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Wang L, Wang F, Kang W, Gao G, Liu T, Chen B, Liu W. Impact of paravertebral block on perioperative neurocognitive disorder: a systematic review and meta-analysis of randomized controlled trials. Front Aging Neurosci 2023; 15:1237001. [PMID: 37854033 PMCID: PMC10580806 DOI: 10.3389/fnagi.2023.1237001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/28/2023] [Indexed: 10/20/2023] Open
Abstract
Objective To investigate whether paravertebral block reduces postoperative delirium (POD)/delayed neurocognitive recovery (DNR) in adults after major surgery with general anesthesia. Methods For this systematic review and meta-analysis, we searched online databases PubMed, EMBASE, CENTRAL, and Web of Science till March 19th, 2023 to examine studies which use paravertebral block (PVB) for perioperative neurocognitive disorder. Primary and secondary outcomes were identified for the incidence of perioperative neurocognitive disorder. We did not restrict the follow-up duration of the included studies. Statistical analysis was performed to calculate mean difference (MD), Odd ratios (OR) and CI between RCTs. The quality of the evidence was assessed with the Cochrane risk of bias tool. The registration number of the study in PROSPERO is CRD42023409502. PROSPERO is an international database of prospectively registered systematic reviews. Registration provides transparency in the review process and it helps counter publication bias. Results Total 1,225 patients from 9 RCTs were analyzed. The incidence of POD [Odds Ratio (OR) = 0.48, 95% CI 0.32, 0.72; p = 0.0004; I2 = 0%] and DNR [OR = 0.32, 95% CI 0.13, 0.80; p = 0.01; I2 = 0%] were significantly reduced in PVB group. The analysis showed no significant differences in postoperative MMSE scores [MD = 0.50, 95% CI -2.14, 3.15; p = 0.71; I2 = 98%]. Paravertebral block analgesia reduces pain scores and/or opioid use after surgery. Additionally, blood pressure was significantly lower in the PVB group, intraoperatively [MD = -15.50, 95% CI -20.71, -10.28; p < 0.001; I2 = 12%] and postoperatively [MD = -5.34, 95% CI -10.65, -0.03 p = 0.05; I2 = 36%]. Finally, PVB group had significantly shorter hospital stays [MD = -0.86, 95% CI -1.13, -0.59; p < 0.001; I2 = 0%]. Conclusion Paravertebral block analgesia may prevent perioperative POD/DNR in patients undergoing major surgery. Further research with large sample sizes is required to confirm its effectiveness.
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Affiliation(s)
- Lu Wang
- Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital Capital Medical University, Beijing, China
| | - Fei Wang
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Wanli Kang
- Department for Disease Prevention and Control, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Guangkuo Gao
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Tao Liu
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Bin Chen
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Wei Liu
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
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Roberts DJ, Hall RI, Wang Y, Julien LC, Wood J, Goralski KB. S100B as a biomarker of blood-brain barrier disruption after thoracoabdominal aortic aneurysm repair: a secondary analysis from a prospective cohort study. Can J Anaesth 2021; 68:1756-1768. [PMID: 34570352 DOI: 10.1007/s12630-021-02110-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 08/05/2021] [Accepted: 08/08/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The objective of this study was to determine whether the magnitude of the peripheral inflammatory response to cardiovascular surgery is associated with increases in blood-brain barrier (BBB) permeability as reflected by changes in cerebrospinal fluid (CSF)/plasma S100B concentrations. METHODS We conducted a secondary analysis from a prospective cohort study of 35 patients undergoing elective thoracoabdominal