Pulmonary Effects of Methylprednisolone in Patients Undergoing Coronary Artery Bypass Grafting and Early Tracheal Extubation

Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery

BACKGROUND

Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added.

OBJECTIVES

Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness.

SECONDARY OBJECTIVE

to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses.

SEARCH METHODS

We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022.

SELECTION CRITERIA

We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis.

AUTHORS' CONCLUSIONS

A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.

Pulmonary reperfusion injury in post-palliative intervention of oligaemic cyanotic CHD: a new catastrophic consequence or just revisiting the same old story?

Pulmonary reperfusion injury is a well-recognised clinical entity in the setting pulmonary artery angioplasty for pulmonary artery stenosis or chronic thromboembolic disease, but not much is known about this complication in post-palliative intervention of oligaemic cyanotic CHD. The pathophysiology of pulmonary reperfusion injury in this population consists of both ischaemic and reperfusion injury, mainly resulting in oxidative stress from reactive oxygen species generation, followed by endothelial dysfunction, and cytokine storm that may induce multiple organ dysfunction. Other mechanisms of pulmonary reperfusion injury are "no-reflow" phenomenon, overcirculation from high pressure in pulmonary artery, and increased left ventricular end-diastolic pressure. Chronic hypoxia in cyanotic CHD eventually depletes endogenous antioxidant and increased the risk of pulmonary reperfusion injury, thus becoming a concern for palliative interventions in the oligaemic subgroup. The incidence of pulmonary reperfusion injury varies depending on multifactors. Despite its inconsistence occurrence, pulmonary reperfusion injury does occur and may lead to morbidity and mortality in this population. The current management of pulmonary reperfusion injury is supportive therapy to prevent deterioration of lung injury. Therefore, a general consensus on pulmonary reperfusion injury is necessary for the diagnosis and management of this complication as well as further studies to establish the use of novel and potential therapies for pulmonary reperfusion injury.

Effects of different doses of glucocorticoids on postoperative atrial fibrillation: a meta-analysis

BACKGROUND

Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery, and its occurrence is closely related to inflammation. This paper intends to apply meta-analysis to investigate the effect of glucocorticoids on POAF.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched using the internationally recognized systematic evaluation and retrieval strategy. Two review authors independently selected relevant studies and extracted data based on the Cochrane handbook for systematic reviews of interventions approach. Stata 17 was used for data analysis. In the subgroup analysis, we grouped the participant data according to differences in glucocorticoids dose and type of surgery. At the same time, we also conducted a meta-analysis on the possible infection and gastrointestinal injury caused by glucocorticoids use.

RESULTS

27 studies and 14,442 patients were finally included. Results from the random-effects model indicated that the incidence of POAF was lower in glucocorticoid group (RR 0.80, 95% CI 0.71-0.92, P = 0.001). According to the subgroup analysis result, low doses of glucocorticoids reduced the incidence of POAF (RR 0.81, 95% CI 0.71-0.92, P = 0.001). The effect of high doses glucocorticoids on the POAF was not statistically significant (RR 0.81, 95% CI 0.56-1.19, P = 0.286). In the coronary artery bypass grafting (CABG) subgroup, the glucocorticoids reduced the incidence of POAF (RR 0.71, 95% CI 0.58-0.87, P = 0.001). In the CABG OR Valvular Surgery group, the effect of glucocorticoids on POAF was not statistically significant (RR 0.88, 95% CI 0.75-1.03, P = 0.108). 15 studies documented postoperative complications of infection, two studies were excluded from the system because the end point event was 0, and meta-analysis showed no increased risk of infection from glucocorticoid use (RR 0.85, 95% CI 0.68-1.06, P = 0.158). Eight studies documented the effects of glucocorticoids on gastrointestinal diseases, and meta-analysis showed no differences between the two groups (RR 1.12, 95% CI 0.83-1.50, P = 0.450).

