Bench-to-bedside review: Inotropic drug therapy after adult cardiac surgery -- a systematic literature review

The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review

Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.

Determinants of 30-day mortality in elderly patients admitted to a cardiovascular surgery intensive care unit

BACKGROUND

This study aims to identify the factors influencing 30-day morbidity and mortality in patients aged 65 and older undergoing cardiovascular surgery.

METHODS

Data from 360 patients who underwent cardiac surgery between January 2012 and August 2021 in the Cardiovascular Surgery Intensive Care Unit (CVS ICU) were analyzed. Patients were categorized into two groups: "mortality+" (33 patients) and "mortality-" (327 patients). Factors influencing mortality, including preoperative, intraoperative, and postoperative risk factors, complications, and outcomes, were assessed.

RESULTS

Significant differences were observed between the two groups in factors affecting mortality, including extubation time, ICU stay duration, blood transfusion, surgical reexploration, aortic clamp duration, glomerular filtration rate (GFR), blood urea nitrogen (BUN), creatinine, hemoglobin A1c (HbA1c) levels, and the lowest systolic blood pressure during the first 24 hours in the ICU (p<0.05). The "mortality+" group had longer extubation times and ICU stays, required more blood transfusions, and had higher BUN-creatinine ratios, but lower systolic blood pressures, GFR, and HbA1c levels. Mortality was also higher in patients needing noradrenaline infusions and those who underwent reoperation for bleeding (p<0.05).

CONCLUSION

By optimizing preoperative renal function, minimizing extubation time, shortening ICU stays, and carefully managing blood transfusions, surgical reexplorations, aortic clamp duration, and HbA1c levels, we believe that the mortality rate can be reduced in elderly patients. Key strategies include shortening aortic clamp times, reducing perioperative blood transfusions, and ensuring effective bleeding control.

The epidemiology of postoperative dobutamine and phosphodiesterase inhibitors after adult elective cardiac surgery and its impact on the length of hospital stay: a post hoc analysis from the multicenter retrospective observational study

The optimal administration of inotrope after cardiac surgery is unknown. This study aimed to investigate the impact of postoperative inotrope on clinical outcomes in adult elective cardiac surgery patients. Data from the Blood Pressure and Relative Optimal Target after Heart Surgery in Epidemiologic Registry study were analyzed, employing propensity score considering the hospital of admission. The primary outcome was the length of hospital stay evaluated using quantile regression. Secondary outcomes were kidney injury progression, renal replacement therapy, atrial fibrillation, mortality, mechanical ventilation duration, and length of intensive care unit (ICU) stay. Among 870 patients from 14 ICUs in Japan, 535 received inotropes within 24 h of ICU admission, with usage rates ranging from 40 to 100% among facilities. After propensity score matching, 218 patients were included in each group. The inotrope group had a significantly longer hospital stay compared to the control group (16 days vs. 14 days; median difference 1.78 [95% confidence interval [CI] 0.31-3.24]; p = 0.018). However, no significant differences were observed in the secondary outcomes, except for mechanical ventilation duration. The results of the sensitivity analysis using a mixed-effects quantile regression analysis considering the hospital of admission for length of hospital stay in the original cohort were consistent with the results of the propensity analyses (median difference in days, 2.35 [95% CI, 0.35-4.36]; p = 0.022). The use of inotropes within 24 h of ICU admission in adult elective cardiac surgery patients was associated with an extended hospitalization period of approximately 2 days, without offering any prognostic benefit. Clinical trial registration: UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.

Alterations to Kidney Physiology during Cardiopulmonary Bypass-A Narrative Review of the Literature and Practical Remarks

INTRODUCTION

According to different authors, cardiac surgery-associated acute kidney injury (CSA-AKI) incidence can be as high as 20-50%. This complication increases postoperative morbidity and mortality and impairs long-term kidney function in some patients. This review aims to summarize current knowledge regarding alterations to renal physiology during cardiopulmonary bypass (CPB) and to discuss possible nephroprotective strategies for cardiac surgeries. Relevant sections: Systemic and renal circulation, Vasoactive drugs, Fluid balance and Osmotic regulation and Inflammatory response.

CONCLUSIONS

Considering the available scientific evidence, it is concluded that adequate kidney perfusion and fluid balance are the most critical factors determining postoperative kidney function. By adequate perfusion, one should understand perfusion with proper oxygen delivery and sufficient perfusion pressure. Maintaining the fluid balance is imperative for a normal kidney filtration process, which is essential for preserving the intra- and postoperative kidney function.

FUTURE DIRECTIONS

The review of the available literature regarding kidney function during cardiac surgery revealed a need for a more holistic approach to this subject.

Central Oxygen Venous Saturation and Mortality in Patients Undergoing Coronary Artery Bypass Grafting

Purpose

Central venous oxygen saturation (ScvO₂) has been reported as a prognostic marker of in-hospital mortality when it is below 60% in certain situations. Nevertheless, it has not been widely reported in patients undergoing coronary artery bypass graft (CABG). The study determined the association between ScvO₂ and in-hospital mortality in patients undergoing CABG in a high-complexity health institution in Santiago de Cali, Colombia.

Patients and Methods

A retrospective cohort study was conducted with patients undergoing isolated CABG. The subject sample included 515 subjects aged 18 years or older. Exposure was defined as ScvO₂ <60% upon admission to the intensive care unit (ICU) following surgery. The major outcome was mortality rates after 30 days. Furthermore, exposure variables were measured at preoperative, intra-operative, and postoperative time points.

Results

A total of 103 exposed and 412 unexposed subjects were included. The final model revealed a higher mortality risk in individuals with ScvO₂ <60% upon ICU admission compared with those with higher saturation levels (relative risk 4.2, 95% confidence interval: 2.4-7.2; p = 0.001). Values were adjusted using variables such as age (>75 years), low socioeconomic stratum, chronic kidney failure before surgery, unstable angina before surgery, ischemia time (>60 min), and intra-operative inotrope use. The primary cause of death was cardiogenic shock (54.7%), followed by sepsis (25.0%) and postoperative bleeding (17.2%).

Conclusion

The study identified an association between ScvO₂ <60% and in-hospital mortality in patients undergoing CABG.

