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Orbegozo D, Stringari G, Damazio R, De Backer D, Vincent JL, Creteur J. Altered Microvascular Reactivity During a Skin Thermal Challenge Is Associated With Organ Dysfunction and Slow Recovery After Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00436-1. [PMID: 39034163 DOI: 10.1053/j.jvca.2024.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/26/2024] [Accepted: 06/30/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES To assess microvascular reactivity during a skin thermal challenge early post-cardiac surgery and its association with outcomes. DESIGN Noninvasive physiological study. SETTING Thirty-five-bed department of intensive care. PARTICIPANTS Patients admitted to the intensive care unit post-cardiac surgery. INTERVENTIONS Thermal challenge. MEASUREMENTS AND MAIN RESULTS A total of 46 patients were included; 14 needed vasoactive or ventilatory support for at least 48 hours (slow recovery), and 32 had a more rapid recovery. Skin blood flow (SBF) was measured on the anterior proximal forearm using skin laser Doppler. A thermal challenge was performed by abruptly increasing local skin temperature from 37°C to 43°C while monitoring SBF. The ratio between SBFs at 43°C and 37°C was calculated to measure microvascular reactivity. SBF at 37°C was not significantly different in patients with a slow recovery and those with a rapid recovery, but SBF after 9 minutes at 43°C was lower (48.5 [17.3-69.0] v 85.1 [45.2-125.7], p < 0.01), resulting in a lower SBF ratio (2.8 [1.5-4.7] v 4.8 [3.7-7.8], p < 0.01). Patients with lower SBF ratios were more likely to have dysfunction of at least one organ (assessed using the sequential organ dysfunction score) 48 hours post-cardiac surgery than those with higher ratios: 88% versus 40% versus 27% (p < 0.01), respectively, for the lowest, middle, and highest tertiles of SBF ratio. In multivariable analysis, a lower SBF ratio was an independent risk factor for slow recovery. CONCLUSIONS Early alterations in microvascular reactivity, evaluated by a skin thermal challenge, are correlated with organ dysfunction. These observations may help in the development of new, simple, noninvasive monitoring systems in postoperative patients.
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Affiliation(s)
- Diego Orbegozo
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gianni Stringari
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Rafael Damazio
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel De Backer
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Sevuk U, Bahadir MV. Symptom progression following on-pump versus off-pump coronary artery bypass graft surgery in patients with peripheral arterial disease. Gen Thorac Cardiovasc Surg 2023; 71:158-166. [PMID: 35943642 DOI: 10.1007/s11748-022-01855-x] [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: 04/13/2022] [Accepted: 07/18/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This study aims to examine whether cardiac surgery leads to symptom progression in the early postoperative period in patients with the peripheral arterial disease (PAD) and evaluate the difference between on-pump (OPCAB) and off-pump (ONCAB) coronary artery bypass graft surgery with regard to the symptom progression. METHODS This retrospective study included one hundred consecutive adult patients with PAD at Fontaine stage 2b (pain-free walking distance less than 100 m) undergoing ONCAB and one hundred consecutive adult patients with PAD at Fontaine stage 2b (pain-free walking distance less than 100 m) undergoing OPCAB. Symptom progression was defined as the development of ischemic rest pain (Fontaine stage 3). RESULTS In the first week after surgery, 12 patients in the OPCAB group and 53 patients in the ONCAB group had postoperative symptom progression (p < 0.001). Rest pain resolved in most of these patients on the 15th postoperative day. At the end of the second month, rest pain resolved in all patients. Logistic regression analysis revealed that cardiac surgery with CPB, ABI < 0.5, postoperative nadir hct levels ≤ 25%, and intraoperative tissue hypoxia were independently associated with postoperative symptom progression. CONCLUSIONS In summary, we found that cardiac surgery may lead to symptom progression in patients with severe claudication in the early postoperative period. Our results suggest that OPCAB may lead to lower rates of symptom progression compared to ONCAB.
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Affiliation(s)
- Utkan Sevuk
- Department of Cardiovascular Surgery, Bower Hospital, Diyarbakir, 21300, Turkey
| | - Mehmet Veysi Bahadir
- Division of Transplantation, Dicle University, Organ Nakli Klinigi, Yenişehir, Silvan Yolu, Diyarbakir, 21100, Turkey.
