chaney MA, Durazo-Arvizu RA, Nikolov MP, Blakeman BP, Bakhos M. Methylprednisolone does not benefit patients undergoing coronary artery bypass grafting and early tracheal extubation. J Thorac Cardiovasc Surg 2001; 121:561-9. [PMID: 11241092 DOI: 10.1067/mtc.2001.112343] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to determine whether methylprednisolone, when administered to patients undergoing cardiac surgery, is able to ward off the detrimental hemodynamic and pulmonary alterations associated with cardiopulmonary bypass. METHODS After institutional review board approval and informed consent was obtained, 90 patients scheduled for elective cardiac surgery were randomized to 1 of 3 groups. Group 30MP patients received 30 mg/kg intravenous methylprednisolone during sternotomy and 30 mg/kg during initiation of cardiopulmonary bypass, group 15MP patients received 15 mg/kg methylprednisolone at the same 2 times, and group NS patients received similar volumes of isotonic sodium chloride solution at the same 2 times. Perioperative care was standardized, and all caregivers were blinded to treatment group. Various hemodynamic and pulmonary measurements were obtained perioperatively, as well as fluid balance, weight, peak postoperative blood glucose level, and tracheal extubation time. RESULTS Demographic and clinical characteristics of patients and intraoperative data were similar among the 3 groups. Patients receiving methylprednisolone (either dose) exhibited significantly increased cardiac index (P =.0006), significantly decreased systemic vascular resistance (P =.0005), and significantly increased shunt flow (P =.0020) during the immediate postoperative period. All 3 groups exhibited significant increases in alveolar-arterial oxygen gradient (P <.0001), significant decreases in dynamic lung compliance (P <.0001), and significant decreases in static lung compliance (P <.0001) during the immediate postoperative period, with no differences between groups. Perioperative fluid balance and weights were similar between groups. A statistically significant difference in peak postoperative blood glucose level existed (P =.016) among group NS (234 +/- 96 mg/dL), group 15MP (292 +/- 93 mg/dL), and group 30MP (311 +/- 90 mg/dL). In patients extubated within 12 hours of intensive care unit arrival, a statistically significant difference in extubation times existed (P =.025) between group NS (5.7 +/- 2.3 hours), group 15MP (5.9 +/- 2.2 hours), and group 30MP (7.5 +/- 2.7 hours). CONCLUSIONS Methylprednisolone, as used in this investigation, offers no clinical benefits to patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass and may in fact be detrimental by initiating postoperative hyperglycemia and possibly hindering early postoperative tracheal extubation for undetermined reasons.
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Affiliation(s)
- M A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Ill, USA.
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Bichel T, Rouge JC, Schlegel S, Spahr-Schopfer I, Kalangos A. Epidural sufentanil during paediatric cardiac surgery: effects on metabolic response and postoperative outcome. Paediatr Anaesth 2001; 10:609-17. [PMID: 11119193 DOI: 10.1111/j.1460-9592.2000.00557.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The metabolic and neuroendocrine effects of caudal epidural analgesia were studied during paediatric cardiac surgery. Combined epidural and general anaesthesia (EPI group; n=12) was compared with deep opioid anaesthesia (DOA group; n=12). During anaesthesia and surgery, haemodynamic stability was similar in the two groups. There was no significant difference between groups concerning the metabolic response to surgery but circulating catecholamines were significantly lower in the EPI group during and after surgery. Perioperative release of IL-6 was higher in the EPI group possibly reflecting a longer aortic clamp time. Incidence of postoperative life-threatening dysrhythmias was very low in the two groups. No significant reduction of postoperative mechanical ventilation, intensive care unit or hospital stays was reported with epidural analgesia. The incidence of postoperative infections was higher than expected in the two groups because of the poor properative clinical status of most of the children included in the study.