aortic aneurysm repair with (n = 17) or without (n = 18) cardiopulmonary bypass (CPB). Plasma and CSF S100B, interleukin-6 (IL-6), and albumin concentrations were measured at baseline (C0) and serially for up to five days. RESULTS Following CPB, the median [interquartile range] plasma S100B concentration increased from 58 [32-88] pg·mL-1 at C0 to a maximum concentration (Cmax) of 1,131 [655-1,875] pg·mL-1 over a median time (tmax) of 6.3 [5.9-7.0] hr. In the non-CPB group, the median plasma S100B increased to a lesser extent. There was a delayed increase in CSF S100B to a median Cmax of 436 [406-922] pg·mL-1 in the CPB group at a tmax of 23.7 [18.5-40.2] hr. In the non-CPB group, the CSF concentrations were similar at all time points. In the CPB group, we did not detect significant correlations between plasma and CSF S100B with plasma IL-6 [r = 0.52 (95% confidence interval [CI], -0.061 to 0.84)] and CSF IL-6 [r = 0.53 (95% CI, -0.073 to 0.85)] concentrations, respectively. Correlations of plasma or CSF S100B levels with BBB permeability were not significant. CONCLUSION The lack of parallel increases in plasma and CSF S100B following CPB indicates that S100B may not be a reliable biomarker for BBB disruption after thoracoabdominal aortic aneurysm repair employing CPB. TRIAL REGISTRATION www.clinicaltrials.gov (NCT00878371); registered 7 April 2009.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- The Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Richard I Hall
- Department of Pharmacology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Critical Care Medicine, Central Zone, Nova Scotia Health Authority, Halifax, NS, Canada
- Department of Anesthesia, Pain Management, and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Yan Wang
- College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Lisa C Julien
- Department of Critical Care Medicine, Central Zone, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Jeremy Wood
- Divisions of Cardiac and Vascular Surgery, Department of Surgery, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kerry B Goralski
- Department of Pharmacology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
- College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
- Department of Pediatrics, Faculty of Medicine, Dalhousie University and IWK Health Centre, Halifax, NS, Canada.
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Meng F, Ma J, Wang W, Lin B. Meta-analysis of interleukin 6, 8, and 10 between off-pump and on-pump coronary artery bypass groups. Bosn J Basic Med Sci 2017; 17:85-94. [PMID: 28284177 DOI: 10.17305/bjbms.2017.1505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 10/06/2016] [Accepted: 10/07/2016] [Indexed: 12/24/2022] Open
Abstract
This study aimed to evaluate the role of off-pump coronary artery bypass (CAB) surgery on the decrease of postoperative inflammatory responses in patients. We systematically searched databases of PubMed and Embase to select the related studies. Interleukin (IL) 6, 8, and 10 were used as outcomes and pooled analysis was performed using R 3.12 software. Standardized mean differences (SMDs) and their 95% confidence intervals (95% CIs) were considered as effect estimates. A total of 27 studies, including 1340 participants, were recruited in this meta-analysis. The pooled analyses showed that postoperative concentration of IL-10 at 12 hours was significantly lower in off-pump CAB group compared to on-pump CAB group (SMD = -1.3640, 95% CI = -2.0086--0.7193). However, no significant differences were found in pre and postoperative concentrations of IL-6 and 8 between off-pump and on-pump CAB groups. These results suggest that there is no advantage of off-pump CAB surgery in the reduction of inflammation compared to on-pump CAB surgery.
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Affiliation(s)
- Fanbo Meng
- Department of Cardiology, China Japan Union Hospital of Jilin University, Changchun, China.
