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Turra J, Riesterer D, Eisner C, Wenzel F, Möbius A, Karck M, Arif R, Lichtenstern C, Fischer D. Prospective clinical study testing the efficacy and safety of a new formula to increase the precision of oxygen therapy in the initiation phase of cardiopulmonary bypass. Perfusion 2023; 38:1203-1212. [PMID: 35608437 PMCID: PMC10466968 DOI: 10.1177/02676591221100743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION During cardiopulmonary bypass (CPB), supranormal concentrations of oxygen are routinely administered with the intention to prevent cellular hypoxia. However, hyperoxemia may have adverse effects on patient outcome. Oxygen settings are based on the perfusionist's individual work experience rather than profound recommendations and studies analyzing the effect of oxygen levels are in need of methodological improvement. We aimed to advance perfusion technique by developing and clinically applying a formula for tailored oxygen therapy in CPB. METHODS A formula to precalculate the oxygenator setting before CPB was developed. The newly-derived formula was then evaluated in a prospective, single-center pilot study to test whether a predefined arterial partial oxygen pressure (PaO2) of 150-250 mmHg could be reached. 80 patients were enrolled in the study between April and September 2021. RESULTS The mean oxygen fraction calculated for the setting of the gas blender was 52% ±0,12. The mean PaO2 after initiation of the CPB was 193 ± 99 mmHg (min-max: 61-484, median 163 mmHg). 38.75% of the values were in the desired PaO2 corridor of 150 to 250 mmHg. 8.75% of all PaO2 values were below <79.9 mmHg, 31.25% between 80 and 149.9 mmHg, 38.75% between 150 and 249.9 mmHg and 21.25%>250 mmHg. CONCLUSIONS Conceptually, perfusion technique should be goal-directed, guided by objective parameters and formulas. Although the optimal CPB oxygenation target remains unknown, it is nevertheless important to develop strategies to tailor oxygen therapy to aid in creating evidence as to what level of oxygen is best for patients during CPB. The formula we derived needs further adjustments to increase results in the target range.
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Affiliation(s)
- Jan Turra
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - David Riesterer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Eisner
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Folker Wenzel
- Furtwangen University, University Schwenningen, Schwenningen, Germany
| | - Andreas Möbius
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Dania Fischer
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
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Liu H, Hu YJ, Zheng SQ, Chen T, Zeng ZH, Wu DD, Zhao S, Zeng B, Liu ZG, Shao YF. Effect of perfusate oxygenation on inflammatory response in congenital heart disease children from low versus high altitude. J Thorac Cardiovasc Surg 2021; 161:2180-2190. [DOI: 10.1016/j.jtcvs.2020.05.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 05/13/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
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Bae J, Kim J, Lee S, Ju JW, Cho YJ, Kim TK, Jeon Y, Nam K. Association Between Intraoperative Hyperoxia and Acute Kidney Injury After Cardiac Surgery: A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2020; 35:2405-2414. [PMID: 33342731 DOI: 10.1053/j.jvca.2020.11.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Optimal oxygen management during cardiac surgery has not been established, and studies on the effects of perioperative hyperoxia on postoperative acute kidney injury (AKI) are scarce. The association between intraoperative hyperoxia and AKI after cardiac surgery involving cardiopulmonary bypass was evaluated for the present study. DESIGN Retrospective observational study. SETTING A tertiary teaching hospital. PARTICIPANTS Adult patients who underwent cardiac surgery with cardiopulmonary bypass from November 2006-December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The area above arterial oxygen partial pressure (PaO2) threshold of 300 mmHg (AOT300, mmHg × h) was used as a metric of intraoperative hyperoxia and was associated with postoperative AKI, using the logistic regression analysis. Data also were fitted using the restricted cubic spline model. Sensitivity analyses were conducted using different PaO2 thresholds (150, 200, 250, and 350 mmHg). A total of 2,926 patients were analyzed. Intraoperative AOT300 independently was associated with the risk of AKI (odds ratio 1.0009; 95% confidence interval 1.0002-1.0015). A PaO2 increment of 100 mmHg above PaO2 300 mmHg for an hour was associated with an increased risk of AKI by 9.4% (1.0009100 ≈ 1.094). In the spline model, the log-odds of AKI increased as AOT300 increased. In the sensitivity analyses, AOT250 and AOT350 also significantly were associated with the risk of AKI, whereas AOT150 and AOT200 were not. As the PaO2 threshold increased from 150 to 350 mmHg, the odds ratio gradually increased. CONCLUSIONS Intraoperative hyperoxia significantly was associated with the risk of AKI after cardiac surgery involving cardiopulmonary bypass.