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Affiliation(s)
- T Bichel
- Department of Anaesthesiology, University Hospital of Geneva, Switzerland
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16
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Sauerland S, Nagelschmidt M, Mallmann P, Neugebauer EA. Risks and benefits of preoperative high dose methylprednisolone in surgical patients: a systematic review. Drug Saf 2000; 23:449-61. [PMID: 11085349 DOI: 10.2165/00002018-200023050-00007] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND A single preoperative high dose of methylprednisolone (15 to 30 mg/kg) has been advocated in surgery, because it may inhibit the surgical stress response and thereby improve postoperative outcome and convalescence. However, these potential clinical benefits must be weighed against possible adverse effects. OBJECTIVE To conduct a risk-benefit analysis using a meta-analysis, to compare complication rates and clinical advantages associated with the use of high dose methylprednisolone in surgical patients. METHODS Randomised controlled trials of high dose methylprednisolone in elective and trauma surgery were systematically searched for in various literature databases. Outcome data on adverse effects, postoperative pain and hospital stay were extracted and statistically pooled in fixed-effects meta-analyses. RESULTS We located 51 studies in elective cardiac and noncardiac surgery, as well as traumatology. Pooled data failed to show any significant increase in complication rates. In patients treated with corticosteroids, nonsignificantly more gastrointestinal bleeding and wound complications were observed; the 95% confidence interval boundaries of the numbers-needed-to-harm were 59 and 38, respectively. The only significant finding was a reduction of pulmonary complications (risk difference -3.5%; 95% confidence interval -1.0 to -6.1), mainly in trauma patients. CONCLUSION For patients undergoing surgical procedures, a perioperative single-shot administration of high dose methylprednisolone is not associated with a significant increase in the incidence of adverse effects. In patients with multiple fractures, limited evidence suggests promising benefits of glucocorticoids on pulmonary complications.
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Affiliation(s)
- S Sauerland
- 2nd Department of Surgery, University of Cologne, Germany.
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17
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Chaney MA, Nikolov MP, Blakeman BP, Bakhos M, Slogoff S. Hemodynamic effects of methylprednisolone in patients undergoing cardiac operation and early extubation. Ann Thorac Surg 1999; 67:1006-11. [PMID: 10320243 DOI: 10.1016/s0003-4975(99)00067-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Whether or not methylprednisolone is beneficial during cardiac operation remains controversial. This study examines the effects of the drug on complement activation and hemodynamics in patients undergoing cardiac operation and early extubation. METHODS Patients undergoing cardiac operation were randomized to receive either intravenous methylprednisolone (group MP) or intravenous placebo (group NS). Complement 3a (C3a) levels and hemodynamic parameters were obtained perioperatively. Extubation was accomplished at the earliest clinically appropriate time. RESULTS Both groups exhibited equivalent increases in C3a levels after exposure to bypass. Group MP exhibited increased cardiac index, decreased systemic vascular resistance, and increased shunt flow when compared to group NS. More group MP patients required hemodynamic support and group MP patients had prolonged extubation times. CONCLUSIONS Methylprednisolone was unable to attenuate complement activation and led to hemodynamic alterations (primarily vasodilation) that may hinder early extubation in patients after cardiac operations.
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Affiliation(s)
- M A Chaney
- Department of Anesthesiology, Loyola University Medical Center, Foster G. McGaw Hospital, Maywood, Illinois 60153, USA
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18
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Lodge AJ, Chai PJ, Daggett CW, Ungerleider RM, Jaggers J. Methylprednisolone reduces the inflammatory response to cardiopulmonary bypass in neonatal piglets: timing of dose is important. J Thorac Cardiovasc Surg 1999; 117:515-22. [PMID: 10047655 DOI: 10.1016/s0022-5223(99)70331-4] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Cardiopulmonary bypass produces an inflammatory response that can cause significant postoperative pulmonary dysfunction and total body edema. This study evaluates the efficacy of preoperative methylprednisolone administration in limiting this injury in neonates and compares the effect of giving methylprednisolone 8 hours before an operation to the common practice of adding methylprednisolone to the cardiopulmonary bypass circuit prime. METHODS A control group of neonatal pigs (control; n = 6) received no preoperative medication. One experimental group (n = 6) received methylprednisolone sodium succinate (30 mg/kg) both 8 and 1.5 hours before the operation. A second experimental group received no preoperative treatment, but methylprednisolone (30 mg/kg) was added to the cardiopulmonary bypass circuit prime. All animals underwent cardiopulmonary bypass and 45 minutes of deep hypothermic circulatory arrest. Hemodynamic and pulmonary function data were acquired before cardiopulmonary bypass and at 30 and 60 minutes after bypass. RESULTS In the control group, pulmonary compliance, alveolar-arterial gradient, and pulmonary vascular resistance were significantly impaired after bypass (P <.01 for each by analysis of variance). In the group that received methylprednisolone, compliance (P =.02), alveolar-arterial gradient (P =.0003), pulmonary vascular resistance (P =.007), and extracellular fluid accumulation (P =.003) were significantly better after bypass when compared with the control group. Results for the group that received no preoperative treatment fell between the control group and the group that received methylprednisolone. CONCLUSIONS When given 8 hours and immediately before the operation, methylprednisolone improves pulmonary compliance after bypass, alveolar-arterial gradient, and pulmonary vascular resistance compared with no treatment. The addition of methylprednisolone to the cardiopulmonary bypass circuit prime is beneficial but inferior to preoperative administration.