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4
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Mach L, Bedanova H, Soucek M, Karpisek M, Konecny T, Nemec P, Orban M. Impact of cardiopulmonary bypass surgery on cytokines in epicardial adipose tissue: comparison with subcutaneous fat. Perfusion 2016; 32:279-284. [PMID: 28155592 DOI: 10.1177/0267659116683791] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cardiac surgery and cardiopulmonary bypass (CPB) have been shown to stimulate a systemic inflammatory response which has been associated with adverse postoperative outcomes. Adipose tissue, both epicardial (EAT) and subcutaneous (SAT), is a known source of inflammatory cytokines, but its role in the pathophysiology of surgery- and CPB-induced systemic inflammatory response has not been fully elucidated. Therefore, we conducted a study to establish levels of selected cytokines in EAT and SAT prior to and after surgery with CPB. METHODS Adipose tissue samples were obtained from patients undergoing planned cardiac surgery on CPB. Samples from EAT and SAT were collected before and immediately after CPB. Levels of tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6), adipocyte fatty acid-binding protein (AFABP), leptin and adiponectin were determined by ELISA, which were adjusted for a total concentration of proteins in the individual samples. RESULTS Samples from 77 patients (mean age 67.68 ± 11.5 years) were obtained and analysed. Leptin, adiponectin, TNF-α and AFABP were shown to decrease their concentrations statistically significantly in the EAT after CPB while no statistically significant drop was observed in the SAT. On the contrary, IL-6 showed only a slight and statistically insignificant decrease in the EAT after CPB and it was in the SAT where a statistically significant drop was observed. DISCUSSION One of the most relevant findings of this study was the marked decrease in EAT levels of TNF-α, AFABP, leptin and adiponectin after the CPB termination. Our results suggest that EAT might serve as a pool of cytokines which are released into the circulation in reaction to surgery with CPB. Should these novel findings be confirmed, new strategies to assess and possibly reduce EAT contribution on adverse outcomes of cardiac surgery may be developed.
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Affiliation(s)
- Lukas Mach
- 1 University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.,2 International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Helena Bedanova
- 3 Centre of Cardiovascular Surgery and Organ Transplantation Brno, Brno, Czech Republic
| | - Miroslav Soucek
- 2 International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Michal Karpisek
- 4 Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Tomas Konecny
- 5 Keck Medical Centre of the University of Southern California, Los Angeles, CA, USA
| | - Petr Nemec
- 2 International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czech Republic.,3 Centre of Cardiovascular Surgery and Organ Transplantation Brno, Brno, Czech Republic
| | - Marek Orban
- 3 Centre of Cardiovascular Surgery and Organ Transplantation Brno, Brno, Czech Republic.,4 Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
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Djaiani G, Fedorko L, Beattie WS. Regional Anesthesia in Cardiac Surgery: A Friend or A Foe? Semin Cardiothorac Vasc Anesth 2016; 9:87-104. [PMID: 15735847 DOI: 10.1177/108925320500900109] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Escalating costs and change in the profile of patients presenting for cardiac surgery requires modification of perioperative management strategies. Regional anesthesia has played an integral part of many fast-track anesthesia protocols across North America and Europe. This review suggests that for patients undergoing coronary artery bypass graft surgery, the risk-to-benefit ratio is in favor of epidural and spinal anesthesia, provided there are no specific contraindications and the guidelines for the use of regional techniques in cardiac surgery are followed. Patients managed with regional techniques seem to benefit from superior postoperative analgesia, shorter postoperative ventilation, reduced incidence of supraventricular arrhythmia, and lower rates of perioperative myocardial infarction. The results of this analysis suggest that for each episode of neurologic complication, 20 myocardial infarctions and 76 episodes of atrial fibrillation would be prevented, thus, we would consider the regional anesthesia and analgesia to be an effective strategy that improves perioperative morbidity. However, other treatment modalities such as the addition of calcium channel blockers, aspirin, and beating heart surgery, are also suggested to be beneficial in cardiac surgical patients and may impose less risk than the use of regional techniques. We believe that the results presented in this review are encouraging enough to permit continued investigation. A prospective, randomized, controlled multicenter trial needs to be adequately powered to answer important clinical questions and allow for a long-term follow-up.