CONCLUSION

The use of glucocorticoids can reduce the incidence of POAF. The subgroup analysis result showed that low-dose glucocorticoids were more effective than high-dose glucocorticoids in inhibiting POAF. The use of glucocorticoids in CABG alone can better inhibit the occurrence of POAF. The effects of glucocorticoids on infection and gastrointestinal injury were not statistically significant.

REVIEW REGISTRATION

PROSPERO, CRD42022304521.

Effect of low-dose dexamethasone on extra vascular lung water in patients following on-pump elective primary coronary artery bypass graft surgery

Background

The primary objective was to compare the effect of a low-dose dexamethasone as against a saline placebo on extravascular lung water index (EVLWI) in patients undergoing elective primary coronary artery bypass surgery. The secondary endpoints were to assess the effect of dexamethasone on other volumetric parameters (pulmonary vascular permeability index, global end diastolic volume index, and intrathoracic blood volume index), Vasoactive Inotrope Scores, hemodynamic parameters and serum osmolality in both groups.

Settings and Design

Prospective observational study performed at a single tertiary cardiac care center.

Materials and Methods

Twenty patients were randomized to receive either dexamethasone (steroid group, n = 10) or placebo (nonsteroid group, n = 10) twice before the institution of cardiopulmonary bypass (CPB). EVLWI and other volumetric parameters were obtained with the help of VolumeView™ Combo Kit connected to EV 1000 clinical platform at predetermined intervals. Hemodynamic parameters, vasoactive-inotropic Scores, hematocrit values were recorded at the predetermined time intervals. Baseline and 1^st postoperative day serum osmolality values were also obtained.

Results

The two groups were evenly matched in terms of demographic and CPB data. Intra- and inter-group comparison of the baseline EVLWI including other volumetric and hemodynamic parameters with those recorded at subsequent intervals revealed no statistical difference and was similar. Generalized estimating equation model was obtained to compare the changes between the groups over the entire study period which showed that on an average the changes between the steroid and nonsteroid group in terms of all volumetric parameters were not statistically significant.

Conclusions

There were no beneficial effects of low-dose dexamethasone on EVLWI or other volumetric parameters in patients subjected to on-pump primary coronary bypass surgery. Hemodynamic parameters were also not affected. Probably, the advanced hemodynamic monitoring aided in optimal fluid management in the nonsteroidal group impacting EVLW accumulation.

Steroids and Survival in Critically Ill Adult Patients: A Meta-analysis of 135 Randomized Trials

OBJECTIVE

Corticosteroids have important effects on intermediate outcomes in critically ill patients, but their effect on survival is unknown. The objective of this meta-analysis was to analyze the effect on mortality of corticosteroids in critical and perioperative settings.

DESIGN

A meta-analysis of randomized trials.

SETTING

PubMed, Embase, BioMed Central, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched to February 1, 2018, for randomized trials comparing corticosteroids with placebo or standard care.

PARTICIPANTS

Critically ill or surgical adult patients.

INTERVENTIONS

Corticosteroids compared with placebo or standard care.

MEASUREMENTS AND MAIN RESULTS

A total of 44,553 patients from 135 studies were included. Overall, mortality in the corticosteroid group and in the control group were similar (16% v 16%; p = 0.9). Subanalyses identified a beneficial effect of corticosteroids on survival in patients with respiratory system diseases (9% v 13%; p < 0.001) and bacterial meningitis (28% v 32%; p= 0.04), and a detrimental effect on survival in patients with traumatic brain injury (22% v 19%; p < 0.001). No differences in mortality were found in patients with cardiac diseases (7% v 6%; p = 0.7), in patients undergoing cardiac surgery (2.8% v 3.2% p = 0.14), and when treatment duration or patient age were considered.

CONCLUSIONS

This meta-analysis documents the safety of corticosteroids in the overall critically ill population with the notable exception of brain injury patients, a setting where the authors confirmed their detrimental effect on survival. A possible beneficial effect of corticosteroids on survival was found among patients with respiratory diseases and in patients with bacterial meningitis.