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Affiliation(s)
- Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jay Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Centre, Seoul National University College of Medicine, Seoul, Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Grocott BB, Kashani HH, Maakamedi H, Dutta V, Hiebert B, Rakar M, Grocott HP. Oxygen Management During Cardiopulmonary Bypass: A Single-Center, 8-Year Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:100-105. [PMID: 32921614 DOI: 10.1053/j.jvca.2020.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 08/05/2020] [Accepted: 08/12/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To characterize the institutional oxygen management practices during cardiopulmonary bypass (CPB) in patients undergoing cardiac surgery, including any potential changes during an 8-year study period. DESIGN A retrospective cohort study. SETTING A tertiary care cardiac surgical program. PARTICIPANTS Patients who underwent cardiac surgery involving CPB, with or without hypothermic circulatory arrest (HCA), between January 1, 2010, and December 31, 2017. MEASUREMENTS AND MAIN RESULTS In addition to baseline patient characteristics, the authors recorded the partial pressures of arterial oxygen (Pao2), fraction of inspired oxygen, and mixed venous oxygen saturation during CPB of 696 randomly selected patients during an 8-year study period. The overall mean Pao2 was 255 ± 48 mmHg, without any significant change during the 8-year study period (p = 0.30). The mean Pao2 of HCA patients was significantly higher than in patients without HCA (327 ± 93 mmHg v 252 ± 45 mmHg, respectively; p < 0.001). CONCLUSIONS The current approach to oxygen management during CPB at the authors' institution is within the range of hyperoxemic levels, and these practices have not changed over time. The impact of these practices on patients' outcomes is not fully understood, and additional studies are needed to establish firm evidence to guide optimal oxygen management practice during CPB.
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Affiliation(s)
- Bronwen B Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hessam H Kashani
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Vikas Dutta
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Martin Rakar
- Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Hilary P Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada.
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Topcu AC, Bolukcu A, Ozeren K, Kavasoglu T, Kayacioglu I. Normoxic management of cardiopulmonary bypass reduces myocardial oxidative stress in adult patients undergoing coronary artery bypass graft surgery. Perfusion 2020; 36:261-268. [PMID: 32755372 DOI: 10.1177/0267659120946733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION We aimed to investigate whether normoxic cardiopulmonary bypass would limit myocardial oxidative stress in adults undergoing coronary artery bypass grafting. METHODS Patients scheduled to undergo elective isolated on-pump coronary artery bypass grafting were randomized to normoxia and hyperoxia groups. The normoxia group received 35% oxygen during anesthetic induction, 35% during hypothermic bypass, and 45% during rewarming. The hyperoxia group received 70%, 50%, and 70% oxygen, respectively. Coronary sinus blood samples were taken prior to initiation of cardiopulmonary bypass and after reperfusion for myocardial total oxidant and antioxidant status measurements. The primary endpoint was myocardial total oxidant status. Secondary endpoints were myocardial total antioxidant status and length of intensive care unit and hospital stay. RESULTS Forty-eight patients were included. Twenty-two received normoxic management. Mean ± standard deviation of age was 58 ± 9.07 years. Groups were balanced in terms of demographics, risk factors, and operative data. Myocardial total oxidant status was significantly lower in the normoxia group following reperfusion (p = 0.03). There was no statistically significant difference regarding myocardial total antioxidant status and length of intensive care unit and hospital stay (p = 0.08, p = 0.82, and p = 0.54, respectively). CONCLUSIONS Normoxic cardiopulmonary bypass is associated with reduced myocardial oxidative stress compared to hyperoxic cardiopulmonary bypass in adult coronary artery bypass patients.