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Affiliation(s)
- George Djaiani
- Department of Anesthesiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Tóth Z, Györimolnár I, Abrahám H, Hevesi A. Cannulation and Cardiopulmonary Bypass Produce Selective Brain Lesions in Pigs. Asian Cardiovasc Thorac Ann 2016; 14:273-8. [PMID: 16868098 DOI: 10.1177/021849230601400402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Whether cardiopulmonary bypass alone or together with manipulation of the aorta produces neurologic complications remains controversial. Using a pig model, the immediate effects of aortic cannulation and cardiopulmonary bypass on neural injury in different brain regions were investigated in 3 experimental groups: non-operated controls; operated controls with aortic cannulation without cardiopulmonary bypass; and operated animals undergoing cardiopulmonary bypass. Immunohistochemistry using a monoclonal antibody against calretinin was used to show possible ischemic damage in the hippocampal formation which is one of the most vulnerable regions to ischemia. Both cannulation of the aorta alone and cardiopulmonary bypass resulted in numerous argyrophilic neurons in discrete regions of the prefrontal and cerebellar cortex. Decreased calretinin immunoreaction and a reduced number of calretinin-positive neurons were observed following aortic cannulation or cardiopulmonary bypass compared to the non-operated controls. This suggests that both cannulation of the aorta alone and cardiopulmonary bypass affect a selected population of neurons. Therefore, off-pump, aorta no-touch technique may prevent neurologic complications.
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Affiliation(s)
- Zsolt Tóth
- Division of Cardiac Surgery, Heart Institute, Faculty of Medicine, University of Pécs, 7624 Pécs, Ifjuság út 13, Hungary.
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Ouk T, Amr G, Azzaoui R, Delassus L, Fossaert E, Tailleux A, Bordet R, Modine T. Lipid-lowering drugs prevent neurovascular and cognitive consequences of cardiopulmonary bypass. Vascul Pharmacol 2016; 80:59-66. [DOI: 10.1016/j.vph.2015.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/22/2015] [Accepted: 12/16/2015] [Indexed: 01/07/2023]
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8
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Pain and inflammatory response following off-pump coronary artery bypass grafting. Curr Opin Anaesthesiol 2014; 27:106-15. [DOI: 10.1097/aco.0000000000000036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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10
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Finley MJ, Clark KA, Alferiev IS, Levy RJ, Stachelek SJ. Intracellular signaling mechanisms associated with CD47 modified surfaces. Biomaterials 2013; 34:8640-9. [PMID: 23948164 DOI: 10.1016/j.biomaterials.2013.07.088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/25/2013] [Indexed: 01/07/2023]
Abstract
We have previously established that recombinant CD47 can ameliorate the inflammatory response to synthetic polymeric surfaces. Here, we begin to profile, at the transcriptional, translational and cell signaling level, the inflammatory cell response when blood interacts with CD47 modified polyvinyl chloride (PVC) (CD47-PVC). We used qPCR arrays to compare transcriptional changes between human whole blood exposed to CD47-PVC or PVC. Transcription of IL1F5, IL1F10, IL17F, CCL3, CCL8, CCL28, CXCL12, and CXCL13 was upregulated in blood exposed to PVC, compared to CD47-PVC. The increase in CCL3 and CCL8 transcription correlated with an increase in the chemokines' presence in the plasma. Exposure of blood to CD47-PVC resulted in an increase, compared to PVC, in transcription of CCL2, CCL4, CCL20, CXCL1, TGFβ3, GDF3, GDF10, CD40LG, and TNFSF10. CD47-PVC exposure resulted in an increase of the following matrix metalloproteinase related genes: MMP1, MMP7, MMP13, and MMP16. Phosflow cytometry, and assays examining transcription factor binding, cell attachment, and genome-wide chromatin association indicated that members of the JAK-STAT signaling pathway, particularly JAK2 and STAT5, mediate inflammatory cell interactions with CD47-PVC. Our data demonstrate that differential molecular responses to CD47 involve downregulation of cytokines, upregulation of MMPs, and JAK/STAT signaling mechanisms.