Minor Infection Encouraged by Steroid Administration during Cardiac Surgery

The aim of this study was to investigate whether steroid administration would increase the risk of postoperative infection. Sixty adults who underwent elective cardiac surgery under cardiopulmonary bypass were prospectively randomized into two groups. Thirty-one patients received hydrocortisone (50 mg·kg−1) before and after cardiopulmonary bypass, the other 29 served as controls. Various hemodynamic and pulmonary measurements were obtained perioperatively, and the white blood cell counts and levels of C-reactive protein were checked up to the 14th postoperative day. Steroid administration did not have any favorable effects during the perioperative period. Re-administration of antibiotics was needed in 7 patients (22.6%) after the 7th postoperative day in the steroid group, and in 3 (10.3%) in the control group. The peak white cell counts and C-reactive protein levels after the 7th postoperative day were significantly higher in the steroid group. Steroid administration offered no clinical benefit to patients undergoing cardiac surgery with cardiopulmonary bypass, and it may encourage minor infections in the late postoperative period.

The efficacy of glucocorticoids for the prevention of atrial fibrillation, or length of intensive care unite or hospital stay after cardiac surgery: a meta-analysis

AIMS

cardiopulmonary bypass and cardiac surgery are associated with a significant systemic inflammatory response that has been suggested playing a causative role in the development of perioperative atrial fibrillation (POAF). The goal of this meta-analysis was to determine the efficacy of glucocorticoid prophylaxis in preventing POAF, or length of intensive care unite (ICU) or hospital stay.

METHODS

A systematic electronic database literature search of Cochrane controlled trials register (2013, issue 4) and MEDLINE (1966 to April, 2013) was conducted using specific search terms for all relevant articles. Including criteria were: randomized controlled clinical trials, participants were adults (≥18 years of age) undergoing cardiac surgery, evaluated glucocorticoid prophylaxis in cardiac surgery with adequately reported data on incidence of POAF, or length of ICU or hospital stay.

RESULTS

Forty-two randomized controlled trials involving 7621 participants were included in the meta-analysis. Overall, glucocorticoids prophylaxis significantly lowered participants' risk of developing POAF (Relative Risk [RR] 0.77; 95% confidence interval [CI] 0.66-0.90), P < 0.01), reduced length of ICU stay by 0.25 day (95% CI -0.40 to -0.10, P < 0.01). Glucocorticoid prophylaxis in cardiac surgery was not associated with increased all-cause of infection (RR 0.68; 95% CI 0.58-0.78, P < 0.01) and mortality (RR 0.75; 95% CI 0.52-1.08, P = 0.12).

CONCLUSIONS

Pooled evidence suggests that glucocorticoid prophylaxis may reduce the incidence of POAF. The beneficial effect on POAF is associated with reduced length of ICU and hospital stay, and infection rate.

Rationale and design of the steroids in cardiac surgery trial

BACKGROUND

Steroids may improve outcomes in high-risk patients undergoing cardiac surgery with the use of cardiopulmonary bypass (CBP). There is a need\ for a large randomized controlled trial to clarify the effect of steroids in such patients.

METHODS

We plan to randomize 7,500 patients with elevated European System for Cardiac Operative Risk Evaluation who are undergoing cardiac surgery with the use of CBP to methylprednisolone or placebo. The first coprimary outcome is 30-day all-cause mortality, and the most second coprimary outcome is a composite of death, MI, stroke, renal failure, or respiratory failure within 30 days. Other outcomes include a composite of MI or mortality at 30 days, new onset atrial fibrillation, bleeding and transfusion requirements, length of intensive care unit stay and hospital stay, infection, stroke, wound complications, gastrointestinal complications, delirium, postoperative insulin use and peak blood glucose, and all-cause mortality at 6 months.

RESULTS

As of October 22, 2013, 7,034 patients have been recruited into SIRS in 82 centers from 18 countries. Patient's mean age is 67.3 years, and 60.4% are male. The average European System for Cardiac Operative Risk Evaluation is 7.0 with 22.1% having an isolated coronary artery bypass graft procedure, and 66.1% having a valve procedure.