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Affiliation(s)
- A J Lodge
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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19
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Pulmonary Effects of Methylprednisolone in Patients Undergoing Coronary Artery Bypass Grafting and Early Tracheal Extubation. Anesth Analg 1998. [DOI: 10.1213/00000539-199807000-00007] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Chaney MA, Nikolov MP, Blakeman B, Bakhos M, Slogoff S. Pulmonary effects of methylprednisolone in patients undergoing coronary artery bypass grafting and early tracheal extubation. Anesth Analg 1998; 87:27-33. [PMID: 9661540 DOI: 10.1097/00000539-199807000-00007] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Numerous clinical studies suggest that methylprednisolone may facilitate early tracheal extubation after cardiac surgery, yet no investigation has rigorously examined the use of the drug in this setting. In this prospective, randomized, double-blind, placebo-controlled study, we examined the pulmonary effects of methylprednisolone in patients undergoing coronary artery bypass grafting (CABG) and early tracheal extubation. Sixty patients undergoing elective CABG and early tracheal extubation were randomized into two groups. Group MP patients received i.v. methylprednisolone (30 mg/kg during sternotomy and 30 mg/kg during initiation of cardiopulmonary bypass) and Group NS patients received i.v. placebo at the same two times. Perioperative management was standardized. Alveolar-arterial (A-a) oxygen gradient, lung compliance, shunt, and dead space were determined four times perioperatively. Postoperative tracheal extubation was accomplished at the earliest appropriate time. Both groups exhibited significant postoperative increases in A-a oxygen gradient and shunt (P < 0.000001 for each group) and significant postoperative decreases in dynamic lung compliance (P < 0.000001 for each group). Patients in Group MP exhibited significantly larger increases in postoperative A-a oxygen gradient (P = 0.001) and shunt (P = 0.001) compared with patients in Group NS. Postoperative alterations in dynamic lung compliance, static lung compliance, and dead space were not statistically significant between the groups. The time to postoperative tracheal extubation was prolonged in Group MP patients compared with Group NS patients (769 +/- 294 vs 604 +/- 315 min, respectively; P = 0.05). Methylprednisolone was associated with larger increases in postoperative A-a oxygen gradient and shunt, was unable to prevent postoperative decreases in lung compliance, and prolonged extubation time, which indicate that use of the drug may hinder early tracheal extubation in patients after cardiac surgery. IMPLICATIONS Traditionally, methylprednisolone has been administered to patients undergoing cardiac surgery to decrease postoperative pulmonary dysfunction. This study revealed that the drug is associated with larger increases in postoperative alveolar-arterial oxygen gradient and shunt and prolonged tracheal extubation time in patients undergoing coronary artery bypass grafting, which indicate that use of the drug may hinder early tracheal extubation.