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Affiliation(s)
- Matthew J Finley
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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11
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Erdoes G, Balmer ML, Slack E, Kocsis I, Lehmann LE, Eberle B, Stüber F, Book M. CD62L (L-selectin) shedding for assessment of perioperative immune sensitivity in patients undergoing cardiac surgery with cardiopulmonary bypass. PLoS One 2013; 8:e53045. [PMID: 23301018 PMCID: PMC3536798 DOI: 10.1371/journal.pone.0053045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 11/23/2012] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To investigate the suitability of blood granulocyte and monocyte sensitivity, as measured by the quantity of different agonists required to induce CD62L shedding, for assessment of perioperative immune changes in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS Patients scheduled for aortocoronary bypass grafting or for valve surgery were included in this prospective observational study. Blood samples were drawn before anesthesia induction, directly after surgery and 48 hours after anesthesia induction. We determined the concentration of two different inflammatory stimuli--lipoteichoic acid (LTA) and tumor necrosis factor alpha (TNF)--required to induce shedding of 50% of surface CD62L from blood granulocytes and monocytes. In parallel monocyte surface human leukocyte antigen (HLA)-DR, and plasma interleukin (IL)-8, soluble (s)CD62L, soluble (s)Toll-like receptor (TLR)-2 and ADAM17 quantification were used to illustrate perioperative immunomodulation. RESULTS 25 patients were enrolled. Blood granulocytes and monocytes showed decreased sensitivity to the TLR 2/6 agonist Staphylococcus aureus LTA immediately after surgery (p = 0.001 and p = 0.004 respectively). In contrast, granulocytes (p = 0.01), but not monocytes (p = 0.057) displayed a decreased postoperative sensitivity to TNF. We confirmed the presence of a systemic inflammatory response and a decreased immune sensitivity in the post-surgical period by measuring significant increases in the perioperative plasma concentration of IL-8 (p ≤ 0.001) and sTLR (p = 0.004), and decreases in monocyte HLA-DR (p<0.001), plasma sCD62L (p ≤ 0.001). In contrast, ADAM17 plasma levels did not show significant differences over the observation period (p = 0.401). CONCLUSIONS Monitoring granulocyte and monocyte sensitivity using the "CD62L shedding assay" in the perioperative period in cardiac surgical patients treated with the use of cardiopulmonary bypass reveals common changes in sensitivity to TLR2/6 ligands and to TNF stimulus. Further long-term follow-up studies will address the predictive value of these observations for clinical purposes.
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Affiliation(s)
- Gabor Erdoes
- University Department of Anesthesiology and Pain Therapy, Inselspital, Bern University Hospital, Bern, Switzerland.
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12
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van Harten AE, Scheeren TWL, Absalom AR. A review of postoperative cognitive dysfunction and neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia 2012; 67:280-93. [DOI: 10.1111/j.1365-2044.2011.07008.x] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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13
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Cata JP, Abdelmalak B, Farag E. Neurological biomarkers in the perioperative period. Br J Anaesth 2011; 107:844-58. [PMID: 22065690 DOI: 10.1093/bja/aer338] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The rapid detection and evaluation of patients presenting with perioperative neurological dysfunction is of great clinical relevance. Biomarkers have been defined as biological molecules that can be used as an indicator of new onset or progression of a biological process or effect of treatment. Biomarkers have become increasingly important in this setting to supplement other modalities of diagnosis such as EEG, sensory- or motor-evoked potential, transcranial Doppler, near-infrared spectroscopy, or imaging methods. A number of neuro-proteins have been identified and are currently under investigation for potential to provide insights into injury severity, outcome, and the ability to monitor cellular damage and molecular events that occur during neurological injury. S100B is a protein released by glial cells and is considered a marker of blood-brain barrier dysfunction. Clinical studies in patients undergoing cardiac and non-cardiac surgery indicate that serum levels of S100B are increased intraoperatively and after operation. The neurone-specific enolase has also been extensively investigated as a potential marker of neuronal injury in the context of cardiac and non-cardiac surgery. A third biomarker of interest is the Tau protein, which has been linked to neurodegenerative disorders. Tau appears to be more specific than the previous two biomarkers since it is only found in the central nervous system. The metalloproteinase and ubiquitin C terminal hydroxylase-L1 (UCH-L1) are the most recently researched markers; however, their usefulness is still unclear. This review presents a comprehensive overview of S100B, neuronal-specific enolase, metalloproteinases, and UCH-L1 in the perioperative period.