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Cho AR, Lee HJ, Hong JM, Kang C, Kim HJ, Kim EJ, Kim MS, Jeon S, Hwang H. Microvascular reactivity as a predictor of major adverse events in patients with on-pump cardiac surgery. Korean J Anesthesiol 2022; 75:338-349. [PMID: 35618262 PMCID: PMC9346279 DOI: 10.4097/kja.22097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Microcirculatory disturbances are typically most severe during cardiopulmonary bypass (CPB), which occurs during cardiac surgeries. If microvascular reactivity compensates for microcirculatory disturbances during CPB, tissue hypoxemia can be minimized. The primary aim of this study was to assess whether microvascular reactivity during CPB could predict major adverse events (MAE) after cardiac surgery. Methods This prospective observational study included 115 patients who underwent elective on-pump cardiac surgeries. A vascular occlusion test (VOT) with near-infrared spectroscopy was performed five times for each patient: before the induction of general anesthesia, 30 min after the induction of general anesthesia, 30 min after applying CPB, 10 min after protamine injection, and post-sternal closure. The postoperative MAE was recorded. The area under the receiver operating characteristic (AUROC) curve analysis was performed for the prediction of MAE using the recovery slope. Results Of the 109 patients, MAE occurred in 32 (29.4%). The AUROC curve for the recovery slope during CPB was 0.701 (P < 0.001; 95% CI [0.606, 0.785]). If the recovery slope during CPB was < 1.08%/s, MAE were predicted with a sensitivity of 62.5% and specificity of 72.7%. Conclusions Our study demonstrated that the recovery slope of the VOT during CPB could predict MAE after cardiac surgery. These results support the idea that disturbances in microcirculation induced by CPB can predict the development of poor clinical outcomes, thereby demonstrating the potential role of microvascular reactivity as an early predictor of MAE after cardiac surgery.
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Affiliation(s)
- Ah-Reum Cho
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyeon-Jeong Lee
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jeong-Min Hong
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Christine Kang
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyea-Jin Kim
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Pusan National University, Yangsan, Republic of Korea
| | - Min Su Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea
| | - Soeun Jeon
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyewon Hwang
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Niezen CK, Massari D, Vos JJ, Scheeren TWL. The use of a vascular occlusion test combined with near-infrared spectroscopy in perioperative care: a systematic review. J Clin Monit Comput 2022; 36:933-946. [PMID: 34982349 DOI: 10.1007/s10877-021-00779-w] [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: 08/09/2021] [Accepted: 11/12/2021] [Indexed: 11/30/2022]
Abstract
In the perioperative phase oxygen delivery and consumption can be influenced by different factors, i.e. type of surgery, anesthetic and cardiovascular drugs, or fluids. By combining near-infrared spectroscopy (NIRS) monitoring of regional tissue oxygen saturation (StO2) with an ischemic provocation test, the vascular occlusion test (VOT), local tissue oxygen consumption and vascular reactivity at the microcirculatory level can be assessed. This systematic review aims to give an overview of the clinical information that VOT-derived NIRS values can provide in the perioperative period. After performing a systematic literature search, we included 29 articles. It was not possible to perform a meta-analysis because of the lack of comparable data and the observational nature of the majority of the included articles. We have clustered the found articles in two groups: non-cardiac surgery and cardiac surgery. We found that VOT-derived NIRS values show a wide variability and are influenced by the effects of anesthetics, cardiovascular drugs, fluids, and by the type of surgery. Additionally, deviations in VOT-derived NIRS values are also associated with adverse patients' outcomes, such as postoperative complications, prolonged mechanical ventilation and prolonged hospital length of stay. However, given the variability in VOT-derived NIRS values, clinical applicability remains elusive. Future clinical interventional trials might provide additional insight into the potential of VOT associated with NIRS to optimize perioperative care by targeting specific interventions to optimize the function of the microvasculature.
