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Pratomo BY, Sudadi S, Setianto BY, Novenanto TT, Raksawardana YK, Rayhan A, Kurniawaty J. Intraoperative Goal-Directed Perfusion in Cardiac Surgery with Cardiopulmonary Bypass: The Roles of Delivery Oxygen Index and Cardiac Index. Ann Thorac Cardiovasc Surg 2024; 30:23-00189. [PMID: 38684395 PMCID: PMC11082497 DOI: 10.5761/atcs.ra.23-00188] [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: 10/24/2023] [Accepted: 04/01/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE Goal-directed perfusion (GDP) refers to individualized goal-directed therapy using comprehensive monitoring and optimizing the delivery of oxygen during cardiopulmonary bypass (CPB). This study aims to determine whether the intraoperative GDP protocol method has better outcomes compared to conventional methods. METHODS We searched the PubMed, Central, and Scopus databases up to October 12, 2023. We primarily examined the GDP protocol in adult cardiac surgery, using CPB with oxygen delivery index (DO2I) and cardiac index (CI) as the main parameters. RESULTS In all, 1128 participants from seven studies were included in our analysis. The results showed significant differences in the duration of intensive care unit (ICU) stays (p = 0.01), with a mean difference of -0.33 (-0.59 to 0.07), and hospital length of stay (LOS) (p = 0.0002), with a mean difference of -0.84 (-1.29 to -0.39). There was also a notable reduction in postoperative complications (p <0.00001), odds ratio (OR) of 0.43 (0.32-0.60). However, there was no significant decrease in mortality rate (p = 0.54), OR of 0.77 (0.34-1.77). CONCLUSION Postoperative acute kidney injury and ICU and hospital LOS are significantly reduced when GDP protocols with indicators of flow management, oxygen delivery index, and CI are used in intraoperative cardiac surgery using CPB.
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Affiliation(s)
- Bhirowo Yudo Pratomo
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Sudadi Sudadi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Budi Yuli Setianto
- Department of Cardiology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Tandean Tommy Novenanto
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | | | - Amar Rayhan
- Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Juni Kurniawaty
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
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Fleseriu CM, Sultan I, Brown JA, Mina A, Frenchman J, Crammond DJ, Balzer J, Anetakis KM, Subramaniam K, Shandal V, Navid F, Thirumala PD. Role of Intraoperative Neurophysiological Monitoring in Preventing Stroke After Cardiac Surgery. Ann Thorac Surg 2023; 116:623-629. [PMID: 36634835 DOI: 10.1016/j.athoracsur.2023.01.004] [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: 07/12/2022] [Revised: 12/09/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Perioperative stroke after cardiac surgical procedures carries significant morbidity. Dual intraoperative neurophysiological monitoring with electroencephalography (EEG) and somatosensory-evoked potentials detects cerebral hypoperfusion and predicts postoperative stroke in noncardiac procedures. We further evaluated preoperative risk factors and intraoperative neuromonitoring ability to predict postoperative stroke after cardiac operations. METHODS All patients who underwent cardiac operations with intraoperative neurophysiological monitoring from 2009 to 2020 at a single academic medical center were retrospectively analyzed. Patients with circulatory arrest were excluded. Risks factors analyzed were sex, age, tobacco use, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, prior cerebrovascular accident, cerebrovascular disease, antiplatelet/anticoagulant use, abnormal somatosensory-evoked potentials and EEG baselines, and significant somatosensory-evoked potentials and EEG change as well as their permanence. Patients were divided into 2 groups by 30-day postoperative stroke occurrence. Univariate and multivariate logistical regressions were used for postoperative stroke significant predictors, and Kaplan-Meier curves estimated survival. RESULTS The study included 620 patients (67.6% men), mean age 65.1 ± 14.1 years, with stroke in 5.32%. In univariate analysis, diabetes (odds ratio [OR], 2.62) and permanence of EEG change (OR, 5.35) were each associated with increased postoperative stroke odds. In multivariate analysis, diabetes (OR, 2.64) and permanent EEG change (OR, 4.22) were independently significantly associated with postoperative stroke. Overall survival was significantly better for patients with no intraoperative neurophysiological monitoring changes (P < .005). CONCLUSIONS Permanent EEG change and diabetes were significant postoperative stroke predictors in cardiac operations. Furthermore, overall survival out to 10 years postoperatively was significantly higher in the group without intraoperative neurophysiological monitoring changes, emphasizing its important predictive role.