Renal Dysfunction and Arrhythmia Association in Patients Receiving Milrinone After Cardiac Surgery

OBJECTIVE

The altered pharmacokinetics of milrinone in renal impairment could result in an increased risk of cardiac arrhythmias. This study aimed to determine if there is an association between new-onset arrhythmias and renal impairment after cardiac surgery following milrinone administration.

DESIGN

A retrospective cohort study.

SETTING

A single-center tertiary care hospital.

PARTICIPANTS

Adult patients who received a milrinone infusion in the intensive care unit (ICU) setting after coronary artery bypass graft, valvuloplasty, annuloplasty, or a combination of these surgeries from July 1, 2014 to July 1, 2021. Renal impairment was defined using a creatinine clearance <60 mL/min, calculated using the Cockcroft-Gault equation.

INTERVENTIONS

Patients received a weight-based continuous intravenous infusion of milrinone.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the presence of new arrhythmias after the initial administration of a weight-based continuous intravenous infusion of milrinone postcardiac surgery. Of the 197 patients who met inclusion, there was no difference in the presence of new arrhythmias (42.9% v 40.3%, p = 0.76) or in the time to first new arrhythmia from milrinone initiation in those with renal impairment compared to those without renal impairment (29.1 hours v 33.3 hours, p = 0.54). Patients with renal impairment had a longer hospital stay than patients without renal impairment (17.5 days v 13.9 days, p = 0.016). Arrhythmia type, length of ICU stay, ICU mortality, and hospital mortality were not different between the cohorts.

CONCLUSIONS

There was no association between new arrhythmias, milrinone, and renal impairment in patients postcardiac surgery.

Kidney Damage and Stress Biomarkers for Early Identification of Drug-Induced Kidney Injury: A Systematic Review

INTRODUCTION

Acute kidney injury (AKI) resulting from nephrotoxic medication use is prominent in hospitalized patients and is attributable to overall increases in mortality and costs of care. Serum creatinine (SCr), the current standard for identifying drug-induced AKI (DIAKI) is often delayed in its response to kidney insult by 26-36 h.

OBJECTIVE

This systematic review seeks to evaluate the clinical utility of several novel kidney damage and stress biomarkers for the prediction/timely detection of DIAKI, in comparison with traditional methods.

METHODS

A systematic review of the CINAHL, Cochrane Library, Embase, and PubMed databases was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, for articles analyzing the use of β2-microglobulin (B2M), interleukin (IL)-18, kidney injury molecule-1 (KIM-1), liver-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), and tissue inhibitor of metalloproteinase-2 * insulin-like growth factor-binding protein 7 [TIMP-1]*[IGFBP-7], for identifying DIAKI. Primary outcomes included time to DIAKI diagnosis using traditional methods and the time to significant difference in biomarker concentrations between DIAKI and non-AKI study subjects. Secondary outcomes included biomarker concentrations at the time of significant difference between the AKI status groups.

RESULTS

Fifteen unique articles were identified from the literature search. Twelve studies consisted of strictly hospitalized patient populations and three studies included hospitalized patients and patients discharged to home treatment. No studies reported values for urine volume output. Seventy-three percent of studies reported earlier times to significant difference of novel biomarker concentrations between the AKI and non-AKI groups than diagnosis of DIAKI by SCr alone. Significant variation was observed for individual urine biomarker concentrations at time of significant difference between the AKI status groups.

CONCLUSIONS

All analyzed biomarkers showed potential for use as early clinical markers of DIAKI, however further consensus on threshold urine concentrations for DIAKI is needed for meaningful implementation of these biomarkers in clinical practice.

The evaluation of levosimendan in patients with acute myocardial infarction related ventricular septal rupture undergoing cardiac surgery: a prospective observational cohort study with propensity score analysis

STUDY OBJECTIVE

The purpose of the present study was to evaluate the efficacy of levosimendan in patients with acute myocardial infarction related ventricular septal rupture (AMI-VSR) underwent cardiac surgery.

DESIGN

Prospective observational cohort study with propensity score analysis.

PATIENTS

There were 261 patients with AMI-VSR in our study. After 1:1 propensity matching, 106 patients (53 levosimendan and 53 control) were selected in the matched cohort.

INTERVENTIONS

None.

MEASUREMENTS

Patients who received levosimendan were assigned to the levosimendan group (n = 164). The patients who were not received were levosimendan assigned to the control group (n = 97). The levosimendan was initiated immediately after cardiopulmonary bypass. Then, it has been maintained during the postoperative 3 days. The poor outcomes were identified as follows: death and postoperative complications (postoperative stroke, low cardiac output syndromeneeded mechanical circulatory support after surgery, acute kidney injury (≥ stage III), postoperative infection or septic shock, new developed atrial fibrillation or ventricular arrhythmias).

MAIN RESULTS

Before matching, the control group had more length of ICU stay (6.69 ± 3.90 d vs. 5.20 ± 2.24 d, p < 0.001) and longer mechanical ventilation time (23 h, IQR: 16-53 h vs. 16 h, IQR: 11-23 h, p < 0.001). Other postoperative outcomes have not shown significant differences between two groups. After matching, no significant difference was found between both groups for all postoperative outcomes. The Kaplan-Meier survivul estimate and log-rank test showed that the 90-day survival had no significant differences between two groups before and after matching.

CONCLUSION

Our study found that a low-dose infusion of levosimendan in AMI-VSR patients underwent surgical repair did not associated with positively affect to postoperative outcomes.

Time to abandon ampicillin plus gentamicin in favour of ampicillin plus ceftriaxone in Enterococcus faecalis infective endocarditis? A meta-analysis of comparative trials

Background

Current guidelines recommend either ampicillin plus ceftriaxone (AC) or amoxicillin/ampicillin plus gentamicin (AG) with an equivalent class IB recommendation in Enterococcus faecalis endocarditis. However, previous observational studies suggest that AC might be favourable in terms of adverse events.

Objectives

To investigate whether AC is non-inferior to AG, and if it is associated with less adverse events.