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Affiliation(s)
- J P Cata
- Department of Anaesthesiology and Perioperative Medicine, The University of Texas-MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Increased levels of baseline biomarkers reflecting platelet and endothelial activation predict early cognitive dysfunction after lung surgery. Eur J Anaesthesiol 2009; 26:708-10. [PMID: 19352185 DOI: 10.1097/eja.0b013e32832a0c18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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15
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Raja SG, Berg GA. Impact of off-pump coronary artery bypass surgery on systemic inflammation: current best available evidence. J Card Surg 2007; 22:445-55. [PMID: 17803591 DOI: 10.1111/j.1540-8191.2007.00447.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The systemic inflammatory response after coronary artery bypass grafting using cardiopulmonary bypass (CPB) contributes substantially to postoperative organ dysfunction and coagulation disorders. Important features of this inflammatory reaction include the activation of complement and leukocytes, the release of proinflammatory cytokines, alterations in the metabolism of nitric oxide, and an increase in the production of oxygen-free radicals, which in some cases may lead to oxidant stress injury. Several strategies including the use of steroids, use of aprotinin, heparin-coated CPB circuits, and hemofiltration have been reported to reduce the inflammatory reaction induced by CPB and its consequences. A more radical and effective way of counteracting the effects of the inflammatory reaction and oxidative stress may be the omission of CPB itself. The development and application of off-pump coronary artery bypass (OPCAB) technology has largely been driven by this theme of avoiding systemic inflammatory reaction to decrease the incidence and/or severity of adverse outcomes. This review article discusses the influence of cardiopulmonary bypass on systemic inflammation and attempts to evaluate the current best available evidence on the impact of OPCAB on systemic inflammation.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Western Infirmary Glasgow, Glasgow, United Kingdom.
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16
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Brown JR, Hernandez F, Klemperer JD, Clough RA, DiPierro FV, Hofmaster PA, Ross CS, O'Connor GT. Cardiac troponin T levels in on- and off-pump coronary artery bypass surgery. Heart Surg Forum 2006; 10:E42-6. [PMID: 17162401 DOI: 10.1532/hsf98.20061105] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Conventional coronary artery bypass graft surgery (CCAB) has been associated with greater myocardial injury than off-pump surgery (OPCAB). However, the extent of myocardial injury following CCAB and OPCAB has not been assessed by priority of surgery or the number of diseased vessels. We tested the hypothesis that the additional myocardial injury associated with CCAB compared with OPCAB is sustained when patients are stratified by priority and 2- or 3-vessel disease. METHODS AND RESULTS In this prospective cohort, we measured 24-hour postoperative cardiac troponin T (cTnT) following CCAB and OPCAB surgery to determine if OPCAB results in less perioperative myocardial damage by priority (urgent or elective). We studied 1511 patients who underwent heart surgery in one hospital in northern New England between 2000 and 2004. Surgeons used either CCAB (778 patients) of OPCAB (733 patients). Unpaired t tests were used to test the mean difference in cTnT between CCAB and OPCAB subgroups. Mean cTnT levels were significantly higher in the CCAB group (0.94 ng/mL) than the OPCAB group (0.18 ng/mL) with P < .001; this difference was consistent across urgent and elective surgeries, and patients with both 2- and 3-vessel disease. CCAB patients consistently demonstrated higher cTnT levels. Similar results were evident when stratified by patient characteristics and surgeon. CONCLUSIONS In summary, higher postoperative cTnT levels are associated with CCAB than with OPCAB, regardless of priority, number of diseased vessels, patient characteristics, or surgeon. OPCAB results in less myocardial injury in patients, whether they present with 2- or 3-vessel disease and whether they undergo urgent or elective cardiac surgery.
