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Association between anion gap and mortality of aortic aneurysm in intensive care unit after open surgery. BMC Cardiovasc Disord 2021; 21:458. [PMID: 34556051 PMCID: PMC8459533 DOI: 10.1186/s12872-021-02263-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/03/2021] [Indexed: 01/16/2023] Open
Abstract
Background There has not been a well-accepted prognostic model to predict the mortality of aortic aneurysm patients in intensive care unit after open surgery repair. Otherwise, our previous study found that anion gap was a prognosis factor for aortic aneurysm patients. Therefore, we wanted to investigate the relationship between anion gap and mortality of aortic aneurysm patients in intensive care unit after open surgery repair. Methods From Medical Information Mart for Intensive Care III, data of aortic aneurysm patients in intensive care unit after open surgery were enrolled. The primary clinical outcome was defined as death in intensive care unit. Univariate analysis was conducted to compare the baseline data in different groups stratified by clinical outcome or by anion gap level. Restricted cubic spline was drawn to find out the association between anion gap level and mortality. Subgroup analysis was then conducted to show the association in different level and was presented as frost plot. Multivariate regression models were built based on anion gap and were adjusted by admission information, severity score, complication, operation and laboratory indicators. Receiver operating characteristic curves were drawn to compare the prognosis ability of anion gap and simplified acute physiology score II. Decision curve analysis was finally conducted to indicate the net benefit of the models. Results A total of 405 aortic aneurysm patients were enrolled in this study and the in-intensive-care-unit (in-ICU) mortality was 6.9%. Univariate analysis showed that elevated anion gap was associated with high mortality (P value < 0.001), and restricted cubic spline analysis showed the positive correlation between anion gap and mortality. Receiver operating characteristic curve showed that the mortality predictive ability of anion gap approached that of simplified acute physiology score II and even performed better in predicting in-hospital mortality (P value < 0.05). Moreover, models based on anion gap showed that 1 mEq/L increase of anion gap improved up to 42.3% (95% confidence interval 28.5–59.8%) risk of death. Conclusions The level of serum anion gap was an important prognosis factor for aortic aneurysm mortality in intensive care unit after open surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02263-4.
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Umer A, Ługowska-Umer H, Schönborn-Kellenberger O, Korolkiewicz PK, Sein-Anand Ł, Kuziemski K, Korolkiewicz RP. Tachykinin Antagonists Reverse Ischemia/Reperfusion Gastrointestinal Motility Impairment in Rats. J Surg Res 2020; 255:510-516. [PMID: 32629333 DOI: 10.1016/j.jss.2020.05.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/26/2020] [Accepted: 05/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Supraceliac aortic clamping and unclamping produces ischemia-reperfusion (I/R) injury of the splanchnic organs. The protective effects of tachykinin receptor antagonists, SR140333 (NK1 receptor), SR48968 (NK2 receptor), and SB222200 (NK3 receptor), against I/R-induced inhibition of intestinal motility were tested in rats. MATERIAL AND METHODS The intestinal transit of Evans blue was measured in untreated rats and animals subjected to skin incision, I/R (1 h superior mesenteric artery occlusion followed by 24 h reperfusion) or sham operation. Surgical procedures were conducted under diethyl ether anesthesia. RESULTS The gastrointestinal transit has not been markedly affected in rats, which were anesthetized or subjected to skin incision in comparison with untreated animals. In contrast, a sham operation and I/R have significantly reduced the intestinal motility. Pretreatment with NK1-3 blockers (SR140333 [3-30 μg/kg]; SR48968 [3-100 μg/kg]; and SB222200 [10-100 μg/kg]) reversed dose dependently the effects of I/R to the level observed after sham operation only. A combination of NK1+NK2+NK3 inhibitors exerted an additive effect compared with NK1 and NK2 antagonists used as single agents. Similarly, combined NK1+NK2 were more effective than NK2 alone. Sham operation and I/R have shifted the in vitro carbachol concentration-response curves to the right in comparison with untreated animals, a phenomenon partially reversed by NK1-NK3 pretreatment. CONCLUSIONS Single-agent and combined treatment with NK1-3 antagonists markedly attenuated the gastrointestinal dysmotility evoked by I/R injury. The pretreatment with NK3 blocker proved to be the most active in this experimental setting.