CONCLUSIONS

SIRS will lead to a better understanding of the safety and efficacy of prophylactic steroids for cardiac surgery requiring CBP.

Role of corticosteroids during cardiopulmonary bypass

Corticosteroids are commonly used in the peri-operative setting for patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The inflammatory response to CPB is associated with organ dysfunction and increased mortality. Corticosteroids reduce biochemical inflammatory markers associated with CPB, however the impact on clinical outcomes is mixed. The purpose of this article is to evaluate the evidence of changes in clinical outcomes associated with the peri-operative administration of corticosteroids in patients undergoing cardiac surgery with CPB. Randomized, placebo-controlled trials and meta-analyses were reviewed for evidence evaluating the impact of corticosteroids on clinical outcomes including mortality, myocardial infarction, atrial fibrillation (AF), duration of intubation, length of intensive care unit (ICU) or hospital stay, hyperglycemia, and gastrointestinal complications. Most of the relevant studies are underpowered to assess major clinical outcomes. Although corticosteroids likely reduce the risk of AF, this needs to be evaluated when used in addition to or in lieu of other anti-arrhythmic agents. Evidence does not equivocally support the use of corticosteroids to improve clinical outcomes in cardiac surgery patients.

Steroids for surgery during cardiopulmonary bypass in adults: a meta-analysis

STUDY OBJECTIVE

To evaluate the effect of steroid administration on myocardial infarction (MI), stroke, renal insufficiency, death, intensive care (ICU) length of stay (LOS) and hospital LOS of patients undergoing cardiopulmonary bypass (CPB).

DESIGN

Meta-analysis of parallel randomized controlled trials.

SETTING

University hospital.

MEAUREMENTS

A search was conducted in PubMed, EMBASE, MEDLINE(R) and the Cochrane Central Register of Controlled Trials of studies on adults undergoing surgery with CPB who received steroid administration. Effect size (risk ratio or mean difference) for MI, stroke, renal insufficiency, death, ICU LOS, and hospital LOS were evaluated.

MAIN RESULTS

48 RCTs published between 1977 and 2012 were retained for analysis. Steroids had no effect on the MI risk ratio (RR) 0.91 (95% confidence interval [CI] 0.63, 1.32); death at 30 days RR 0.84 (0.59, 1.20); stroke RR 0.92 (0.60, 1.42) or renal insufficiency RR 0.83 (0.52, 1.32). Administration of steroids reduced ICU LOS (P = 0.00001; I(2) 87.5%) and hospital LOS (P = 0.03; I(2) 81.1%). Metaregressions showed that duration of steroid administration was correlated with the reduction in ICU LOS (P = 0.0004) and hospital LOS (P < 0.00001).

CONCLUSIONS

Increasing the duration of steroid administration may reduce ICU and hospital LOS greater than increasing the dose.

Efficacy of methylprednisolone in preventing lung injury following pulmonary thromboendarterectomy

BACKGROUND

We sought to determine the efficacy and safety of perioperative treatment with methylprednisolone on the development of lung injury after pulmonary thromboendarterectomy.

METHODS

This was a randomized, prospective, double-blind, placebo-controlled study of 98 adult patients with chronic thromboembolic pulmonary hypertension who were undergoing pulmonary thromboendarterectomy at a single institution. The patients received either placebo (n = 47) or methylprednisolone (n = 51) (30 mg/kg in the cardiopulmonary bypass prime, 500 mg IV bolus following the final circulatory arrest, and 250 mg IV bolus 36 h after surgery). The primary end point was the presence of lung injury as determined by two independent, blinded physicians using prospectively defined criteria. The secondary end points included ventilator-free, ICU-free, and hospital-free days and selected levels of cytokines in the blood and in BAL fluid.

RESULTS

The incidence of lung injury was similar in both treatment groups (45% placebo, 41% steroid; P = .72). There were no statistical differences in the secondary clinical end points between treatment groups. Treatment with methylprednisolone, compared with placebo, was associated with a statistically significant reduction in plasma IL-6 and IL-8, a significant increase in plasma IL-10, and a significant reduction in postoperative IL-1ra and IL-6, but not IL-8 in BAL fluid obtained 1 day after surgery.