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Affiliation(s)
- M A Chaney
- Department of Anesthesiology, Loyola University Medical Center, Foster G. McGaw Hospital, Maywood, Illinois 60153, USA
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Andresen B, Loebe M, Friedel N, Harke C, Ullmann H, Hetzer R. Verlauf von Elastase, Komplementfaktor C3a und Endotoxin bei Patienten mit mechanischen extrakorporalen Kreislaufunterstützungssystemen Typ Berlin Heart. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 1997. [DOI: 10.1007/bf03042632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
During cardiac surgery, steroids are frequently administered before the initiation of cardiopulmonary bypass (CPB), termed "pre-treatment," to reduce "first phase" complement activation during cardiopulmonary bypass (CPB). "Second phase" complement activation also occurs during heparin neutralization with protamine, although the effects of steroid pretreatment on such activation are unknown. This study was performed in patients undergoing coronary artery bypass graft surgery to determine whether high-dose methylprednisolone pretreatment affected complement activation during heparin-protamine interaction after termination of CPB. In eight patients (group MP), methylprednisolone, 30 mg/kg, was administered before CPB commencement, whereas another eight patients received placebo (group C). By using 125I des Arg radioimmunoassay, C3a, C4a, and C5a were measured in the arterial blood samples drawn before and 10 min after administration of protamine. An increase in C3a and C4a was observed in both groups after protamine, suggesting classic pathway activation (delta C3a: group C, 4,484 +/- 3,320; group MP, 1,394 +/- 1,653; delta C4a: group C, 1,810 +/- 731; group MP, 717 +/- 580). C3a and C4a levels were significantly lower in group MP patients after protamine compared with controls [delta C3a, 3,499 +/- 1,826 (p < 0.05); delta C4a, 1,241 +/- 232 (p < 0.05)]. C5a was not detected in any samples. These results demonstrate that the effect of pretreatment persists beyond the period of CPB and that methylprednisolone inhibits second-phase complement activation during heparin-protamine interaction. These findings have implication for patients with severe anaphylactoid reactions to protamine.
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Affiliation(s)
- P G Loubser
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
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23
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Jorens PG, De Jongh R, De Backer W, Van Damme J, Van Overveld F, Bossaert L, Walter P, Herman AG, Rampart M. Interleukin-8 production in patients undergoing cardiopulmonary bypass. The influence of pretreatment with methylprednisolone. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1993; 148:890-5. [PMID: 8214944 DOI: 10.1164/ajrccm/148.4_pt_1.890] [Citation(s) in RCA: 90] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pulmonary dysfunction caused by pulmonary neutrophil sequestration is a frequent postoperative complication in patients undergoing cardiopulmonary bypass (CPB) surgery. It is yet unclear whether treatment with corticosteroids in vivo in these patients can prevent complement-mediated neutrophil activation and sequestration in the lungs. Therefore, we conducted a prospective study in order to investigate whether methylprednisolone (MP) pretreatment (30 mg/kg) could influence the appearance of IL-8 (a recently discovered cytokine with potent neutrophil-chemotactic activity) in the peripheral circulation. We also studied the effects of MP pretreatment on the inflammatory parameters in the bronchoalveolar lavage (BAL) fluid 4 h postoperatively. Although peripheral neutropenia and the rise in IL-8 serum levels was less pronounced in MP-treated than in non-steroid-treated patients, there was no significant difference in albumin, total protein, concentrations of IL-8 and C3a, and the number of neutrophils in the BAL fluid between the two groups. However, when cultured in vitro, alveolar macrophages from patients treated with MP released significantly lower IL-8, both in basal conditions and after stimulation with lipopolysaccharide. Our results show that MP does not prevent (IL-8-mediated) pulmonary neutrophil infiltration after CPB, although it might affect certain aspects of the microvascular lung injury.
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Affiliation(s)
- P G Jorens
- Division of Respiratory Medicine, University of Antwerp, Wilrijk, Belgium
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24
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Overveld FJ, Jongh RF, Jorens PG, Walter P, Bossaert L, Backer WA. Histamine and tryptase in serum of patients after coronary surgery: influence of pretreatment with methylprednisolone. Inflamm Res 1993. [DOI: 10.1007/bf01996485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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25
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Tulunay M, Demiralp S, Tastan S, Akalin H, Ozyurda U, Corapcioglu T, Akarsu ES. Complement (C3, C4) and C-reactive protein responses to cardiopulmonary bypass and protamine administration. Anaesth Intensive Care 1993; 21:50-5. [PMID: 8447607 DOI: 10.1177/0310057x9302100113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Complement activation has been deemed responsible for the damaging effects of cardiopulmonary bypass (CPB) in patients undergoing open heart surgery. We studied C3, C4 and C-reactive protein (CRP) in 22 patients undergoing CPB. In Group 1 (11 patients), protamine was given intravenously and in Group 2 (11 patients), via the aortic root after CPB. Significant decreases were observed in C3 and C4 during CPB in both groups indicating complement activation primarily by the classic pathway. Protamine did not lead to further activation of the complement system. In both groups, C3 levels gradually returned toward baseline within 24 hours but C4 levels were still lower than baseline 24 hours postoperatively. CPB and protamine administration did not cause any significant changes in CRP levels, but CRP increased abruptly 24 hours after operation. Although activation of complement system during CPB is expected to invoke an acute phase response, we conclude that this period is not long enough to induce an increased production of CRP in response to tissue injury or inflammation.