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Affiliation(s)
- Artur Umer
- Department of Thoracic Surgery, Medical University of Gdansk, Smoluchowskiego, Gdańsk, Poland
| | - Hanna Ługowska-Umer
- Department of Dermatology, Venerology, Allergology, Medical University of Gdańsk, Gdańsk, Poland
| | | | | | - Łukasz Sein-Anand
- Department of Clinical Toxicology, Medical University of Gdańsk, Gdańsk, Poland
| | - Krzysztof Kuziemski
- Department of Allergology and Pneumonology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Abdominal Aortic and Junctional Tourniquet release after 240 minutes is survivable and associated with small intestine and liver ischemia after porcine class II hemorrhage. J Trauma Acute Care Surg 2019; 85:717-724. [PMID: 29985233 DOI: 10.1097/ta.0000000000002013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Uncontrolled hemorrhage is a leading cause of tactical trauma-related deaths. Hemorrhage from the pelvis and junctional regions are particularly difficult to control due to the inability of focal compression. The Abdominal Aortic and Junctional Tourniquet (AAJT) occludes aortic blood flow by compression of the abdomen. The survivability of tourniquet release beyond 120 minutes is unknown and fluid requirements to maintain sufficient blood pressure during prolonged application are undetermined. We therefore compared 60-minute and 240-minute applications and release of the AAJT for 30 minutes, with crystalloid fluid therapy, after a Class II hemorrhage. METHODS Sixty-kilogram anesthetized pigs were subjected to 900-mL hemorrhage and AAJT application for 60 minutes (n = 5), 240 minutes (n = 5), and fluid therapy only for 240 minutes (n = 5) and reperfusion for 30 minutes. RESULTS The AAJT application was hemodynamically and respiratory tolerable for 60 minutes and 240 minutes. Cumulative fluid requirements decreased by 64%, comparable to 3000 mL of crystalloids. Mechanical ventilation was impaired. AAJT increased the core temperature by 0.9°C compared with fluid therapy. Reperfusion consequences were reversible after 60 minutes but not after 240 minutes. A 240-minute application resulted in small intestine and liver ischemia, persisting hyperkalemia, metabolic acidosis, and myoglobinemia, suggesting rhabdomyolysis. CONCLUSION The AAJT application for 240 minutes with reperfusion was survivable in an intensive care setting and associated with abdominal organ damage. Long time consequences and spinal cord effects was not assessed. We propose an application time limit within 60 minutes to 240 minutes, though further studies are needed to increase the temporal resolution. The AAJT application may be considered as a rescue option to maintain central blood pressure and core temperature in cases of hemorrhagic shock from extremity bleedings, if fluid therapy is unavailable or if the supply is limited. LEVEL OF EVIDENCE Therapeutic study, level II.
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Martelli E, Cho JS. Merits of and Technical Tips for Supra-Mesenteric Aortic Cross Clamping. Vasc Specialist Int 2019; 35:55-59. [PMID: 31297354 PMCID: PMC6609017 DOI: 10.5758/vsi.2019.35.2.55] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/20/2022] Open
Abstract
Supra-celiac aortic cross clamping is often utilized during aortic reconstruction for aneurysmal/occlusive disease involving the pararenal aorta. However, this may be accompanied a myriad of complications related to hemodynamic disturbances, cardiopulmonary compromise and hepatic ischemia. Supra-mesenteric aortic cross clamping may be an excellent option in selected patients with suitable anatomy to minimize or avoid these complications. Herein, the merits of and technical tips for supra-mesenteric aortic cross clamping are discussed.
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Affiliation(s)
- Eugenio Martelli
- Division of Vascular Surgery, Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Jae Sung Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg 2016; 80:324-34. [PMID: 26816219 DOI: 10.1097/ta.0000000000000913] [Citation(s) in RCA: 201] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Torso hemorrhage remains a leading cause of potentially preventable death within trauma, acute care, vascular, and obstetric practice. A proportion of patients exsanguinate before hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive hemostasis. A systematic review was conducted to characterize the current clinical use of REBOA and its effect on hemodynamic profile and mortality. METHODS A systematic review (1946-2015) was conducted using EMBASE and MEDLINE. Original studies on human subjects, published in English language journals, were considered. Articles were included if they reported data on hemodynamic profile and mortality. RESULTS A total of 83 studies were identified; 41 met criteria for inclusion. Clinical settings included postpartum hemorrhage (5), upper gastrointestinal bleeding (3), pelvic surgery (8), trauma (15), and ruptured aortic aneurysm (10). Of the 857 patients, overall mortality was 423 (49.4%); shock was evident in 643 (75.0%). Pooled analysis demonstrated an increase in mean systolic pressure by 53 mm Hg (95% confidence interval, 44-61 mm Hg) following REBOA use. Data exhibited moderate heterogeneity with an I of 35.5. CONCLUSION REBOA has been used in a variety of clinical settings to successfully elevate central blood pressure in the setting of shock. Overall, the evidence base is weak with no clear reduction in hemorrhage-related mortality demonstrated. Formal, prospective study is warranted to clarify the role of this adjunct in torso hemorrhage. LEVEL OF EVIDENCE Systematic review, level IV.