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Affiliation(s)
- Ahmet Can Topcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Bolukcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Kamile Ozeren
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tugba Kavasoglu
- Department of Anesthesiology and Reanimation, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ilyas Kayacioglu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Ko TS, Mavroudis CD, Baker WB, Morano VC, Mensah-Brown K, Boorady TW, Schmidt AL, Lynch JM, Busch DR, Gentile J, Bratinov G, Lin Y, Jeong S, Melchior RW, Rosenthal TM, Shade BC, Schiavo KL, Xiao R, Gaynor JW, Yodh AG, Kilbaugh TJ, Licht DJ. Non-invasive optical neuromonitoring of the temperature-dependence of cerebral oxygen metabolism during deep hypothermic cardiopulmonary bypass in neonatal swine. J Cereb Blood Flow Metab 2020; 40:187-203. [PMID: 30375917 PMCID: PMC6928559 DOI: 10.1177/0271678x18809828] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Management of deep hypothermic (DH) cardiopulmonary bypass (CPB), a critical neuroprotective strategy, currently relies on non-invasive temperature to guide cerebral metabolic suppression during complex cardiac surgery in neonates. Considerable inter-subject variability in temperature response and residual metabolism may contribute to the persisting risk for postoperative neurological injury. To characterize and mitigate this variability, we assess the sufficiency of conventional nasopharyngeal temperature (NPT) guidance, and in the process, validate combined non-invasive frequency-domain diffuse optical spectroscopy (FD-DOS) and diffuse correlation spectroscopy (DCS) for direct measurement of cerebral metabolic rate of oxygen (CMRO2). During CPB, n = 8 neonatal swine underwent cooling from normothermia to 18℃, sustained DH perfusion for 40 min, and then rewarming to simulate cardiac surgery. Continuous non-invasive and invasive measurements of intracranial temperature (ICT) and CMRO2 were acquired. Significant hysteresis (p < 0.001) between cooling and rewarming periods in the NPT versus ICT and NPT versus CMRO2 relationships were found. Resolution of this hysteresis in the ICT versus CMRO2 relationship identified a crucial insufficiency of conventional NPT guidance. Non-invasive CMRO2 temperature coefficients with respect to NPT (Q10 = 2.0) and ICT (Q10 = 2.5) are consistent with previous reports and provide further validation of FD-DOS/DCS CMRO2 monitoring during DH CPB to optimize management.
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Affiliation(s)
- Tiffany S Ko
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.,Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA.,Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Constantine D Mavroudis
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wesley B Baker
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vincent C Morano
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Kobina Mensah-Brown
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy W Boorady
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Jennifer M Lynch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David R Busch
- Department of Anesthesiology & Pain Management, University of Texas Southwestern, Dallas, TX, USA.,Department of Neurology & Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
| | - Javier Gentile
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - George Bratinov
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sejin Jeong
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard W Melchior
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tami M Rosenthal
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brandon C Shade
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kellie L Schiavo
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rui Xiao
- Department of Pediatrics, Division of Biostatistics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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7
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The impact of hyperoxia on outcomes after cardiac surgery: a systematic review and narrative synthesis. Can J Anaesth 2018; 65:923-935. [DOI: 10.1007/s12630-018-1143-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 01/05/2023] Open
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Heinrichs J, Grocott HP. Pro: Hyperoxia Should Be Used During Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:2070-2074. [PMID: 29567040 DOI: 10.1053/j.jvca.2018.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Jeffrey Heinrichs
- Department of Anesthesia, Pain, and Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hilary P Grocott
- Department of Anesthesia, Pain, and Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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A Multicenter, Randomized, Controlled Phase IIb Trial of Avoidance of Hyperoxemia during Cardiopulmonary Bypass. Anesthesiology 2017; 125:465-73. [PMID: 27404222 DOI: 10.1097/aln.0000000000001226] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cardiac surgery utilizing cardiopulmonary bypass (CPB) is one of the most common forms of major surgery. Cardiac surgery-associated multiorgan dysfunction (CSA-MOD) is well recognized and includes acute kidney injury (AKI), hepatic impairment, myocardial damage, and postoperative neurologic deficit. Pathophysiology of CSA-MOD involves numerous injurious pathways linked to the use of CPB including oxidative stress and formation of reactive iron species. During cardiac surgery with CPB, arterial return blood is oxygenated to supranormal levels. This study aimed to determine whether the avoidance of arterial hyperoxemia decreased oxidative stress and reduced the severity of the multiorgan dysfunction in patients undergoing cardiac surgery utilizing CPB. METHODS The study was a multicenter, open-label, parallel-group, randomized controlled study of the avoidance of arterial hyperoxemia versus usual care in patients undergoing cardiac surgery involving CPB. Primary outcome was the incidence and severity of AKI. Secondary outcomes included serum biomarkers for CSA-MOD, duration of mechanical ventilation, and length of intensive care and hospital stay. RESULTS A total of 298 patients were randomized and analyzed at two hospitals in New Zealand and Australia. Mean PaO2 was significantly different between groups during CPB. There was no difference in the development of AKI (intervention arm 72.0% vs. usual care 66.2%; difference, -5.8% [95% CI, -16.1 to 4.7%]; P = 0.28), other markers of organ damage, or intensive care unit and hospital length of stay. CONCLUSIONS Avoiding modest hyperoxemia during CPB failed to demonstrate any difference in AKI, markers of organ damage, or length of stay.