Methods

In June 2021, a systematic literature search using the databases PubMed/MEDLINE, CDSR, CENTRAL, CCAs, EBM Reviews, Web of Science and LILACS was conducted by two independent reviewers. Studies were considered eligible if (P) patients included were ≥ 18 years of age and had IE with E. faecalis, (I) treatment with AC was compared to (C) treatment with AG and (O) outcomes on in-hospital mortality, nephrotoxicity and adverse events requiring drug withdrawal were reported. Odds ratios and 95% confidence intervals were calculated using random-effects models with the Mantel–Haenszel method, the Sidik–Jonkman estimator for τ² and the Hartung–Knapp adjustment.

Results

Treatment with AC was non-inferior to AG, as depicted by no significant differences in-hospital mortality, 3-month mortality, relapses or treatment failure. Furthermore, AC was associated with a lower prevalence of nephrotoxicity (OR 0.45 [0.26–0.77], p = 0.0182) and drug withdrawal due to adverse events (OR 0.11 [0.03–0.46], p = 0.0160) than AG.

Conclusions

Treatment with AC was non-inferior to treatment with AG, and it was associated with a reduced prevalence of nephrotoxicity and drug withdrawal due to adverse events. Thus, combination therapy with AC appears favourable over AG in patients with E. faecalis IE.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01971-3.

SEDAR/SECCE ECMO management consensus document

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.

Calcium administration In patients undergoing CardiAc suRgery under cardiopulmonary bypasS (ICARUS trial): Rationale and design of a randomized controlled trial

Introduction

Weaning from cardiopulmonary bypass (CPB) is a critical step of any cardiac surgical procedure and often requires pharmacologic intervention. Calcium ions are pivotal elements for the excitation-contraction coupling process of cardiac myocytes. Thus, calcium administration might be helpful during weaning from CPB.

Methods

We describe a multicenter, placebo-controlled, double blind randomized clinical trial to assess the effect of calcium chloride on the need for inotropic support among adult patients during weaning from CPB. The experimental group (409 patients) will receive 15 mg/kg of calcium chloride. The control group (409 patients) will receive an equivalent volume of 0.9% sodium chloride. Both drugs will be administered intravenously as a bolus at the beginning of weaning from CPB.

Results

The primary outcome will be the need for inotropic support between termination of CPB and completion of surgery. Secondary outcomes will be: duration of inotropic support, vasoactive-inotropic score 30 min after transfer to intensive care unit and on postoperative day 1, plasma alpha-amylase on postoperative day 1, plasma Ca²⁺ concentration immediately before and 10–15 min after calcium chloride administration, non-fatal myocardial infarction, blood loss on postoperative day 1, need for transfusion of red blood cells, signs of myocardial ischemia on electrocardiogram after arrival to intensive care unit, all-cause mortality at 30 days or during hospital stay if this is longer than 30 days.

Discussion

This trial is designed to assess whether intravenous calcium chloride administration could reduce the need for inotropic support after cardiopulmonary bypass weaning among adults undergoing cardiac surgery.

Utility of NT-proBNP as an objective marker of postoperative heart failure after coronary artery bypass surgery: a prospective observational study

Background

Postoperative heart failure (PHF) is the main cause for mortality after cardiac surgery but unbiased evaluation of PHF is difficult. We investigated the utility of postoperative NT-proBNP as an objective marker of PHF after coronary artery bypass surgery (CABG).

Methods

Prospective study on 382 patients undergoing isolated CABG for acute coronary syndrome. NT-proBNP was measured preoperatively, the first (POD1) and third postoperative morning (POD3). A blinded Endpoints Committee used prespecified criteria for PHF. Use of circulatory support was scrutinized.

Results

After adjusting for confounders PHF was associated with 1.46 times higher NT-proBNP on POD1 (p = 0.002), 1.54 times higher on POD3 (p < 0.0001). In severe PHF, NT-proBNP was 2.18 times higher on POD1 (p = 0.001) and 1.81 times higher on POD3 (p = 0.019). Postoperative change of NT-proBNP was independently associated with PHF (OR 5.12, 95% CI 1.86–14.10, p = 0.002). The use of inotropes and ICU resources increased with incremental quartiles of postoperative NT-proBNP.

Conclusions

Postoperative NT-proBNP can serve as an objective marker of the severity of postoperative myocardial dysfunction. Due to overlap in individuals, NT-proBNP is useful mainly for comparisons at cohort level. As such, it provides a tool for study purposes when an unbiased assessment of prevention or treatment of PHF is desirable.

Trial registration

ClinicalTrials.gov Identifier: NCT00489827https://clinicaltrials.gov/ct2/show/NCT00489827?term=glutamics&draw=2&rank=1.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00194-4.

Simulation of the Positive Inotropic Peptide S100A1ct in Aqueous Environment by Gaussian Accelerated Molecular Dynamics

The S100A1ct peptide, consisting of the C-terminal 20 residues of the S100A1 protein fused to an N-terminal 6-residue hydrophilic tag, has been found to exert a positive inotropic effect, resulting in improved contractile performance of failing cardiac and skeletal muscle without arrhythmic side-effects. The S100A1ct peptide thus has high potential for the treatment of acute heart failure. As a step toward understanding its molecular mechanism of action, and to provide a basis for peptidomimetic design to optimize its properties, we here describe de novo structure predictions and molecular dynamics simulations to characterize the conformational landscape of S100A1ct in aqueous environment. In S100A1, the C-terminal 20 residues form an α-helix, but de novo peptide structure predictions indicate that other conformations are also possible. Conventional molecular dynamics simulations in implicit and explicit solvent corroborated this finding. To ensure adequate sampling, we performed simulations of a tagged 10-residue segment of S100A1ct, and we carried out Gaussian accelerated molecular dynamics simulations of the peptides. These simulations showed that although the helical conformation of S100A1ct was the most energetically stable, the peptide can adopt a range of kinked conformations, suggesting that its activity may be related to its ability to act as a conformational switch.