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Lim S, Halandras PM, Saqib NU, Ching YA, Villella E, Park T, Son H, Cho JS. Comparison of supramesenteric aortic cross-clamping with supraceliac aortic cross-clamping for aortic reconstruction. J Vasc Surg 2016; 64:941-7. [PMID: 27038834 DOI: 10.1016/j.jvs.2016.01.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/29/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Supraceliac aortic cross-clamping (SCXC) is routinely used during open aortic reconstruction (OAR) of pararenal aortic disease when suprarenal control is not feasible. On occasion, however, aortic control may be obtained at the supramesenteric level by supramesenteric cross-clamping (SMXC) between the superior mesenteric artery and the celiac axis. The purpose of this study was to compare outcomes between patients who had SMXC vs SCXC during OAR for both aneurysmal and occlusive diseases. METHODS A retrospective chart review identified 69 patients who underwent elective OAR requiring SMXC (n = 18) or SCXC (n = 51). All patients with thoracoabdominal aneurysms and those who had inframesenteric (suprarenal and infrarenal) aortic control were excluded. Propensity score-based matching was performed to adjust for confounding factors in a 1:1 ratio to compare outcomes. Late survival was estimated by Kaplan-Meier methods. RESULTS Propensity score-based matching was performed at a 1:1 ratio; 18 SMXC cases were matched with 18 SCXC cases. The average age was 66.7 years, and men constituted 72%. Baseline characteristics were matched, except for the incidence of peripheral vascular occlusive disease (72.2% in the SMXC group vs 33.3% in the SCXC group; P = .04). A majority (80.6%) of patients underwent OAR for aneurysmal disease (72.2% in the SMXC group, 88.9% in the SCXC group). Intraoperatively, there were no differences in operative times (325 minutes for SMXC vs 298 minutes for SCXC; P = .48), but the SMXC group had a longer renal ischemia time (40 minutes vs 28 minutes; P = .03). There were no significant differences in intraoperative blood loss (2.4 L vs 1.6 L; P = .2) or blood product transfusion requirements (packed red blood cells, 2.2 units vs 1.6 units [P = .5]; Cell Saver, 1.3 L vs 0.7 L [P = .09]). Overall complication rates did not differ significantly (27.8% for SMXC vs 44.4% for SCXC; P = .24). Thirty-day mortality rates did not differ between the two groups (0% for SMXC vs 5.6% for SCXC; P = 1). CONCLUSIONS In this study, there were no differences in early morbidity or mortality between SMXC and SCXC during aortic reconstruction. SMXC, however, can be performed safely and effectively in properly selected patients. A larger, multicenter prospective study would help elucidate the potential benefits.
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Affiliation(s)
- Sungho Lim
- Department of Surgery, Loyola University Medical Center, Maywood, Ill
| | - Pegge M Halandras
- Department of Surgery, Loyola University Medical Center, Maywood, Ill
| | - Naveed U Saqib
- Department of Cardiothoracic and Vascular Surgery, University of Texas Houston Medical Center, Houston, Tex
| | - Y Avery Ching
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Tex
| | - Edward Villella
- Department of Surgery, Loyola University Medical Center, Maywood, Ill
| | - Taeyoung Park
- Department of Applied Statistics, Yonsei University, Seoul, Korea
| | - Hyunju Son
- Department of Applied Statistics, Yonsei University, Seoul, Korea
| | - Jae S Cho
- Department of Surgery, Loyola University Medical Center, Maywood, Ill.