CONCLUSIONS

Perioperative methylprednisolone does not reduce the incidence of lung injury following pulmonary thromboendarterectomy surgery despite having an antiinflammatory effect on plasma and lavage cytokine levels.

Prophylactic corticosteroids for cardiopulmonary bypass in adults

BACKGROUND

High-dose prophylactic corticosteroids are often administered during cardiac surgery. Their use, however, remains controversial, as no trials are available that have been sufficiently powered to draw conclusions on their effect on major clinical outcomes.

OBJECTIVES

The objective of this meta-analysis was to estimate the effect of prophylactic corticosteroids in cardiac surgery on mortality, cardiac and pulmonary complications.

SEARCH STRATEGY

Major medical databases (CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched for randomised studies assessing the effect of corticosteroids in adult cardiac surgery. Database were searched for the full period covered, up to December 2009. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials comparing corticosteroid treatment to either placebo treatment or no treatment in adult cardiac surgery were selected. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more end-points.

DATA COLLECTION AND ANALYSIS

The processes of searching and selection for inclusion eligibility were performed independently by two authors. Also, quality assessment and data-extraction of selected studies were independently performed by two authors. The primary endpoints were mortality, cardiac and pulmonary complications. The main effect measure was the Peto odds ratio comparing corticosteroids to no treatment/placebo.

MAIN RESULTS

Fifty-four randomised studies, mostly of limited quality, were included. Altogether, 3615 patients were included in these studies. The pooled odds ratio for mortality was 1.12 (95% CI 0.65 to 1.92), showing no mortality reduction in patients treated with corticosteroids. The odds ratios for myocardial and pulmonary complications were 0.95, (95% CI 0.57 to 1.60) and 0.83 (95% CI 0.49 to 1.40), respectively. The use of a random effects model did not substantially influence study results. Analyses of secondary endpoints showed a reduction of atrial fibrillation and an increase in gastrointestinal bleeding in the corticosteroids group.

AUTHORS' CONCLUSIONS

This meta-analysis showed no beneficial effect of corticosteroid use on mortality, cardiac and pulmonary complications in cardiac surgery patients.

Review: Beyond the Guidelines: New and Novel Agents for the Prevention of Atrial Fibrillation After Cardiothoracic Surgery

Postoperative atrial fibrillation (POAF), a common complication of cardiac surgery, can increase the morbidity and mortality, as well as the costs of the surgery being preformed. Guidelines recommend the use of β-blockers, amiodarone, or sotalol to decrease the risk of experiencing POAF. However, none of these agents fully protect the patient from POAF, thus newer agents are needed to be used in combination with them. Many different agents have been studied to fit this role and may be grouped into 2 categories: agents with antiarrhythmic activity such as magnesium and polyunsaturated fatty acids and agents with anti-inflammatory activity such as statins and free radical scavengers. Most of these novel agents have been studied in a wide variety of trials; however, some clearly have more effect than others. Although none of these newer agents have the data required to make blanket recommendations for use at this point, given the safety profile and low costs of some, many continue to be evaluated in randomized-controlled trials.

Atrial fibrillation and inflammation

Atrial fibrillation (AF) is the most common clinical arrhythmia. Recent investigations have suggested that inflammation might have a role in the pathophysiology of AF. In this review, the association between inflammation and AF, and the effects of several agents that have anti-inflammatory actions, such as statins, polyunsaturated fatty acids, corticosteroids and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, have been investigated.

Protective effects of steroids in cardiac surgery: a meta-analysis of randomized double-blind trials

OBJECTIVE

Cardiac surgery and cardiopulmonary bypass (CPB) induce an acute inflammatory response contributing to postoperative morbidity. The use of steroids as anti-inflammatory agents in surgery using CPB has been tested in many trials and has been shown to have good anti-inflammatory effects but no clear clinical advantages for the lack of an adequately powered sample size. The aim of this study was to evaluate the effects of steroid treatment on mortality and morbidity after cardiac surgery.