Comprehensive Comparisons among Inotropic Agents on Mortality and Risk of Renal Dysfunction in Patients Who Underwent Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Several kinds of inotropes have been used in critically ill patients to improve hemodynamics and renal dysfunction after cardiac surgery; however, the treatment strategies for reducing mortality and increasing renal protection in patients who underwent cardiac surgery remain controversial. Therefore, we performed a comprehensive network meta-analysis to overcome the lack of head-to-head comparisons. A systematic database was searched up to 31 December 2020, for randomized controlled trials that compared different inotropes on mortality outcomes and renal protective effects after cardiac surgery. A total of 29 trials were included and a frequentist network meta-analysis was performed. Inconsistency analyses, publication bias, and subgroup analyses were also conducted. Compared with placebo, use of levosimendan significantly decreased the risks of mortality (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.56–0.97) and risk of acute renal injury (OR: 0.61; 95% CI: 0.45–0.82), especially in low systolic function patients. Use of levosimendan also ranked the best treatment based on the P-score (90.1%), followed by placebo (64.5%), milrinone (49.6%), dopamine (49.5%), dobutamine (29.1%), and fenoldopam (17.0%). Taking all the available data into consideration, levosimendan was a safe renal-protective choice for the treatment of patients undergoing cardiac surgery, especially for those with low systolic function.

A Descriptive Study of Perioperative Hemodynamics in Open Cardiac Surgery Patients

OBJECTIVES

The purpose of the present study was to describe how the perioperative hemodynamic profile before and after cardiopulmonary bypass during cardiac surgery is influenced by age and to describe the association between postoperative hemodynamics and one-year mortality.

DESIGN

A retrospective registry-based study.

SETTING

University Hospital of Aarhus, Denmark.

PARTICIPANTS

The study comprised 6,595 patients undergoing elective on-pump cardiac surgery from 2006 to 2016.

MEASUREMENTS AND MAIN RESULTS

Perioperative hemodynamic values were derived from computerized anesthesia and intensive care reports, including mean arterial pressure, cardiac index, and oxygenation saturation from mixed venous blood in the pulmonary artery, during the perioperative period. Perioperative hemodynamic values were stratified according to age. Logistic regression was applied to predict the crude probability of death within one year from surgery according to hemodynamic values at six hours after surgery, stratified by age and use of inotropic agents, respectively. Lower values for cardiac index and mixed venous blood in the pulmonary artery with increasing age, across all points in time in the perioperative course, were observed. Higher probability of death was associated with lower hemodynamic values in the postoperative phase, and the probability of death was modified by age and the need for inotropic agents.

DISCUSSION

This is a large registry based study describing the perioperative hemodynamic profile of patients undergoing cardiac surgery and the results enhance our understanding of age-differentiated values of CI and SvO2 in this specific population.

Inotropic and Mechanical Support of Critically Ill Patient after Cardiac Surgery

INTRODUCTION

Cardiac surgery patients often need inotropic support to establish hemodynamic stability and adequate oxygen supply. The management of patients with coronary vascular disease can be challenging especially in patients with severe left ventricular dysfunction and critical left main or severe triple vessel disease.

METHODS

Article has descriptive character and presents a case report of 58 years old male patient who was admitted to our hospital due to planned coronary bypass surgery.

RESULTS

Applying inotropic support, IABP and adequate volume management during surgery and post surgery period in ICU has led to hemodynamic stability. Leading to the recovery of the patient and hospital discharge.

DISCUSSION

Given the availability of the treatment options, inotropic and mechanical support played a major role to produce the positive outcome in the presented case. Many factors were unfavourable, extreme hypotension, high lactate and creatining levels, mechanical ventilation and related complications.

The relationship between inotropic support therapy and central partial pressure of venous-arterial carbon dioxide after cardiopulmonary bypass

Background

This study aims to investigate the effects of partial pressure of venous-arterial carbon dioxide changes in the early period after cardiopulmonary bypass in patients who did or did not receive inotropic support therapy and the effect of these changes on tissue perfusion.

Methods

A total of 100 consecutive patients (70 males, 30 females; mean age 61.8±2.3 years; range, 20 to 75 years) who underwent open heart surgery were divided into two groups as those who did not receive any inotropic agent (group 1, n=50) and those who received at least one inotropic agent (group 2, n=50) during the early postoperative period. Heart rate, blood oxygen saturation level, mean arterial pressure, central venous pressure and urine volume, lactate and base excess levels were recorded during the postoperative first 24 hours. At the same timeframe, partial pressure of venous-arterial carbon dioxide level was calculated from central venous and peripheral blood samples.

Results

In both groups, partial pressure of venous-arterial carbon dioxide were significantly higher in the postoperative fourth hour compared with basal values. This significant difference continued for the postoperative first 24 hours. Partial pressure of venous-arterial carbon dioxide in group 2 was significantly higher at the 12^th-hour measurement (p=0.002). Lactate levels at zeroth and eighth hours were significantly higher in group 2 (p=0.012 and p=0.017, respectively). Fourthhour urine excretion volumes were significantly lower in group 1 (p=0.010). Mean arterial pressure at zeroth, 12th and 20th hours was significantly higher in group 2 (p=0.001, p=0.016, and p=0.027, respectively). At the eighth-hour measurement, a positive weak relationship was detected between partial pressure of venousarterial carbon dioxide and lactate levels (r=0.253 and p=0.033).

Conclusion

This study demonstrated that partial pressure of venous-arterial carbon dioxide increased in the first few hours and remained to be high for 24 hours after cardiopulmonary bypass independently of the use of inotropic support. However, in the postoperative period, even after lactate and base excess levels return to baseline values, partial pressure of venous-arterial carbon dioxide may continue to remain at high values, which may indicate impaired perfusion in some tissues.