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The Effect of Perioperative Ischemia and Reperfusion on Multiorgan Dysfunction following Abdominal Aortic Aneurysm Repair. BIOMED RESEARCH INTERNATIONAL 2015; 2015:598980. [PMID: 26798637 PMCID: PMC4698535 DOI: 10.1155/2015/598980] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/30/2015] [Accepted: 09/07/2015] [Indexed: 12/03/2022]
Abstract
Abdominal aortic aneurysms (AAAs) are relatively common and are potentially life-threatening medical problems. The aim of this review is to provide an overview of the effect of I/R injury on multiorgan failure following AAA repair. The PubMed, CINAHL, EMBASE, Medline, Cochrane Review, and Scopus databases were comprehensively searched for articles concerning the pathophysiology of I/R and its systemic effects. Cross-referencing was performed using the bibliographies from the articles obtained. Articles retrieved were restricted to those published in English. One of the most prominent characteristics of AAA open repair is the double physiological phenomenon of ischemia-reperfusion (I/R) that happens either at the time of clamping or following the aortic clamp removal. Ischemia-reperfusion injury causes significant pathophysiological disturbances to distant organs, increasing the possibility for postoperative multiorgan failure. Although tissue injury is mediated by diverse mechanisms, microvascular dysfunction seems to be the final outcome of I/R.
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Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage. Shock 2014; 41:130-7. [DOI: 10.1097/shk.0000000000000085] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Erling Junior N, Montero EFDS, Sannomiya P, Poli-de-Figueiredo LF. Local and remote ischemic preconditioning protect against intestinal ischemic/reperfusion injury after supraceliac aortic clamping. Clinics (Sao Paulo) 2013; 68:1548-54. [PMID: 24473514 PMCID: PMC3840383 DOI: 10.6061/clinics/2013(12)12] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 06/20/2013] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES This study tests the hypothesis that local or remote ischemic preconditioning may protect the intestinal mucosa against ischemia and reperfusion injuries resulting from temporary supraceliac aortic clamping. METHODS Twenty-eight Wistar rats were divided into four groups: the sham surgery group, the supraceliac aortic occlusion group, the local ischemic preconditioning prior to supraceliac aortic occlusion group, and the remote ischemic preconditioning prior to supraceliac aortic occlusion group. Tissue samples from the small bowel were used for quantitative morphometric analysis of mucosal injury, and blood samples were collected for laboratory analyses. RESULTS Supraceliac aortic occlusion decreased intestinal mucosal length by reducing villous height and elevated serum lactic dehydrogenase and lactate levels. Both local and remote ischemic preconditioning mitigated these histopathological and laboratory changes. CONCLUSIONS Both local and remote ischemic preconditioning protect intestinal mucosa against ischemia and reperfusion injury following supraceliac aortic clamping.
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Affiliation(s)
- Nilon Erling Junior
- Vascular Surgery, Department of Surgery, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto AlegreRS, Brazil
| | | | - Paulina Sannomiya
- Institute of Heart, Faculdade de Medicina da Universidade de São Paulo, São PauloSP, Brazil
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Brattli OS, Nystuen K, Saether OD, Aadahl P, Grønbech JE, Myhre HO. Regional distribution of blood flow during proximal aortic cross‐clamping: An experimental study using coloured microspheres. Scandinavian Journal of Clinical and Laboratory Investigation 2009; 67:526-35. [PMID: 17763189 DOI: 10.1080/00365510701196906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the effect of thoracic aortic cross-clamping on blood perfusion of the brain, spinal cord, heart, muscular tissue and visceral organs. MATERIAL AND METHODS Nine pigs underwent 30 min cross-clamping of the descending thoracic aorta. Multiple coloured microspheres (15.0 microm +/- 0.1) were infused into the left ventricle before and during aortic cross-clamping (XC) and after declamping (DC). Tissue samples were analysed by spectrophotometry. RESULTS Blood perfusion of the middle and lower segments of the spinal cord was significantly reduced during aortic XC. Perfusion of the brain was not significantly altered by aortic XC, while perfusion of myocardium increased 3-fold. During XC, perfusion of the deltoid muscle and diaphragm increased 5-fold and 13-fold, respectively, while a decrease was found in the gluteus muscle. Renal blood flow was significantly reduced during XC. Finally, XC induced a significant decrease of perfusion in the bowel, spleen, liver and pancreas. CONCLUSION During XC of the thoracic aorta, the perfusion of the muscular tissue was significantly increased proximal to the level of XC. The circulation of the brain was unchanged, probably because of autoregulatory mechanisms. Blood perfusion of the myocardium increased 3-fold during XC.
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Affiliation(s)
- O S Brattli
- Department of Surgery, University Hospital of Trondheim, Trondheim, Norway
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