DESIGN

A systematic meta-analysis of randomized double-blind trials (RDBs).

SETTING

A university hospital.

PARTICIPANTS

Adult patients who underwent cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

A trial search was performed through PubMed and Cochrane databases from 1966 to January 2009. Among 104 clinical trials reviewed, 31 RDB trials (1,974 patients) were considered suitable to be analyzed. A quality assessment of the trials was performed using the Jadad score. The types of steroid used in these trials were methylprednisolone (51.4%), dexamethasone (34.3%), hydrocortisone (5.7%), prednisolone (2.9%), or a combination of methylprednisolone and dexamethasone (5.7%). Steroid prophylaxis provided a protective effect preventing postoperative atrial fibrillation (odds ratio = 0.56; confidence interval [CI] 0.44-0.72, p < 0.0001), reducing postoperative blood loss (mean difference = -204.2 mL; CI from -287.4 to -121 mL; p < 0.0001), and reducing intensive care unit (mean difference = -6.6 hours; CI from -10.5 to -2.7 hours, p = 0.0007) and overall hospital stay (mean difference = -0.8 days; CI from -1.4 to -0.2 days, p = 0.01). Steroid prophylaxis had no effect on postoperative mortality, mechanical ventilation duration, re-exploration for bleeding, and postoperative infection.

CONCLUSIONS

A systematic review of RDB trials reveals that steroid prophylaxis may reduce morbidity after cardiac surgery and does not increase the risk of postoperative infections.

Upstream therapy of atrial fibrillation

Failure of current pharmacological therapy for atrial fibrillation in maintaining sinus rhythm may be due to structural atrial remodeling caused by inflammation and fibrosis. Upstream therapy that interferes in the structural remodeling process may be effective in maintaining sinus rhythm. This article reviews upstream therapy in atrial fibrillation. Various prospective and retrospective studies demonstrate that upstream therapy, consisting of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins, fish oils, glucocorticoids, or moderate physical activity, is associated with a reduced incidence of new-onset atrial fibrillation (i.e., primary prevention) and with a reduced recurrence of atrial fibrillation (i.e., secondary prevention). Larger clinical trials are required to further elucidate the position of upstream therapy in the primary and secondary prevention of atrial fibrillation.

Alveolar recruitment strategy during cardiopulmonary bypass does not improve postoperative gas exchange and lung function

Pulmonary dysfunction with impairment of lung function and oxygenation is one of the most serious problems in the early postoperative period after cardiac surgery. In this study we investigated the effect of alveolar recruitment strategy during cardiopulmonary bypass on postoperative gas exchange and lung function. This prospective randomized study included 32 patients undergoing elective myocardial revascularization with cardiopulmonary bypass. In 16 patients 5 cm H(2)O of positive end-expiratory pressure was applied after intubation and maintained until extubation (Group I). In the other 16 patients (group II) a positive end expiratory pressure (PEEP) of 5 cm H(2)O was maintained as well but was increased to 14 cm H(2)O every 20 min for 2 min during cross clamp. Measurements were taken preoperatively, before skin incision, before and after (3, 24, 48 h) cardiopulmonary bypass and before discharge (6th postoperative day). Postoperative gas exchange, extravascular lung water and lung function showed no significant difference between the groups. Postoperative pulmonary function variables were lower in both groups compared to baseline values. In patients with normal preoperative pulmonary function, application of an alveolar recruitment strategy during cardiopulmonary bypass does not improve postoperative gas exchange and lung function after cardiac surgery.

Benefits and Risks of Corticosteroid Prophylaxis in Adult Cardiac Surgery

Background— Cardiopulmonary bypass and cardiac surgery are associated with a significant systemic inflammatory response that may increase postoperative complications. This meta-analysis assessed whether the benefits and risks of corticosteroid use were dose dependent in adult cardiac surgery.