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Affiliation(s)
- Jeremiah R Brown
- Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Lebanon, New Hampshire, USA.
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Baufreton C, Allain P, Chevailler A, Etcharry-Bouyx F, Corbeau JJ, Legall D, de Brux JL. Brain injury and neuropsychological outcome after coronary artery surgery are affected by complement activation. Ann Thorac Surg 2006; 79:1597-605. [PMID: 15854939 DOI: 10.1016/j.athoracsur.2004.08.061] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2004] [Indexed: 12/22/2022]
Abstract
BACKGROUND The impact of the postoperative inflammatory response on the central nervous system after cardiac surgery is uncertain. The goal of the study was to evaluate the role of complement activation on cellular brain injury in patients undergoing coronary artery bypass grafting. In addition, neuropsychological functioning was assessed. METHODS We randomly assigned 30 patients to undergo surgery using either standard noncoated or heparin-coated extracorporeal circuits. Closed cardiopulmonary bypass and controlled suctions of pericardial shed blood were standardized in both groups. Complement activation and cellular brain injury were assessed by measuring sC5b-9 and protein s100beta. Neuropsychometric tests were performed at least 2 weeks before operation and at discharge. They served to calculate z scores of cognitive domains and changes in neuropsychological functioning. RESULTS Peak value of sC5b-9 at the end of cardiopulmonary bypass in the noncoated group was significantly higher than in the heparin-coated group (p = 0.005). Changes in the heparin-coated group were not significant. Glial injury started after initiation of surgery and peaked at the end of cardiopulmonary bypass with significantly higher concentration of s100beta in the noncoated than in the heparin-coated group (p = 0.008). Values of s100beta and of sC5b-9 were significantly correlated (p = 0.03). Although no statistically significant between group difference was detected, z scores of attention and flexibility or executive functions were lowered postoperatively within the noncoated group (p = 0.033 and p = 0.028), whereas z scores were unchanged within the heparin-coated group. CONCLUSIONS Inhibition of complement activation by heparin-coated cardiopulmonary bypass reduced brain cell injury and was associated with preserved neuropsychological functioning after coronary artery bypass grafting.
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Affiliation(s)
- Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Angers, Angers, France.
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Nimjee SM, Keys JR, Pitoc GA, Quick G, Rusconi CP, Sullenger BA. A novel antidote-controlled anticoagulant reduces thrombin generation and inflammation and improves cardiac function in cardiopulmonary bypass surgery. Mol Ther 2006; 14:408-15. [PMID: 16765093 DOI: 10.1016/j.ymthe.2006.04.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 03/24/2006] [Accepted: 04/16/2006] [Indexed: 10/24/2022] Open
Abstract
Heparin and protamine are the standard anticoagulant-antidote regimen used in almost every cardiopulmonary bypass (CPB) procedure even though both are associated with an array of complications and toxicities. Here we demonstrate that an anticoagulant aptamer-antidote pair targeting factor IXa can replace heparin and protamine in a porcine CPB model and also limit the adverse effects on thrombin generation, inflammation, and cardiac physiology associated with heparin and protamine use. These results demonstrate that targeting clotting factors upstream of thrombin in the coagulation cascade can potentially reduce the perioperative pathologies associated with CPB and suggest that the aptamer-antidote pair to FIXa may improve the outcome of patients undergoing CPB. In particular, this novel anticoagulant-antidote pair may prove to be useful in patients diagnosed with heparin-induced thrombocytopenia or those who have been sensitized to protamine, particularly patients who have insulin-dependent diabetes.