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Effect of sensor location on regional cerebral oxygen saturation measured by INVOS 5100 in on-pump cardiac surgery. J Anesth 2016; 31:178-184. [DOI: 10.1007/s00540-016-2287-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/19/2016] [Indexed: 11/27/2022]
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Smit B, Smulders YM, de Waard MC, Boer C, Vonk ABA, Veerhoek D, Kamminga S, de Grooth HJS, García-Vallejo JJ, Musters RJP, Girbes ARJ, Oudemans-van Straaten HM, Spoelstra-de Man AME. Moderate hyperoxic versus near-physiological oxygen targets during and after coronary artery bypass surgery: a randomised controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:55. [PMID: 26968380 PMCID: PMC4788916 DOI: 10.1186/s13054-016-1240-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/10/2016] [Indexed: 01/21/2023]
Abstract
Background The safety of perioperative hyperoxia is currently unclear. Previous studies in patients undergoing coronary artery bypass surgery suggest reduced myocardial damage when avoiding extreme perioperative hyperoxia (>400 mmHg). In this study we investigated whether an oxygenation strategy from moderate hyperoxia to a near-physiological oxygen tension reduces myocardial damage and improves haemodynamics, organ dysfunction and oxidative stress. Methods This was a single-blind, single-centre, open-label, randomised controlled trial in patients undergoing elective coronary artery bypass surgery. Fifty patients were randomised to a partial pressure of oxygen in arterial blood (PaO2) target of 200–220 mmHg during cardiopulmonary bypass and 130–150 mmHg during intensive care unit (ICU) admission (control group) versus lower targets of 130–150 mmHg during cardiopulmonary bypass and 80–100 mmHg at the ICU (conservative group). Primary outcome was myocardial injury (CK-MB and Troponin-T) at ICU admission and 2, 6 and 12 hours thereafter. Results Weighted PaO2 during cardiopulmonary bypass was 220 mmHg (interquartile range (IQR) 211–233) vs. 157 (151–162) in the control and conservative group, respectively (P < 0.0001). During ICU admission, weighted PaO2 was 107 mmHg (86–141) vs. 90 (84–98) (P = 0.03), respectively. Area under the curve of CK-MB was median 23.5 μg/L/h (IQR 18.4–28.1) vs. 21.5 (15.8–26.6) (P = 0.35) and 0.30 μg/L/h (0.25–0.44) vs. 0.39 (0.24–0.43) (P = 0.81) for Troponin-T. Cardiac index, systemic vascular resistance index, creatinine, lactate and F2-isoprostane levels were not different between groups. Conclusions Compared to moderate hyperoxia, a near-physiological oxygen strategy does not reduce myocardial damage in patients undergoing coronary artery bypass surgery. Conservative oxygen administration was not associated with increased lactate levels or hypoxic events. Trial registration Netherlands Trial Registry NTR4375, registered on 30 January 2014 Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1240-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bob Smit
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
| | - Yvo M Smulders
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Monique C de Waard
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anaesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Dennis Veerhoek
- Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Suzanne Kamminga
- Department of Anaesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm-Jan S de Grooth
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Juan J García-Vallejo
- Department of Molecular Cell Biology & Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Rene J P Musters
- Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
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Spoelstra-de Man AME, Smit B, Oudemans-van Straaten HM, Smulders YM. Cardiovascular effects of hyperoxia during and after cardiac surgery. Anaesthesia 2015; 70:1307-19. [PMID: 26348878 DOI: 10.1111/anae.13218] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 12/23/2022]