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Affiliation(s)
- M Tulunay
- Department of Anaesthesiology, Ibn-i Sina Hospital, University of Ankara, Turkey
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26
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De Jongh RF, De Backer WA, Mohan R, Jorens PG, van Overveld FJ. Angiotensin-converting enzyme activity in serum and bronchoalveolar lavage fluid after damage to the alveolo-capillary barrier in the human lung. Intensive Care Med 1993; 19:390-4. [PMID: 8270718 PMCID: PMC7095338 DOI: 10.1007/bf01724878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Angiotensin-converting enzyme (ACE) is considered as a possible marker for endothelial cell damage in serum or bronchoalveolar lavage fluid. This hypothesis was tested during cardiac surgery and during the adult respiratory distress syndrome. DESIGN We used patients with an expected different degree of endothelial cell damage. ACE levels in serum and bronchoalveolar lavage fluid were compared with indirect markers of alveolo-capillary barrier integrity. SETTING Interdisciplinary team in a university hospital. METHODS 13 Cardiac surgery patients received no glucocorticoids and 13 others received 2 g methylprednisolone before extracorporeal circulation. Thirteen patients were used as controls and 15 patients had nonseptic adult respiratory distress syndrome. All underwent bronchoalveolar lavage for ACE determination. RESULTS At different times during surgery serum angiotensin-converting enzyme levels were not significantly different between the two groups. In post-operative bronchoalveolar lavage fluid, angiotensin-converting enzyme levels were significantly higher in patients who received corticoids (27.8 +/- 1.7 U/l, mean +/- SEM), compared to patients without corticoids (19.8 +/- 1.4 U/l), control patients (18.2 +/- 1.3 U/l) or patients with full blown non-septic adult respiratory distress syndrome (18.8 +/- 1.1 U/l). There were no correlations between lavage angiotensin-converting enzyme and other parameters for alveolo-capillary membrane integrity in the lavage fluid such as the number of neutrophil cells, albumin or protein concentration, and between lavage angiotensin-converting enzyme and PaO2/FIO2 ratio during lavage. CONCLUSION Angiotensin-converting enzyme activity in serum or bronchoalveolar lavage fluid does not reflect damage of endothelial cells or damage of alveolocapillary integrity in acute pulmonary disease.
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Affiliation(s)
- R F De Jongh
- Department of Anesthesiology, Sint Jansziekenhuis, Genk, Belgium
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27
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Wakefield TW, Kirsh MM, Till GO, Brothers TE, Hantler CB, Stanley JC. Absence of complement-mediated events after protamine reversal of heparin anticoagulation. J Surg Res 1991; 51:72-6. [PMID: 2067362 DOI: 10.1016/0022-4804(91)90072-t] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Protamine reversal of heparin anticoagulation is associated with adverse hemodynamic effects that may be attenuated with protamine pretreatment (PP). This study assesses the role of complement activation during these phenomena in adult cardiac surgery patients. Sixteen individuals undergoing cardiopulmonary bypass were given intravenous normal saline or protamine (2 mg/kg) as a randomized pretreatment prior to undergoing heparin anticoagulation (400 IU/kg), coronary artery revascularization, and subsequent reversal of the anticoagulated state with protamine (4 mg/kg). Blood pressure, pulmonary artery diastolic pressure (PAD), heart rate, and cardiac output (CO) were measured during and after pretreatment, prior to heparin reversal by protamine, and for 10 min after reversal. Total hemolytic complement (CH50), C3 conversion to C3b, C3a/C5a, platelet count, and white blood cell count (WBC) were also measured at the same time periods. No significant correlation existed between complement activation and hemodynamic events, as might have been evident by decreased CH50, increased C3 conversion to C3b, or elevations in C3a/C5a levels. PP significantly prevented the CO decrease occurring at 1 and 3 min following heparin reversal by protamine (-0.8 and -1.4 liters/min vs 0.1 and -0.2 liters/min, P less than 0.05 and P less than 0.01, respectively). Reversal hypotension was less with PP, although PAD fell equally in both groups. WBC decreases after heparin reversal were less after PP (-25% vs -7%, P = 0.06). These data support the conclusion that, contrary to earlier reports, adverse hemodynamic and hematologic responses accompanying protamine reversal of heparin anticoagulation do not appear to be correlated with activation of complement. In fact, those patients having the greatest C3a generation exhibited the least hemodynamic changes.