Effect of Prophylactic Levosimendan on All-Cause Mortality in Pediatric Patients Undergoing Cardiac Surgery-An Updated Systematic Review and Meta-Analysis

Background: Levosimendan, a calcium sensitizer, enhances the myocardial function by generating more energy-efficient myocardial contractility than that achieved through adrenergic stimulation with catecholamines. We conducted this meta-analysis to primarily investigate the effects of levosimendan on all-cause mortality in pediatric patients undergoing cardiac surgery under cardiopulmonary bypass. Methods: The databases of Pubmed, Embase, and Cochrane Library were searched till 21st March 2020. The eligible criteria were participants with age<18 year and undergoing cardiac surgery for congenital heart disease (CHD), and studies of comparison between levosimendan and placebo or other inotropes. Stata version 12.0 was used to perform statistical analyses. Results: Six randomized controlled trials (RCTs) and 1 case-control trial (CCT) including 436 patients were included. The results showed that levosimendan did not significantly decrease all-cause mortality compared with control drugs (and placebo) in children undergoing cardiac surgery (P = 0.403). Perioperative prophylactic levosimendan administration strikingly decreased the low cardiac output syndrome (LCOS) incidence (P = 0.016) but did not significantly reduce acute kidney injury (AKI) incidence (P = 0.251) and shorten mechanical ventilation and ICU stay time compared with other inotropes and placebo by analyzing the included literatures [mechanical ventilation (or intubation) time: P = 0.188; ICU stay time: P = 0.620]. Conclusions: Compared with other inotropes and placebo, perioperative prophylactic administration of levosimendan did not decrease the rates of mortality and AKI and shorten the time of mechanical ventilation (or intubation) and ICU stay but demonstrated a significant reduction in LCOS incidence after corrective surgery in pediatric patients for CHD. Due to limited number of included studies, the current data were insufficient to make the conclusions.

Managing Vasoactive Medications Following Cardiothoracic Surgery

This article reviews the use of vasoactive medications prescribed in the postoperative management of patients who have undergone cardiac surgery. With a focus on the influence these medications have on the physiologic contributors to cardiac output and blood pressure, insight into decision making related to use, titration, and discontinuation of these medications is provided. Case studies offer vignettes to demonstrate the application of knowledge gleaned from the article.

Factors Affecting Cardiovascular Physiology in Cardiothoracic Surgery: Implications for Lumped-Parameter Modeling

Cardiothoracic surgeries are complex procedures during which the patient cardiovascular physiology is constantly changing due to various factors. Physiological changes begin with the induction of anesthesia, whose effects remain active into the postoperative period. Depending on the surgery, patients may require the use of cardiopulmonary bypass and cardioplegia, both of which affect postoperative physiology such as cardiac index and vascular resistance. Complications may arise due to adverse reactions to the surgery, causing hemodynamic instability. In response, fluid resuscitation and/or vasoactive agents with varying effects may be used in the intraoperative or postoperative periods to improve patient hemodynamics. These factors have important implications for lumped-parameter computational models which aim to assist surgical planning and medical device evaluation. Patient-specific models are typically tuned based on patient clinical data which may be asynchronously acquired through invasive techniques such as catheterization, during which the patient may be under the effects of drugs such as anesthesia. Due to the limited clinical data available and the inability to foresee short-term physiological regulation, models often retain preoperative parameters for postoperative predictions; however, without accounting for the physiologic changes that may occur during surgical procedures, the accuracy of these predictive models remains limited. Understanding and incorporating the effects of these factors in cardiovascular models will improve the model fidelity and predictive capabilities.

Levosimendan in patients with low cardiac output syndrome undergoing cardiac surgery: A systematic review and meta-analysis

Levosimendan is an inotropic agent that has been shown in small studies to treat low cardiac output syndrome in cardiac surgery. However, large randomised controlled trials (RCTs) have been recently published and presented neutral results. We sought to determine the effect of levosimendan on mortality in adults with low ejection fraction undergoing cardiac surgery. We searched different databases: Medline, Embase, Cochrane Central Register of Controlled Trials, and clinical trial registries. We included RCTs comparing events in the levosimendan versus placebo in adult patients with ejection fraction ≤ 35% undergoing cardiac surgery. Outcomes were mortality at 30-day, mortality beyond 30-day, acute kidney injury and myocardial infarction. Five trials with a total of 1519 patients were selected. Four trials were rated as low risk of bias. Our meta-analysis showed no significant difference between levosimendan versus placebo mortality at 30-day [odds radio (OR): 0.62; 95% confidence intervals (CI): 0.32 to 1.20; I² = 33%; high quality evidence] and mortality beyond 30-day (OR: 0.71; 95% CI: 0.46 to 1.11; I² = 0%). Similarly, there were no significant differences between the levosimendan versus placebo in the incidence of acute kidney injury (OR: 0.61, 95% CI: 0.33-1.13) and myocardial infarction (OR: 0.41, 95% CI: 0.08 to 1.22). The current evidence suggests that levosimendan is not associated with significantly reduced mortality in patients with reduced ejection fraction undergoing cardiac surgery.

Beneficial effects of levosimendan on survival in patients undergoing extracorporeal membrane oxygenation after cardiovascular surgery

BACKGROUND

The impact of levosimendan treatment on clinical outcome in patients undergoing extracorporeal membrane oxygenation (ECMO) support after cardiovascular surgery is unknown. We hypothesized that the beneficial effects of levosimendan might improve survival when adequate end-organ perfusion is ensured by concomitant ECMO therapy. We therefore studied the impact of levosimendan treatment on survival and failure of ECMO weaning in patients after cardiovascular surgery.

METHODS

We enrolled a total of 240 patients undergoing veno-arterial ECMO therapy after cardiovascular surgery at a university-affiliated tertiary care centre into our observational single-centre registry.

RESULTS

During a median follow-up period of 37 months (interquartile range 19-67 months), 65% of patients died. Seventy-five per cent of patients received levosimendan treatment within the first 24 h after initiation of ECMO therapy. Cox regression analysis showed an association between levosimendan treatment and successful ECMO weaning [adjusted hazard ratio (HR) 0.41; 95% confience interval (CI) 0.22-0.80; P=0.008], 30 day mortality (adjusted HR 0.52; 95% CI 0.30-0.89; P=0.016), and long-term mortality (adjusted HR 0.64; 95% CI 0.42-0.98; P=0.04).

CONCLUSIONS

These data suggest an association between levosimendan treatment and improved short- and long-term survival in patients undergoing ECMO support after cardiovascular surgery.

Intraoperative milrinone versus dobutamine in cardiac surgery patients: a retrospective cohort study on mortality

Background

Several choices of inotropic therapy are available and used in relation to cardiac surgery. Comparisons are necessary to select optimal therapy. In Denmark, dobutamine and milrinone are the two inotropic agents most commonly used to treat post-bypass low cardiac output syndrome. This study compares all-cause mortality with these drugs.