Abstract
During and after cardiac surgery with cardiopulmonary bypass, high concentrations of oxygen are routinely administered, with the intention of preventing cellular hypoxia. We systematically reviewed the literature addressing the effects of arterial hyperoxia. Extensive evidence from pre-clinical experiments and clinical studies in other patient groups suggests predominant harm, caused by oxidative stress, vasoconstriction, perfusion heterogeneity and myocardial injury. Whether these alterations are temporary and benign, or actually affect clinical outcome, remains to be demonstrated. In nine clinical cardiac surgical studies in low-risk patients, higher oxygen targets tended to compromise cardiovascular function, but did not affect clinical outcome. No data about potential beneficial effects of hyperoxia, such as reduction of gas micro-emboli or post-cardiac surgery infections, were reported. Current evidence is insufficient to specify optimal oxygen targets. Nevertheless, the safety of supraphysiological oxygen suppletion is unproven. Randomised studies with a variety of oxygen targets and inclusion of high-risk patients are needed to identify optimal oxygen targets during and after cardiac surgery.
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Affiliation(s)
| | - B Smit
- Department of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - Y M Smulders
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
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Ariturk C, Okten M, Ozgen ZSU, Erkek E, Uysal P, Gullu U, Senay S, Karabulut H, Alhan C, Toraman F. Utility of cerebral oxymetry for assessing cerebral arteriolar carbon dioxide reactivity during cardiopulmonary bypass. Heart Surg Forum 2015; 17:E169-72. [PMID: 25002395 DOI: 10.1532/hsf98.2014319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Our study evaluated changes in cerebral arterial oxygen saturation (rSO2) during cardiopulmonary bypass (CPB) that were caused by changes in arterial carbon dioxide tension (PaCO2). METHODS A group of 126 patients undergoing routine, elective, first-time coronary artery bypass graft surgery (CABG) was entered into a prospective study using bilateral near-infrared spectroscopy (NIRS) before anesthetic induction (T1), after anesthetic induction (T2), and continuing at 5-minute intervals during moderate hypothermic (32°C) CPB. Pump flows were set at 2.5 L/min/m(2) and adjusted to maintain mean arterial pressure (MAP) within 10 mmHg of the MAP recorded at the initial fifth minute of CPB (T3). Thirty-two patients were excluded from data collection because MAP could not be stabilized within the target range of 60-90 mmHg. In the remaining 94 patients, after obtaining steady state flow, MAP, and oxygenation, a trial period of hypocarbia (mean PaCO2 of 30 mmHg) was induced by increasing oxygenator fresh gas flow rate (FGFR) to 2.5 L/min/m(2) (T4). A reciprocal period was then measured at reduced FGFR (0.75 L/min/m(2)) (T5). RESULTS After 20 minutes of a higher (2.75 L/min/m(2)) (FGFR), mean PaCO2 decreased from a baseline of 38 ± 4 mmHg to 30 ± 2 mmHg. This was associated with a parallel decrease (-10 ± 9%) in mixed cerebral oxygen saturation without alteration of mean arterial oxygen tension (PaO2), lactate, MAP, CPB flow, or other parameters implying increased cerebral oxygen extraction. CONCLUSION Parallel changes in PaCO2 and rSO2 occur during CPB when other variables remain constant, and are due to the effects of carbon dioxide on cerebral arterioles. Cerebral oxygen saturation measured by NIRS may be a useful indirect measure of PaCO2 when continuous blood gas analysis is not possible during open-heart surgery. Cerebral oximetry values may be useful measurements for setting an optimum gas flow rate through the oxygenator.