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Affiliation(s)
- Cara M Fleseriu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amir Mina
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Frenchman
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey Balzer
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katherine M Anetakis
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Varun Shandal
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Parthasarathy D Thirumala
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Weld J, Kim E, Chandra P, Savorgnan F, Acosta S, Flores S, Loomba RS. Fluid Overload and AKI After the Norwood Operation: The Correlation and Characterization of Routine Clinical Markers. Pediatr Cardiol 2023:10.1007/s00246-023-03167-0. [PMID: 37129600 DOI: 10.1007/s00246-023-03167-0] [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: 05/24/2022] [Accepted: 04/16/2023] [Indexed: 05/03/2023]
Abstract
The purpose of this study was to determine the correlation of different methods of assessing fluid overload and determine which metrics are associated with development of acute kidney injury (AKI) in the period immediately following Norwood palliation. This was a retrospective single-center study of Norwood patients from January 2011 through January 2021. AKI was defined using the Kidney Disease Improving Global Outcomes (KDIGO). Patients were separated into two groups: those with AKI and those without. A logistic regression analysis was conducted with AKI at any point in the study period as the dependent variable and clinical and laboratory data as independent variables. Analysis was conducted as a stepwise regression. The coefficients from the logistic regression were then used to develop a cumulative AKI risk score. Spearman correlations were conducted to analyze the correlation of fluid markers. 116 patients were included, and 49 (42.4%) developed AKI. The duration of open chest, duration of mechanical ventilation, need for dialysis, need for extracorporeal membrane oxygenation, and inpatient mortality were associated with AKI (p ≤ 0.05). Stepwise logistic regression demonstrated the following significant independent associations AKI: age at Norwood in days (p < 0.01), blood urea nitrogen (p < 0.01), central venous pressure (p = 0.04), and renal oxygen extraction ratio (p < 0.01). The area under the receiver operating characteristic curve for the logistic regression was 0.74. The fluid markers had weak R-value. Urea, central venous pressure, and renal oxygen extraction ratio are associated with AKI after the Norwood operation. Common clinical metrics used to assess fluid overload are poorly correlated with each other for postoperative Norwood patients.
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Affiliation(s)
- Julia Weld
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA.
| | - Erin Kim
- Division of Nephrology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Priya Chandra
- Division of Nephrology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Fabio Savorgnan
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Sebastian Acosta
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Saul Flores
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Rohit S Loomba
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
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Condello I, Santarpino G, Nasso G, Moscarelli M, Speziale G, Lorusso R. 'Goal-directed extracorporeal circulation: transferring the knowledge and experience from daily cardiac surgery to extracorporeal membrane oxygenation'. Perfusion 2023; 38:449-454. [PMID: 34927474 DOI: 10.1177/02676591211063826] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Metabolism management plays an essential role in extracorporeal technologies. There are different metabolic management devices integrated to extracorporeal devices; the most commonly used and accepted metabolic target in adult patients is indexed oxygen delivery (280 mL/min/m2) and cardiac index (2.4 L/min/m2), which can be managed independently or according to other metabolic parameters. Extracorporeal membrane oxygenation (ECMO) is a temporary form of life support providing a prolonged biventricular circulatory and pulmonary support for patients experiencing both pulmonary and cardiac failure unresponsive to conventional therapy. The goal-directed perfusion initiative during cardiopulmonary bypass (CPB) reduced the incidence of acute kidney injury after cardiac surgery. On the basis of the available literature, the identified goals to achieve during CPB include maintenance of oxygen delivery > 300 mL O2/min/m2 and reduction in vasopressor use. ECMO and CPB are conceptually similar but differ in many aspects and finality; in particular, they differ in the scientific evidence for metabolic management nadirs. As for CPB, predictive target parameters have been found and consolidated, particularly in terms of acute renal injury and the prevention of anaerobic metabolism, while for ECMO management, a blurred path remains. In this context, we review the strategies for optimal goal-directed therapy during CPB and ECMO, trying to transfer the knowledge and experience from daily cardiac surgery to veno-arterial ECMO.