Methods

In a retrospective observational study we investigated 10,700 consecutive patients undergoing cardiac surgery from 1 April 2006 to 31 December 2013 at Aarhus and Aalborg University Hospitals in the Central and Northern Denmark Region. Prospectively entered data in the Western Danish Heart Registry on intraoperative use of inotropes were used to identify 952 patients treated with milrinone, 418 patients treated with dobutamine, and 82 patients receiving a combination of the two inotropes. All-cause mortality among patients receiving dobutamine was compared to all-cause mortality among milrinone receivers.

Multiple logistic regression analyses including preoperative and intraoperative variables along with g-formula analyses were used to model 30-day and 1-year mortality risks. Reported were standardized mortality risk differences between the treatment groups.

Results

Among patients receiving intraoperative dobutamine, 18 (4.3%) died within 30 days and 49 (11.7%) within 1 year. Corresponding 30-day and 1-year mortality for milrinone receivers were 81 (8.5%) and 170 (17.9%). Risk of death within 30 days and 1 year was increased for intraoperative milrinone compared to dobutamine with a standardized risk difference of 4.06% (confidence interval (CI) 1.23; 6.89, p = 0.005) and 4.77% (CI 0.39; 9.15, p = 0.033), respectively. Sensitivity analyses including adjustment for milrinone preference, hemodynamic instability prior to cardiopulmonary bypass, and separate analyses on hospital level all confirmed a sign toward increased mortality among milrinone receivers.

Conclusions

Intraoperative use of milrinone in cardiac surgery may be associated with an increase in all-cause mortality compared to use of dobutamine.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1969-1) contains supplementary material, which is available to authorized users.

Treatment of Patients with Cardiac Surgery Associated-Acute Kidney Injury

Members of the Acute Dialysis Quality Initiative (ADQI) participated in a 3-day conference in Vicenza in May 2007 to evaluate the available literature on this topic and draft consensus recommendations for research studies in this area. This report summarizes the available evidence and describes the key questions that will need to be addressed with the goal of standardizing the care of patients with cardiac surgery-associated acute kidney injury (CSA-AKI) and improving outcomes.

Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Several studies suggested beneficial effects of perioperative levosimendan on postoperative outcome after cardiac surgery. However, three large randomized controlled trials (RCTs) have been recently published and presented neutral results. We performed a systematic review with meta-analysis and trial sequential analysis (TSA) to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery.

METHODS

Electronic databases were searched up to September 2017 for RCTs on preoperative levosimendan versus any type of control. The Cochrane methodology was employed. We calculated odds ratio (OR) or Risk Ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses and we further performed TSA.

RESULTS

We included data from 40 RCTs and 4246 patients. Pooled analysis of 5 low risk of bias trials (1910 patients) showed no association between levosimendan and mortality (OR 0.86 [95% CI, 0.62, 1.18], p=0.34, TSA inconclusive), acute kidney injury, need of renal replacement therapy, myocardial infarction, ventricular arrhythmias, and serious adverse events, but an association with higher incidence of supraventricular arrhythmias (RR 1.11 [95% CI, 1.00, 1.24], p=0.05, TSA inconclusive) and hypotension (RR 1.15 [95% CI, 1.01, 1.30], p=0.04, TSA inconclusive). Analysis including all 40 trials found that levosimendan was associated with lower postoperative mortality (OR 0.56 [95% CI, 0.44, 0.71], p<0.00001, TSA conclusive), acute kidney injury, and renal replacement therapy, and higher incidence of hypotension.

CONCLUSIONS

There is not enough high-quality evidence to neither support nor discourage the systematic use of levosimendan in cardiac surgery.

Levosimendan for Hemodynamic Support after Cardiac Surgery

BACKGROUND

Acute left ventricular dysfunction is a major complication of cardiac surgery and is associated with increased mortality. Meta-analyses of small trials suggest that levosimendan may result in a higher rate of survival among patients undergoing cardiac surgery.

METHODS

We conducted a multicenter, randomized, double-blind, placebo-controlled trial involving patients in whom perioperative hemodynamic support was indicated after cardiac surgery, according to prespecified criteria. Patients were randomly assigned to receive levosimendan (in a continuous infusion at a dose of 0.025 to 0.2 μg per kilogram of body weight per minute) or placebo, for up to 48 hours or until discharge from the intensive care unit (ICU), in addition to standard care. The primary outcome was 30-day mortality.

RESULTS

The trial was stopped for futility after 506 patients were enrolled. A total of 248 patients were assigned to receive levosimendan and 258 to receive placebo. There was no significant difference in 30-day mortality between the levosimendan group and the placebo group (32 patients [12.9%] and 33 patients [12.8%], respectively; absolute risk difference, 0.1 percentage points; 95% confidence interval [CI], -5.7 to 5.9; P=0.97). There were no significant differences between the levosimendan group and the placebo group in the durations of mechanical ventilation (median, 19 hours and 21 hours, respectively; median difference, -2 hours; 95% CI, -5 to 1; P=0.48), ICU stay (median, 72 hours and 84 hours, respectively; median difference, -12 hours; 95% CI, -21 to 2; P=0.09), and hospital stay (median, 14 days and 14 days, respectively; median difference, 0 days; 95% CI, -1 to 2; P=0.39). There was no significant difference between the levosimendan group and the placebo group in rates of hypotension or cardiac arrhythmias.

CONCLUSIONS

In patients who required perioperative hemodynamic support after cardiac surgery, low-dose levosimendan in addition to standard care did not result in lower 30-day mortality than placebo. (Funded by the Italian Ministry of Health; CHEETAH ClinicalTrials.gov number, NCT00994825 .).

Comparison of Levosimendan, Milrinone and Dobutamine in treating Low Cardiac Output Syndrome Following Valve Replacement Surgeries with Cardiopulmonary Bypass

INTRODUCTION

Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common and associated with increased mortality. Maintenance of adequate cardiac output is one of the primary objectives in management of such patients.

AIM

To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries.

MATERIALS AND METHODS

Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10μg/kg over 10 minutes, followed by 0.1μg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5μg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m². In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant.