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Affiliation(s)
- Cem Ariturk
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Murat Okten
- Department of Cardiovascular Surgery, Acıbadem Healthcare Group, Kadikoy Hospital
| | - Zehra Serpil Ustalar Ozgen
- Department of Anesthesiology and Reanimation, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Esin Erkek
- Department of Anesthesiology and Reanimation, Acıbadem Healthcare Group, Kadikoy Hospital
| | - Pinar Uysal
- Department of Anesthesiology and Reanimation, Acıbadem Healthcare Group, Kadikoy Hospital
| | - Umit Gullu
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Sahin Senay
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Hasan Karabulut
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Cem Alhan
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Fevzi Toraman
- Department of Anesthesiology and Reanimation, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
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Sutton ADJ, Bailey M, Bellomo R, Eastwood GM, Pilcher DV. The association between early arterial oxygenation in the ICU and mortality following cardiac surgery. Anaesth Intensive Care 2014; 42:730-5. [PMID: 25342405 DOI: 10.1177/0310057x1404200608] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many studies have been conducted to investigate the relationship between hyperoxia and mortality in cohorts of intensive care unit (ICU) patients with varied and often contradictory results. The impact of early hyperoxia post ischaemia remains uncertain in various ICU cohorts. We aimed to investigate the association between arterial oxygenation (PaO2) in the first 24 hours in ICU and mortality in patients following cardiac surgery, using a retrospective cohort study of data from the Australian and New Zealand Intensive Care Society adult patient database. Participants were adults admitted to the ICU following cardiac surgery in Australia and New Zealand between 2003 and 2012. Patients were divided according to worst PaO2 level or alveolar-arterial O2 gradient in the 24 hours from admission. We defined 'hyperoxia' as PaO2 ≥300 mmHg, 'hypoxia/poor O2 transfer' as either PaO2 <60 mmHg or ratio of PaO2 to fraction of inspired oxygen <300 and 'normoxia' as between hypoxia and hyperoxia. The primary outcome was mortality at hospital discharge. Secondary outcomes were ICU mortality and ICU and hospital length-of-stay. Of the 83,060 patients, 12,188 (14.7%) had hyperoxia, 54,420 (65.5%) had hypoxia/poor O2 transfer and 16,452 (19.8%) had normoxia. There was no association between hyperoxia and in-hospital or ICU mortality compared to normoxia. There was a small increased hospital and ICU length-of-stay for hyperoxic compared to normoxic patients. We concluded that there was no association between mortality and hyperoxia in the first 24 hours in ICU after cardiac surgery.
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Affiliation(s)
- A D J Sutton
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria
| | - M Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria
| | - R Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University and Department of Intensive Care, Austin Health, Melbourne, Victoria
| | - G M Eastwood
- Department of Intensive Care, Heidelberg, Victoria
| | - D V Pilcher
- Department of Intensive Care, Alfred Hospital and Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, Victoria
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Normoxic and hyperoxic cardiopulmonary bypass in congenital heart disease. BIOMED RESEARCH INTERNATIONAL 2014; 2014:678268. [PMID: 25328889 PMCID: PMC4189843 DOI: 10.1155/2014/678268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/04/2014] [Indexed: 01/15/2023]
Abstract
Cyanotic congenital heart disease comprises a diverse spectrum of anatomical pathologies. Common to all, however, is chronic hypoxia before these lesions are operated upon when cardiopulmonary bypass is initiated. A range of functional and structural adaptations take place in the chronically hypoxic heart, which, whilst protective in the hypoxic state, are deleterious when the availability of oxygen to the myocardium is suddenly improved. Conventional cardiopulmonary bypass delivers hyperoxic perfusion to the myocardium and is associated with cardiac injury and systemic stress, whilst a normoxic perfusate protects against these insults.
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16
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[What should no longer be seen when performing a CPB]. ACTA ACUST UNITED AC 2014; 33 Suppl 1:S5-9. [PMID: 24613249 DOI: 10.1016/j.annfar.2014.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 01/29/2014] [Indexed: 11/21/2022]
Abstract
Cardiac surgery and cardiopulmonary bypass (CPB) have made significant progress in recent years. Despite these efforts, adverse events continue to occur during surgery. From recent studies of incidents and accidents during CPB, this article focuses on critical recommendations to respect when in charge of a CPB. Some facts are based only on data unsupported by scientific research. Others have not proven their benefit in terms of postoperative morbidity or mortality. The management of anticoagulation, hematocrit, pump flow, and the temperature is discussed. Finally, the importance of teamwork especially in terms of cohesion and communication is highlighted.