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Affiliation(s)
- Ignazio Condello
- Department of Cardiac Surgery, 46804Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, 46804Anthea Hospital, GVM Care & Research, Bari, Italy.,Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany.,Cardiac Surgery Unit, Department of Experimental and Clinical Medicine-University "Magna Graecia" of Catanzaro, Bari, Italy
| | - Giuseppe Nasso
- Department of Cardiac Surgery, 46804Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Marco Moscarelli
- Department of Cardiac Surgery, 46804Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Giuseppe Speziale
- Department of Cardiac Surgery, 46804Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, 199236Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Commentary: Goal-directed perfusion in pediatric heart surgery. J Thorac Cardiovasc Surg 2023; 165:1517-1518. [PMID: 35963798 DOI: 10.1016/j.jtcvs.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/21/2022]
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Hayward A, Robertson A, Thiruchelvam T, Broadhead M, Tsang VT, Sebire NJ, Issitt RW. Oxygen delivery in pediatric cardiac surgery and its association with acute kidney injury using machine learning. J Thorac Cardiovasc Surg 2023; 165:1505-1516. [PMID: 35840430 DOI: 10.1016/j.jtcvs.2022.05.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 05/05/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) after pediatric cardiac surgery with cardiopulmonary bypass (CPB) is a frequently reported complication. In this study we aimed to determine the oxygen delivery indexed to body surface area (Do2i) threshold associated with postoperative AKI in pediatric patients during CPB, and whether it remains clinically important in the context of other known independent risk factors. METHODS A single-institution, retrospective study, encompassing 396 pediatric patients, who underwent heart surgery between April 2019 and April 2021 was undertaken. Time spent below Do2i thresholds were compared to determine the critical value for all stages of AKI occurring within 48 hours of surgery. Do2i threshold was then included in a classification analysis with known risk factors including nephrotoxic drug usage, surgical complexity, intraoperative data, comorbidities and ventricular function data, and vasoactive inotrope requirement to determine Do2i predictive importance. RESULTS Logistic regression models showed cumulative time spent below a Do2i value of 350 mL/min/m2 was associated with AKI. Random forest models, incorporating established risk factors, showed Do2i threshold still maintained predictive importance. Patients who developed post-CPB AKI were younger, had longer CPB and ischemic times, and required higher inotrope support postsurgery. CONCLUSIONS The present data support previous findings that Do2i during CPB is an independent risk factor for AKI development in pediatric patients. Furthermore, the data support previous suggestions of a higher threshold value in children compared with that in adults and indicate that adjustments in Do2i management might reduce incidence of postoperative AKI in the pediatric cardiac surgery population.
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Affiliation(s)
- Alice Hayward
- Department of Perfusion, Great Ormond Street Hospital, London, United Kingdom
| | - Alex Robertson
- Department of Perfusion, Great Ormond Street Hospital, London, United Kingdom
| | - Timothy Thiruchelvam
- Department of Intensive Care, Great Ormond Street Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Michael Broadhead
- Department of Anesthetics, Great Ormond Street Hospital, London, United Kingdom
| | - Victor T Tsang
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Neil J Sebire
- Digital Research, Informatics and Virtual Environment, NIHR Great Ormond Street Hospital BRC, London, United Kingdom
| | - Richard W Issitt
- Department of Perfusion, Great Ormond Street Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom; Digital Research, Informatics and Virtual Environment, NIHR Great Ormond Street Hospital BRC, London, United Kingdom.
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Saleem Y, Darbari A, Sharma R, Vashisth A, Gupta A. Recent advancements in pediatric cardiopulmonary bypass technology for better outcomes of pediatric cardiac surgery. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00084-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pediatric cardiac surgery is in itself very enigmatic and individualized. Presently, there has been a slew of new developments aimed primarily toward pediatric cardiopulmonary bypass for safer, patient-centered pediatric cardiac surgery. Still, lot of technological challenges need to be resolved, and their safer application in pediatric and neonate patients requires further refinement.
Main body of the abstract
Considering various significant yet unresolved issues of pediatric cardiac bypass, an exhaustive literature search was done on various internet databases with standard keywords. There are various new recent improvements; as the first oxygenator explicitly designed for neonatal patients; pediatric oxygenators with low prime volumes and surface areas that allow flows up to 2 L/min; pediatric oxygenators with integrated arterial filters; and miniature ultrafiltration devices that allow for high rates of ultrafiltrate removal. These advancements can significantly reduce cardiopulmonary bypass circuit surface areas and prime volumes. These advancements could reduce or eliminate the requirement for homologous red blood cells during or after surgery with reduction or eliminate bypass-related hemodilution, and inflammation. Because of the immaturity of the neonatal hemostatic system, conventional coagulation tests alone are insufficient to guide neonatal hemostatic therapy. Myocardial preservation techniques, safe temperature with duration are still debatable and yet to be fully explored.
Short conclusion
This review is based on Standards for Quality Improvement Reporting Excellence guidelines to provide a framework for reporting new knowledge to find better management strategy for pediatric cardiac cases.
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Zhang Y, Zhou RH. Time for Pediatric Goal Directed Perfusion: An Accepted Target for Infants. Ann Thorac Surg 2021; 113:1053-1054. [PMID: 33939969 DOI: 10.1016/j.athoracsur.2021.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/18/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Yan Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guoxue Xiang, Wu Hou District, Chengdu, Sichuan 610041, China
| | - Rong-Hua Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guoxue Xiang, Wu Hou District, Chengdu, Sichuan 610041, China.
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Gao P, Liu J. Pediatric Goal Directed Perfusion: Is There a General Target?. Ann Thorac Surg 2021; 113:1052-1053. [PMID: 33737043 DOI: 10.1016/j.athoracsur.2021.02.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/20/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Peng Gao
- Department of Cardiopulmonary Bypass, Fuwai Hospital State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College.
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