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Affiliation(s)
- C K Niezen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands.
| | - D Massari
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - J J Vos
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
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Mizunoya K, Yagi Y, Morimoto Y, Hirano S. Altered microvascular reactivity assessed by near-infrared spectroscopy after hepato-pancreato-biliary surgery. J Clin Monit Comput 2021; 36:703-712. [PMID: 33829357 DOI: 10.1007/s10877-021-00697-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
Little is known about microcirculatory dysfunction following abdominal surgeries. This study aimed to evaluate changes in microvascular reactivity (MVR) before and after major abdominal surgery, assessed by near-infrared spectroscopy in conjunction with a vascular occlusion test. This prospective observational study included 50 adult patients who underwent hepato-pancreato-biliary surgery lasting ≥ 8 h. MVR was assessed by tissue oxygen saturation (StO2) changes in the plantar region of the foot during 3 min of vascular occlusion and subsequent release under general anesthesia before and after surgery. The primary outcome was alteration in the recovery slope of StO2 (RecStO2) and recovery time (tM) between the preoperative and postoperative values. Postoperative short-term outcome was represented by the Post-operative Morbidity Survey (POMS) score on the morning of postoperative day 2. After surgery, RecStO2 was reduced (0.74% [0.58-1.06]/s vs. 0.89% [0.62-1.41]/s, P = 0.001), and tM was longer (57.0 [42.9-71.0] s vs. 41.3 [35.5-56.5] s, P < 0.001), compared to the preoperative values. Macrohemodynamic variables such as cardiac index, arterial pressure, and stroke volume during postoperative measurement did not differ with or without relative MVR decline. In addition, the POMS score was not associated with postoperative alterations in microcirculatory responsiveness. MVR in the plantar region of the foot was reduced after major hepato-pancreato-biliary surgery regardless of macrocirculatory adequacy. Impaired MVR was not associated with short-term outcomes as long as macrocirculatory indices were well maintained. The impact of relative microcirculatory changes, especially combined with inadequate macrocirculation, on postoperative complications remains to be elucidated.Clinical Trial Registrations UMIN-CTR trial ID: 000033461.
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Affiliation(s)
- Kazuyuki Mizunoya
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan.
| | - Yasunori Yagi
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Hospital, Sapporo, Japan
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Effects of anesthetics on microvascular reactivity measured by vascular occlusion tests during off-pump coronary artery bypass surgery: a randomized controlled trial. J Clin Monit Comput 2020; 35:1219-1228. [PMID: 32915370 DOI: 10.1007/s10877-020-00587-8] [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: 05/03/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
Microvascular function may be modulated by various anesthetics. Desflurane and propofol anesthesia have different effects on microvascular function. However, there are few reports on the effects of sevoflurane and desflurane on microvascular function during cardiac surgery. We compared the effects of sevoflurane and desflurane on microvascular reactivity, as measured by the vascular occlusion tests (VOTs) during off-pump coronary artery bypass (OPCAB) surgery. Patients undergoing OPCAB were eligible for study inclusion. Patients were excluded if they were unsuitable for treatment with volatile agents or the VOT, had renal failure or uncontrolled diabetes, or were pregnant. The enrolled patients were randomized to receive sevoflurane or desflurane during surgery. Tissue oxygen saturation (StO2) dynamics during the VOT were measured at baseline (pre-anesthesia), pre-anastomosis, post-anastomosis of vessel grafts, and at the end of surgery. Macrohemodynamic variables, arterial blood gas parameters, and in-hospital adverse events were also evaluated. A total of 64 patients (32 in each group) were analyzed. StO2 dynamics did not differ between the groups. Compared to baseline, StO2 and the rate of recovery following vascular occlusion decreased at the end of surgery in both groups (adjusted p-value, < 0.001), and no group difference was observed. Macrohemodynamic variables, blood gas analysis results, and the rate of postoperative in-hospital adverse events were similar between the groups. Microvascular reactivity, as measured by the VOT during OPCAB, showed no difference between the sevoflurane and desflurane groups. Also, there were no group differences in macrohemodynamics or the rate of postoperative adverse events. TRIAL REGISTRATION : Clinicaltrials.gov, identifier NCT03209193; registered on July 3, 2017.
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