RESULTS

The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1±8.79, 11.3±6.34 and 16.62±9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20^th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs.

CONCLUSION

Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries.

Post hoc analysis of the glutamics-trial: intravenous glutamate infusion and use of inotropic drugs after cabg

BACKGROUND

Intravenous glutamate reduced the risk of developing severe circulatory failure after isolated coronary artery bypass graft surgery (CABG) for acute coronary syndrome (ACS) in a double-blind randomised clinical trial (GLUTAMICS-ClinicalTrials.gov Identifier: NCT00489827 ). Here our aim was to study if glutamate was associated with reduced the use of inotropes.

METHODS

Post-hoc analysis of 824 patients undergoing isolated CABG for ACS in the GLUTAMICS-trial. ICU-records were retrospectively scrutinised including hourly registration of inotropic drug infusion, dosage and total duration during the operation and postoperatively.

RESULTS

ICU-records were found for 171 out of 177 patients who received inotropes perioperatively. Only one fourth of the patients treated with inotropes fulfilled study criteria for postoperative heart failure at weaning from cardiopulmonary bypass (CPB) or later in the ICU. Inotropes were mainly given preemptively to facilitate weaning from CPB or to treat postoperative circulatory instability (bleeding, hypovolaemia). Except for a significantly lower use of epinephrine there were only trends towards lower need of other inotropes overall in the glutamate group. In patients treated with inotropes (glutamate n = 17; placebo n = 13) who fulfilled study criteria for left ventricular failure at weaning from CPB the average duration of inotropic treatment (34 ± 20 v 80 ± 77 h; p = 0.014) and the number of inotropes used (1.35 ± 0.6 v 1.85 ± 0.7; p = 0.047) were lower in the glutamate group.

CONCLUSIONS

Intravenous glutamate was associated with a minor influence on inotrope use overall in patients undergoing CABG for ACS whereas a considerable and significant reduction was observed in patients with heart failure at weaning from CPB.

Pharmacologic agents for acute hemodynamic instability: recent advances in the management of perioperative shock- a systematic review

Despite the growing body of evidence evaluating the efficacy of vasoactive agents in the management of hemodynamic instability and circulatory shock, it appears no agent is superior. This is becoming increasingly accepted as current guidelines are moving away from detailed algorithms for the management of shock, and instead succinctly state that vasoactive agents should be individualized and guided by invasive hemodynamic monitoring. This extends to the perioperative period, where vasoactive agent selection and use may still be left to the discretion of the treating physician with a goal-directed approach, consisting of close hemodynamic monitoring and administration of the lowest effective dose to achieve the hemodynamic goals. Successful therapy depends on the ability to rapidly diagnose the etiology of circulatory shock and thoroughly understand its pathophysiology as well as the pharmacology of vasoactive agents. This review focuses on the physiology and resuscitation goals in perioperative shock, as well as the pharmacology and recent advances in vasoactive agent use in its management.

Literature review of post-traumatic stress disorder in the critical care population

AIM

To determine which factors relate to the development of post-traumatic stress disorder, in adult patients who are admitted to critical care units.

BACKGROUND

Patient survival rates from critical care areas are improving each year and this has led to interest in the long-term outcomes for patients who have been discharged from such environments. Patients typically require invasive and extensive treatment, which places a stress on physical and mental health. Prevalence estimates of post-traumatic stress disorder in the critical care discharge population vary from 5-63%, yet it remains unclear what the predisposing factors are.

DESIGN

A systematised review.

METHOD

Subject heading and keyword searches were conducted in MEDLINE, CINAHL, PsycINFO and ScienceDirect, with 23 articles identified that examined the relationship between critical care and the development of post-traumatic stress disorder.

RESULTS

Three main themes were identified; Critical Care Factors, Patient Factors and Experience Factors. Eight key and three potential causative factors were found: younger age, female, previous psychiatric history, length of ICU stay, benzodiazepine sedation, use of stress hormones, delusional memory and traumatic memory, delirium, GCS score of ≤9 on admission & use of mechanical restraint.

CONCLUSIONS

Post-traumatic stress reactions can be strongly related to the development and presence of traumatic and delusional memories. Younger patients may exclude themselves from research to avoid their traumatic thoughts. The role of prior psychiatric illness is unknown. Distinction between 'factual' and 'false' or delusional memory as occurs in the literature maybe unhelpful in understanding trauma reactions.

RELEVANCE TO CLINICAL PRACTICE

There are around 38,000 occupied critical care beds each year in England. The scale of the issue is therefore substantial. Risk factors can be isolated from available evidence and provide a rudimentary risk assessment tool to inform practice development in this area.

Liver function predicts survival in patients undergoing extracorporeal membrane oxygenation following cardiovascular surgery

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) represents a valuable and rapidly evolving therapeutic option in patients with severe heart or lung failure following cardiovascular surgery. However, despite significant advances in ECMO techniques and management, prognosis remains poor and accurate risk stratification challenging. We therefore evaluated the predictive value of liver function variables on all-cause mortality in patients undergoing venoarterial ECMO support after cardiovascular surgery.

METHODS

We included into our single-center registry a total of 240 patients undergoing venoarterial ECMO therapy following cardiovascular surgery at a university-affiliated tertiary care center.

RESULTS

The median follow-up was 37 months (interquartile range 19-67 months), and a total of 156 patients (65%) died. Alkaline phosphatase and total bilirubin were the strongest predictors for 30-day mortality, with adjusted hazard ratios (HRs) per 1-standard deviation increase of 1.36 (95% confidence interval [CI] 1.10-1.68; P = 0.004) and 1.22 (95% CI 1.07-1.40; P = 0.004), respectively. The observed associations persisted for long-term mortality, with adjusted HRs of 1.27 (95% CI 1.03-1.56; P = 0.023) for alkaline phosphatase and 1.22 (95% CI 1.07-1.39; P = 0.003) for total bilirubin.

CONCLUSIONS

The present study demonstrates that elevated values of alkaline phosphatase and total bilirubin are sensitive parameters for predicting the short-term and long-term outcomes of ECMO patients.