Methods and Results— Randomized controlled trials of the use of corticosteroid prophylaxis in adult cardiac surgery (>18 years of age) requiring cardiopulmonary bypass were selected from MEDLINE (1966 to August 1, 2008), EMBASE (1988 to August 1, 2008), and the Cochrane controlled trials register without any language restrictions. A total of 3323 patients from 50 randomized controlled trials were identified and subject to meta-analysis. Corticosteroid prophylaxis reduced the risk of atrial fibrillation (25.1% versus 35.1%; number needed to treat, 10; relative risk, 0.74; 95% confidence interval [CI], 0.63 to 0.86; P <0.01) and length of stay in the intensive care unit (weighted mean difference, −0.37 days; 95% CI, −0.21 to −0.52; P <0.01) and hospital (weighted mean difference, −0.66 days; 95% CI, −0.77 to −1.25; P =0.03) compared with placebo. The use of corticosteroid was not associated with an increased risk of all-cause infection (relative risk, 0.93; 95% CI, 0.61 to 1.41; P =0.73), but hyperglycemia requiring insulin infusion after corticosteroid prophylaxis was common (28.2%; relative risk, 1.49; 95% CI, 1.11 to 2.01; P <0.01). No additional benefits were found on all outcomes beyond a total dose of 1000 mg hydrocortisone, and very high doses of corticosteroid were associated with prolonged mechanical ventilation.

Conclusions— Evidence suggests that low-dose corticosteroid is as effective as high-dose corticosteroid in reducing the risk of atrial fibrillation and duration of mechanical ventilation but with fewer potential side effects in adult cardiac surgery.

The efficacy and dosage effect of corticosteroids for the prevention of atrial fibrillation after cardiac surgery: a systematic review

BACKGROUND

Atrial fibrillation (AF) complicates up to 60% of patients after cardiac surgery. Current prophylactic measures are inadequate. Corticosteroids down-regulate activation of the proinflammatory response (including C-reactive protein) after cardiopulmonary bypass and have been suggested to reduce the risk of postoperative AF.

OBJECTIVE

The goal of this meta-analysis was to determine (i) the efficacy of corticosteroids in preventing AF after cardiac surgery and (ii) the impact of different dosage regimens on this outcome.

DATA SOURCES

Sources included MEDLINE, Embase, the Cochrane Database of Systematic Reviews, and citation review of relevant primary and review articles.

STUDY SELECTION

The study identified prospective, randomized, placebo-controlled clinical trials that evaluated the role of corticosteroids in preventing AF after cardiac surgery.

DATA EXTRACTION

Data were abstracted on study design, study size, type of cardiac surgery, corticosteroid dosage regimen, and the incidence of AF in the first 72 hours after surgery. The total cumulated dose of corticosteroid was classified as low dose (<200 mg/d), moderate dose (200-1000 mg/d), high dose (1001-10,000 mg/d), and very high dose (10,000 mg/d) of hydrocortisone equivalents. Meta-analytic techniques were used to analyze the data.

DATA SYNTHESIS

We identified 7 relevant studies that included 1046 patients. The corticosteroid regimen differed between all studies with the total cumulative dose varying from 160 to 21,000 mg of hydrocortisone equivalents; one study each used low-dose and very high-dose corticosteroid. Overall, the use of corticosteroids was associated with a significant reduction in the risk of postoperative AF, with an odds ratio of 0.42, 95% confidence interval of 0.27 to 0.68, and P = .0004. Significant heterogeneity was however noted between studies. When the low-dose and very high-dose studies were excluded, the treatment effect was highly significant (odds ratio, 0.32; 95% confidence interval, 0.21 to 0.50; P < .00001) with insignificant heterogeneity.

CONCLUSIONS

Moderate-dosage corticosteroid (hydrocortisone) should be considered for the prevention of AF in high-risk patients undergoing cardiac surgery. Although the optimal dose, dosing interval, and duration of therapy is unclear, a single dose given at induction may be adequate. The interaction between corticosteroids, beta-blockers, and amiodarone requires further study.