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Affiliation(s)
- T W Wakefield
- Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109
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Abstract
Hypocomplementemia is an important marker for the presence of IC-mediated disease and can be used to assess disease activity. However, in interpreting the clinical significance of hypocomplementemia, the following must be kept in mind: 1) There are numerous non-immunologic conditions that also can cause hypocomplementemia. Furthermore, some of these conditions can cause a multisystem disease that, along with the hypocomplementemia, can closely resemble an IC-mediated systemic vasculitis. Furthermore, these nonimmunologic conditions that lower serum complement levels can complicate the course of patients with inactive IC-mediated disease, spuriously indicating that the disease is active. The most relevant of these differential diagnostic problems are listed in Table 2. 2) There are a few conditions (for example, pregnancy) that can raise serum complement levels, thereby possibly obscuring the presence of a disorder (such as, active SLE) that is lowering complement levels. 3) There are some conditions that might be expected to lower serum complement levels, because of their effect on protein metabolism, but do not. Nephrotic syndrome, and moderately poor nutrition are examples. All of these factors should be considered when interpreting results of serum complement levels in a given patient.
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Bonser RS, Dave JR, Davies ET, John L, Taylor P, Gaya H, Lennox SC, Vergani D. Reduction of complement activation during bypass by prime manipulation. Ann Thorac Surg 1990; 49:279-83. [PMID: 2306150 DOI: 10.1016/0003-4975(90)90150-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Complement activation is believed to be of importance in the development of complications arising after cardiopulmonary bypass. The effect on complement activation of priming the extracorporeal circuit with crystalloid alone, crystalloid plus albumin, or crystalloid plus the plasma expander polygeline was assessed in 36 patients undergoing coronary artery operations with cardiopulmonary bypass using a bubble oxygenator. Activation of the alternative and common complement pathways was monitored before, during, and after the bypass period by measuring concentrations of factor B and its fragment Ba and C3 and its fragment C3d. Complement activation occurred in all three groups of patients, with no difference between the crystalloid and crystalloid-albumin groups. In contrast, Ba fragment concentrations were persistently and significantly lower during and after bypass in the polygeline group, denoting reduced complement activation. C3d levels also showed a tendency to be lower in this group. Our results indicate that addition of polygeline to the priming solution reduces complement activation. Because complement activation is associated with morbidity after cardiopulmonary bypass, addition of polygeline to the priming solution may offer an inexpensive method of reducing morbidity after cardiopulmonary bypass.
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Affiliation(s)
- R S Bonser
- Department of Surgery, Brompton Hospital, London, England
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31
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Andersen LW, Baek L, Thomsen BS, Rasmussen JP. Effect of methylprednisolone on endotoxemia and complement activation during cardiac surgery. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1989; 3:544-9. [PMID: 2520931 DOI: 10.1016/0888-6296(89)90150-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The influence of high doses of methylprednisolone on complement activation and endotoxin concentration was investigated in two groups of eight patients undergoing coronary artery bypass grafting. Group 1 received methylprednisolone, 30 mg/kg, at the induction of anesthesia; group 2 served as the control group. The endotoxin concentrations increased significantly in both groups at the start of cardiopulmonary bypass. During cardiopulmonary bypass, the endotoxin concentrations were significantly higher in the steroid group compared with the control group (p less than 0.01). After completion of surgery, the endotoxin concentrations declined to almost zero within seven days in both groups. Complement activation was significantly reduced in the steroid-treated group during cardiopulmonary bypass compared with the control group (P less than 0.01). The clinical outcome after the first postoperative week was the same in the two groups. It appears that high-dose steroids can reduce complement activation during cardiopulmonary bypass, although the clearance of endotoxins may also be reduced.