Cost-benefits of incorporating levosimendan into cardiac surgery practice: German base case

OBJECTIVE

To evaluate the cost-benefit of using levosimendan compared with dobutamine, in the perioperative treatment of patients undergoing cardiac surgery who require inotropic support.

METHODS

A two-part Markov model was designed to simulate health-state transitions of patients undergoing cardiac surgery, and estimate the short- and long-term health benefits of treatment. Hospital length of stay (LOS), mortality, medication, and adverse events were key clinical- and cost-inputs. Cost-benefits were evaluated in terms of costs and bed stays within the German healthcare system. Drug prices were calculated from the German Drug Directory (€/2014) and published literature, with a 3% annual discount rate applied. The base case analysis was for a 1-year time horizon.

RESULTS

The use of levosimendan vs dobutamine was associated with cost savings of €4787 per patient from the German hospital perspective due to reduced adverse events and shorter hospital LOS, leading to increased bed capacity and hospital revenue.

LIMITATIONS

A pharmacoeconomic calculation for the specific situation of the German healthcare system that is based on international clinical trial carries a substantial risk of disregarding potentially relevant but unknown confounding factors (i.e., ICU-staffing, co-medications, standard-ICU care vs fast-tracking, etc.) that may either attenuate or increase the outcome pharmacoeconomic effects of a drug; however, since these conditions would also apply for patients treated with comparators, their net effects may not necessarily influence the conclusions.

CONCLUSIONS

The use of levosimendan in patients undergoing cardiac surgery who require inotropic support appears to be cost-saving. The results of the analysis provide a strong rationale to run local clinical studies with pharmacoeconomic end-points which would allow a much more precise computation of the benefits of levosimendan.

Shock Management for Cardio-surgical ICU Patients - The Golden Hours

Postoperative shock following cardiac surgery is a serious condition with a high morbidity and mortality. There are four types of shock: cardiogenic, hypovolemic, obstructive and distributive and these can occur alone or in combination. Early identification of the underlying diseases and understanding of the mechanisms at play are key for successful management of shock. Prompt resuscitation measures are necessary to reverse the shock state and avoid permanent organ dysfunction or death. In this review, the authors focus on the management during the first 6 hours of shock (the 'golden hours'). They discuss how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery. The review incorporates the findings of recent trials on early goal-directed therapy and includes practical recommendations in areas in which the evidence is scare or controversial. While the review focuses on cardio-surgical patients, the suggested treatment algorithms might be usefully expanded to other critically ill patients with shock arising from other causes.

Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care

OBJECTIVES

Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient.

DATA SOURCE AND SYNTHESIS

Narrative review of relevant English-language peer-reviewed medical literature.

CONCLUSIONS

Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.

Clinical practice in perioperative monitoring in adult cardiac surgery: is there a standard of care? Results from an national survey

This study was to investigate and define what is considered as a current clinical practice in hemodynamic monitoring and vasoactive medication use after cardiac surgery in Italy. A 33-item questionnaire was sent to all intensive care units (ICUs) admitting patients after cardiac surgery. 71 out of 92 identified centers (77.2 %) returned a completed questionnaire. Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature and blood gas analysis were identified as routinely used hemodynamic monitoring, whereas advanced monitoring was performed with pulmonary artery catheter or echocardiography. Crystalloids were the fluids of choice for volume replacement (86.8 % of Centers). To guide volume management, central venous pressure (26.7 %) and invasive blood pressure (19.7 %) were the most frequently used parameters. Dobutamine was the first choice for treatment of left heart dysfunction (40 %) and epinephrine was the first choice for right heart dysfunction (26.8 %). Half of the Centers had an internal protocol for vasoactive drugs administration. Intra-aortic balloon pump and extra-corporeal membrane oxygenation were widely available among Cardiothoracic ICUs. Angiotensin-converting enzyme inhibitors were suspended in 28 % of the Centers. The survey shows what is considered as standard monitoring in Italian Cardiac ICUs. Standard, routinely used monitoring consists of ECG, SpO2, etCO2, invasive BP, CVP, diuresis, body temperature, and BGA. It also shows that there is large variability among the various Centers regarding hemodynamic monitoring of fluid therapy and inotropes administration. Further research is required to better standardize and define the indicators to improve the standards of intensive care after cardiac surgery among Italian cardiac ICUs.

Catecholamine and volume therapy for cardiac surgery in Germany--results from a postal survey

BACKGROUND

Management of cardiac surgery patients is a very standardized procedure in respective local institutions. Yet only very limited evidence exists concerning optimal indication, safety and efficacy of hemodynamic monitoring catecholamine and fluid therapy.

METHODS

Between April and May 2013, all 81 German anaesthesia departments involved in cardiac surgery care were asked to participate in a questionnaire addressing the institutional specific current practice in hemodynamic monitoring, catecholamine and volume therapy.

RESULTS

51 (63%) questionnaires were completed and returned. All participating centers used basic hemodynamic monitoring (i.e. invasive arterial blood pressure and central venous pressure), supplemented by transesophageal echocardiography. Pulmonary arterial catheter and calibrated trend monitoring devices were also routinely available. In contrast, non-calibrated trend monitoring and esophageal doppler ultrasound devices were not commonly in use. Cerebral oximetry is increasingly emerging, but lacks clear indications. The majority of patients undergoing cardiac surgery, especially in university hospitals, required catecholamines during perioperative care, In case of low cardiac output syndrome, dobutamine (32%), epinephrine (30%) or phosphodiesterase inhibitors (8%) were first choice. In case of hypotension following vasoplegia, norepinephrine (96%) represented the most common catecholamine. 88% of the participating centers reported regular use of colloid fluids, with hydroxyethyl starches (HES) being first choice (64%).

CONCLUSIONS

Choice of hemodynamic monitoring is homogenous throughout German centers treating cardiac surgery patients. Norepinephrine is the first line catecholamine in cases of decrease in peripheral vascular resistance. However, catecholamine choice for low cardiac output syndrome varies considerably. HES was the primary colloid used for fluid resuscitation. After conduct of this survey, HES use was restricted by European regulatory authorities in critically ill patients and should only be considered as second-line fluid in surgical patients without renal impairment or severe coagulopathy. Large clinical studies addressing catecholamine and fluid therapy in cardiac surgery patients are lacking.