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Affiliation(s)
- Shahid M Nimjee
- University Program in Genetics and Genomics, Duke University Medical Center, Durham, NC 27710, USA
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Raja SG, Dreyfus GD. Modulation of systemic inflammatory response after cardiac surgery. Asian Cardiovasc Thorac Ann 2006; 13:382-95. [PMID: 16304234 DOI: 10.1177/021849230501300422] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cardiac surgery and cardiopulmonary bypass initiate a systemic inflammatory response largely determined by blood contact with foreign surfaces and the activation of complement. It is generally accepted that cardiopulmonary bypass initiates a whole-body inflammatory reaction. The magnitude of this inflammatory reaction varies, but the persistence of any degree of inflammation may be considered potentially harmful to the cardiac patient. The development of strategies to control the inflammatory response following cardiac surgery is currently the focus of considerable research efforts. Diverse techniques including maintenance of hemodynamic stability, minimization of exposure to cardiopulmonary bypass circuitry, and pharmacologic and immunomodulatory agents have been examined in clinical studies. This article briefly reviews the current concepts of the systemic inflammatory response following cardiac surgery, and the various therapeutic strategies being used to modulate this response.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair Street, Glasgow G3 8SJ, Scotland, United Kingdom.
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Hoedemaekers CW, Pickkers P, Netea MG, van Deuren M, Van der Hoeven JG. Intensive insulin therapy does not alter the inflammatory response in patients undergoing coronary artery bypass grafting: a randomized controlled trial [ISRCTN95608630]. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R790-7. [PMID: 16356228 PMCID: PMC1414017 DOI: 10.1186/cc3911] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2005] [Revised: 10/06/2005] [Accepted: 10/21/2005] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Strict control of plasma glucose in diabetic and non-diabetic patients has been shown to improve outcome in several clinical settings. There is extensive evidence that glucose can stimulate the production of pro-inflammatory cytokines such as tumor necrosis factor (TNF)-alpha and IL-6, with no effect on the anti-inflammatory cytokine IL-10. We hypothesized that strict glucose regulation results in a change in cytokine balance from a pro-inflammatory state to a more balanced anti-inflammatory condition. In a randomized controlled trial we studied the effect of strict glycemic control on the local and systemic pro-inflammatory and anti-inflammatory balance in non-diabetic patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass. METHODS After surgery patients were randomly assigned to intensive insulin therapy (blood glucose between 80 and 110 mg/dl) or conventional insulin therapy (blood glucose less than 200 mg/dl). At 0, 1, 2, 4, 8, 12, 16 and 24 hours after admission to the intensive care unit, plasma samples and samples from the mediastinal drains were obtained. We measured the concentrations of the pro-inflammatory cytokines TNF-alpha and IL-6 and the anti-inflammatory cytokine IL-10 by enzyme-linked immunosorbent assay. RESULTS Both patient groups were comparable in demographics, clinical characteristics and peri-operative data. In the intensive treatment group, glucose levels were significantly lower than in the conventionally treated group. No differences were found between both groups in the concentrations of TNF-alpha, IL-6 and IL-10 in plasma samples or in fluid draining the mediastinal cavity. Levels of IL-6 and IL-10 were significantly higher in mediastinal fluid samples than in plasma samples, suggesting a compartmentalized production of cytokines. CONCLUSION The protective effect of intensive insulin therapy in patients after cardiac surgery with cardiopulmonary bypass is not related to a change in cytokine balance from a pro-inflammatory to an anti-inflammatory pattern. Systemic cytokine levels are not representative of the local inflammatory response.
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Affiliation(s)
- Cornelia W Hoedemaekers
- Department of Intensive Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Marcel van Deuren
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Johannes G Van der Hoeven
- Department of Intensive Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
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Hall RI. Serum S-100beta protein and postoperative neurological dysfunction--ready for prime time? Can J Anaesth 2005; 51:645-8. [PMID: 15310629 DOI: 10.1007/bf03018419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Richard I Hall
- Department of Anesthesia, Halifax Infirmary, Queen Elizabeth II Health Sciences Centre, 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada.
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