Critical illness-related corticosteroid insufficiency

The diagnosis of adrenal failure and the indications for corticosteroid therapy in critically ill patients are controversial. This controversy is fueled by the complexity of the issues and the paucity of data from high quality clinical trials. Nevertheless, while the use of high-dose corticosteroids in patients with severe sepsis and ARDS failed to improve outcome and was associated with increased complications, an extended course of stress-dose corticosteroids has been reported to increase the occurrence of ventilator-free days and survival in select groups of ICU patients. These patients typically have an exaggerated proinflammatory response. Until recently the exaggerated proinflammatory response that characterizes critically ill patients with systemic inflammation has focused on suppression of the hypothalamic-pituitary-adrenal axis and adrenal failure. However, experimental and clinical data suggest that glucocorticoid tissue resistance may also play an important role. This complex syndrome is referred to as critical illness-related corticosteroid insufficiency (CIRCI) and is defined as inadequate corticosteroid activity for the severity of the illness of a patient. The paper reviews cortisol physiology, CIRCI, and the role of corticosteroid therapy in critically ill patients.

Pulmonary protection during cardiac surgery: systematic literature review

Ischemia-reperfusion injury occurs during heart surgery in which cardiopulmonary bypass is used. Current knowledge of the factors contributing to postoperative pulmonary dysfunction and the measures to avoid it are reviewed.

Inflammation in the genesis and perpetuation of atrial fibrillation

The prevalence and persistence of atrial fibrillation (AF) and the relative inefficacy of the currently available pharmacotherapy requires development of new treatment strategies. Recent findings have suggested a mechanistic link between inflammatory processes and the development of AF. Epidemiological studies have shown an association between C-reactive protein and both the presence of AF and the risk of developing future AF. In case-control studies, C-reactive protein is significantly elevated in AF patients and is associated with successful cardioversion. Moreover, C-reactive protein elevation is more pronounced in patients with persistent AF than in those with paroxysmal AF. Furthermore, treatment with glucocorticoids, statins, angiotensin converting enzyme inhibitors, and angiotensin II receptor blockers seems to reduce recurrence of AF. Part of this anti-arrhythmic effect may be through anti-inflammatory activity. This article reviews what is known about inflammation in genesis and perpetuation of AF, the putative underlying mechanisms, and possible therapeutic implications for the inhibition of inflammation as an evolving treatment modality for AF.

Effects of single dose, postinduction dexamethasone on recovery after cardiac surgery

BACKGROUND

Corticosteroids have been recommended to facilitate rapid recovery after cardiac surgery. We previously reported that dexamethasone given after induction of anesthesia decreases the incidence of postoperative shivering. We performed a post hoc analysis of the data obtained during that study, focusing on secondary outcomes.

METHODS

A total of 235 adult patients undergoing elective coronary or valvular heart surgery were randomized to receive dexamethasone 0.6 mg/kg or placebo after induction of anesthesia. Patients who had pharmacologically treated diabetes mellitus, had hypersensitivity to dexamethasone, or were receiving treatment with corticosteroids were excluded.

RESULTS

We found that, compared with placebo, patients receiving dexamethasone were more likely to remain tracheally intubated for 6 hours or less (26.4% vs 10.0%, p = 0.020) and had a lower incidence of early postoperative fever (20.2% vs 36.8%, p = 0.009) and new-onset atrial fibrillation during the first 3 days postoperatively (18.9% vs 32.3%, p = 0.027). However, we could not demonstrate a statistical difference in the intensive care unit or hospital length of stay, or in overall morbidity and mortality. The dexamethasone-treated patients were also more likely to have a higher blood glucose on admission to the intensive care unit (186 mg/dL vs 143 mg/dL, p = 0.012).

CONCLUSIONS

Dexamethasone facilitates early tracheal extubation and is associated with a lower incidence of early postoperative fever and new-onset atrial fibrillation. Apart from a treatable decreased glucose tolerance, dexamethasone treatment was not shown to affect morbidity or mortality significantly.