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Affiliation(s)
- L W Andersen
- Department of Anesthesia, Gentofte Hospital, Copenhagen, Denmark
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Miyamoto Y, Matsuda H, Kawashima Y. Deleterious effects of complement activation on the lungs during extracorporeal circulation and its inhibition by FUT-175. J Biomater Appl 1989; 4:56-68. [PMID: 2664117 DOI: 10.1177/088532828900400104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The purpose of this paper is to review the deleterious effects of complement activation during extracorporeal circulation on the lungs and to discuss the feasibility of FUT-175, a new synthetic protease inhibitor, as a complement activation inhibitor. Complement activation causes leukocyte aggregation and aggregated leukocytes behave as microemboli in the pulmonary vessels. Anaphylatoxins produced by complement activation have potent vasoactive properties and many chemical mediators are also released from leukocytes. FUT-175 might be effective to inhibit complement activation during cardiopulmonary bypass (CPB). Although deleterious effects of CPB on the lungs are multifactorial, we hypothesize that complement activation may play a major role in lung injury during CPB.
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Affiliation(s)
- Y Miyamoto
- First Department of Surgery, Osaka University Medical School, Japan
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Sanders EA, Yewdall VM, Hughes RA, Cameron JS. Absence of complement activation in demyelinating polyradiculoneuropathies. Ann Neurol 1988; 23:102-3. [PMID: 3345064 DOI: 10.1002/ana.410230123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Dalmasso AP. Complement in the pathophysiology and diagnosis of human diseases. Crit Rev Clin Lab Sci 1986; 24:123-83. [PMID: 2971510 DOI: 10.3109/10408368609110272] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Complement is a humoral effector system composed of 21 plasma proteins that was identified initially because of its cytolytic effects. In addition to cytolysis, complement has a number of different functions related to inflammatory and other host defense processes. The description of the reaction mechanism includes: (1) activation of the classical pathway through recognition of IgG and IgM antibodies by C1q, (2) activation of the alternative pathway which is usually achieved without participation of immunoglobulins, (3) generation of proteolytic enzymes composed of heteropolymers that cleave certain precursor proteins, (4) formation of the membrane attack complex (MAC), and (5) participation of control mechanisms. Methodologies for studying protein concentration and functional activities of complement components include not only the classical hemolytic techniques but also the extremely sensitive new radioimmunoassays and enzyme immunoassays for measuring the products of complement activation that are generated in vivo. Examples of genetically controlled complement deficiencies have been published for most complement components. The symptomatology of some of these patients serves to emphasize the protective role of complement. Acquired deficiencies are significant not only as laboratory aids in diagnosis and to evaluate the course of certain diseases, but also to indicate possible pathogenic disease mechanisms. Recently, it has been recognized that the complement proteins with genes located in the HLA region are polymorphic. Certain variants of proteins C2, C4, and factor B occur with higher frequencies in certain diseases than in the general population, which appears to be of great practical importance in laboratory medicine.
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Affiliation(s)
- A P Dalmasso
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
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Collett B, Alhaq A, Abdullah NB, Korjtsas L, Ware RJ, Dodd NJ, Alimo E, Ponte J, Vergani D. Pathways to complement activation during cardiopulmonary bypass. BRITISH MEDICAL JOURNAL 1984; 289:1251-4. [PMID: 6437506 PMCID: PMC1443480 DOI: 10.1136/bmj.289.6454.1251] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Complement activation was assessed in 34 patients undergoing cardiopulmonary bypass. Arterial concentrations of complement fragments Ba and C3d rose in all patients, the increase in Ba preceding that of C3d. At the same time as complement fragments were being generated the arterial neutrophil count fell. These findings suggest (a) that complement activation is initiated by the alternative pathway during cardiopulmonary bypass and (b) that complement activation mediates loss of neutrophils during bypass. Complement mediated loss of neutrophils during the analogous setting of haemodialysis is the result of leucosequestration in the pulmonary vasculature. During cardiopulmonary bypass the lungs are out of circuit, so that activated leucocytes may sequester in other target organs. This may be an aetiological factor in the multi-organ failure occasionally seen after uneventful cardiopulmonary bypass.
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