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Effect of intraoperative high inspired oxygen fraction on surgical site infection, postoperative nausea and vomiting, and pulmonary function: systematic review and meta-analysis of randomized controlled trials. Anesthesiology 2013; 119:303-16. [PMID: 23719611 DOI: 10.1097/aln.0b013e31829aaff4] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraoperative high inspired oxygen fraction (FIO2) is thought to reduce the incidence of surgical site infection (SSI) and postoperative nausea and vomiting, and to promote postoperative atelectasis. METHODS The authors searched for randomized trials (till September 2012) comparing intraoperative high with normal FIO2 in adults undergoing surgery with general anesthesia and reporting on SSI, nausea or vomiting, or pulmonary outcomes. RESULTS The authors included 22 trials (7,001 patients) published in 26 reports. High FIO2 ranged from 80 to 100% (median, 80%); normal FIO2 ranged from 30 to 40% (median, 30%). In nine trials (5,103 patients, most received prophylactic antibiotics), the incidence of SSI decreased from 14.1% with normal FIO2 to 11.4% with high FIO2; risk ratio, 0.77 (95% CI, 0.59-1.00). After colorectal surgery, the incidence of SSI decreased from 19.3 to 15.2%; risk ratio, 0.78 (95% CI, 0.60-1.02). In 11 trials (2,293 patients), the incidence of nausea decreased from 24.8% with normal FIO2 to 19.5% with high FIO2; risk ratio, 0.79 (95% CI, 0.66-0.93). In patients receiving inhalational anesthetics without prophylactic antiemetics, high FIO2 provided a significant protective effect against both nausea and vomiting. Nine trials (3,698 patients) reported on pulmonary outcomes. The risk of atelectasis was not increased with high FIO2. CONCLUSIONS Intraoperative high FIO2 further decreases the risk of SSI in surgical patients receiving prophylactic antibiotics, has a weak beneficial effect on nausea, and does not increase the risk of postoperative atelectasis.
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Morita K. Invited commentary: surgical reoxygenation injury in myocardium of patients with cyanosis: how is it clinically important? World J Pediatr Congenit Heart Surg 2013; 3:317-20. [PMID: 23804863 DOI: 10.1177/2150135112438449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kiyozo Morita
- Department of Pediatric Cardiac Surgery, Jikei University School of Medicine, Tokyo, Japan
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Hayes RA, Shekar K, Fraser JF. Is hyperoxaemia helping or hurting patients during extracorporeal membrane oxygenation? Review of a complex problem. Perfusion 2013; 28:184-93. [DOI: 10.1177/0267659112473172] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) facilitates organ support in patients with refractory cardiorespiratory failure whilst disease-modifying treatments can be administered. Improvements to the ECMO process have resulted in its increased utilisation. However, iatrogenic injuries remain, with bleeding and thrombosis the most significant concerns. Many factors contribute to the formation of thrombi, with the hyperoxaemia experienced during ECMO a potential contributor. Outside of ECMO, emerging evidence associates hyperoxaemia with increased mortality. Currently, no universal definition of hyperoxaemia exists, a gap in clinical standards that may impact patient outcomes. Hyperoxaemia has the potential to induce platelet activation, aggregation and, subsequently, thrombosis through markedly increasing the production of reactive oxygen species. There are minimal data in the current literature that explore the relationship between ECMO-induced hyperoxaemia and the production of reactive oxygen species – a putative link towards pathology. Furthermore, there is limited research directly linking hyperoxaemia and platelet activation. These are areas that warrant investigation as definitive data regarding the nascence of these pathological processes may delineate and define the relative risk of supranormal oxygen tension. These data could then assist in defining optimal oxygenation practice, reducing the risks associated with extracorporeal support.
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Affiliation(s)
- RA Hayes
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - K Shekar
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - JF Fraser
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia
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Morita K. Surgical reoxygenation injury of the myocardium in cyanotic patients: clinical relevance and therapeutic strategies by normoxic management during cardiopulmonary bypass. Gen Thorac Cardiovasc Surg 2012; 60:549-56. [DOI: 10.1007/s11748-012-0115-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Indexed: 10/28/2022]
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