Anesthetic Management During Cardiopulmonary Bypass: A Systematic Review

2024 EACTS/EACTAIC/EBCP Guidelines on cardiopulmonary bypass in adult cardiac surgery

Clinical practice guidelines consolidate and evaluate all pertinent evidence on a specific topic available at the time of their formulation. The goal is to assist physicians in determining the most effective management strategies for patients with a particular condition. These guidelines assess the impact on patient outcomes and weigh the risk-benefit ratio of various diagnostic or therapeutic approaches. While not a replacement for textbooks, they provide supplementary information on topics relevant to current clinical practice and become an essential tool to support the decisions made by specialists in daily practice. Nonetheless, it is crucial to understand that these recommendations are intended to guide, not dictate, clinical practice, and should be adapted to each patient's unique needs. Clinical situations vary, presenting a diverse array of variables and circumstances. Thus, the guidelines are meant to inform, not replace, the clinical judgement of healthcare professionals, grounded in their professional knowledge, experience and comprehension of each patient's specific context. Moreover, these guidelines are not considered legally binding; the legal duties of healthcare professionals are defined by prevailing laws and regulations, and adherence to these guidelines does not modify such responsibilities. The European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) and the European Board of Cardiovascular Perfusion (EBCP) constituted a task force of professionals specializing in cardiopulmonary bypass (CPB) management. To ensure transparency and integrity, all task force members involved in the development and review of these guidelines submitted conflict of interest declarations, which were compiled into a single document available on the EACTS website (https://www.eacts.org/resources/clinical-guidelines). Any alterations to these declarations during the development process were promptly reported to the EACTS, EACTAIC and EBCP. Funding for this task force was provided exclusively by the EACTS, EACTAIC and EBCP, without involvement from the healthcare industry or other entities. Following this collaborative endeavour, the governing bodies of EACTS, EACTAIC and EBCP oversaw the formulation, refinement, and endorsement of these extensively revised guidelines. An external panel of experts thoroughly reviewed the initial draft, and their input guided subsequent amendments. After this detailed revision process, the final document was ratified by all task force experts and the leadership of the EACTS, EACTAIC and EBCP, enabling its publication in the European Journal of Cardio-Thoracic Surgery, the British Journal of Anaesthesia and Interdisciplinary CardioVascular and Thoracic Surgery. Endorsed by the EACTS, EACTAIC and EBCP, these guidelines represent the official standpoint on this subject. They demonstrate a dedication to continual enhancement, with routine updates planned to ensure that the guidelines remain current and valuable in the ever-progressing arena of clinical practice.

Total Intravenous Anesthesia Is Preferred Over Volatile Agents in Cardiac Surgery

The choice of maintenance anesthetic during cardiopulmonary bypass has been a subject of ongoing debate. Systematic reviews on the topic have so far failed to demonstrate a difference between volatile agents and total intravenous anesthesia (TIVA) in terms of mortality, myocardial injury, and neurological outcomes. Studies using animal models and noncardiac surgical populations suggest numerous mechanisms whereby TIVA has been associated with more favorable outcomes. However, even if the different anesthetic methods are assumed to equivalent in terms of patient outcomes in the context of cardiac surgery, additional factors, namely variables of occupational exposure and environmental impact, strongly support the preferred use of TIVA.

Population pharmacokinetic modeling of sufentanil in adult Korean patients undergoing cardiopulmonary bypass surgery

Sufentanil is frequently used as an anesthetic agent in cardiac surgery owing to its cardiovascular safety and favorable pharmacokinetics. However, the pharmacokinetics profiles of sufentanil in patients undergoing cardiopulmonary bypass (CPB) surgery remain less understood, which is crucial for achieving the desired level of anesthesia and mitigating surgical complications. Therefore, this study aimed to develop a population pharmacokinetic model of sufentanil in patients undergoing CPB surgery and elucidate the clinical factors affecting its pharmacokinetic profile. Adult patients who underwent cardiac surgery with CPB and were administered sufentanil for anesthesia were enrolled. Arterial blood samples were collected to quantify plasma concentrations of sufentanil and clinical laboratory parameters, including inflammatory cytokines. A population pharmacokinetic model was established using nonlinear mixed-effects modeling. Simulations were performed using the pharmacokinetic parameters of the final model. Overall, 20 patients were included in the final analysis. Sufentanil pharmacokinetics were modeled using a two-compartment model, accounting for CPB effects. Sufentanil clearance increased 2.80-fold during CPB and warming phases, while the central compartment volume increased 2.74-fold during CPB. CPB was a significant covariate affecting drug clearance and distribution volume. No other significant covariates were identified despite increased levels of the inflammatory cytokines, including IL-6, IL-8, and TNF-α during CPB. The simulation indicated a 30 μg loading dose and 40 μg/h maintenance infusion for target-controlled infusion. Additionally, a bolus dose of 60 μg was added at CPB initiation to adjust for exposure changes during this phase. Considering the target sufentanil concentrations, a uniform dosing regimen was acceptable for effective analgesia.

The effect of mannitol on postoperative renal function in patients undergoing coronary artery bypass surgery: A double-blinded randomized controlled trial

Introduction

Mannitol, an osmotic diuretic solution, is commonly utilized in priming cardiopulmonary bypass (CPB) and can impact kidney function. This study was conducted to investigate the impact of mannitol use during CPB on kidney function in patients undergoing coronary artery bypass surgery.

Methods

This randomized, double-blind clinical trial studied 90 patients undergoing coronary artery bypass surgery. In the control group (n=45), the prime solution included Ringer's lactate, and in the intervention group (n=45), the prime solution had 200 ml of mannitol 20% and Ringer's lactate. A P-value<0.05 was considered significant. The primary endpoint of this study is renal function.

Results

Demographic characteristics and risk factors were not significantly different between the two groups (P>0.05). Additionally, there was no statistically significant difference between two groups in terms of CPB time, aortic cross-clamp time, length of time connected to mechanical ventilation, 30-day mortality, ICU, and hospital stay time (P>0.05). Furthermore, no statistically significant difference was observed between the two groups in serum creatinine levels (P=0.53) or BUN levels (P=0.13). The study also found no statistically significant difference in the diuresis rate between the two groups (P=0.10).

Conclusion

The present study has shown that adding mannitol to the prime has no effect on kidney function, length of time connected to mechanical ventilation, length of stay in the ICU, or 30-day mortality. Therefore, it suggests that mannitol cannot be used as a preventative strategy for acute kidney injury after cardiac surgery.

The evolving role of the modern perfusionist: Insights from processed electro-encephalography

Introduction: Since its origin in the 1920s, electroencephalography (EEG) has become a viable option for anesthesia and perfusion teams to monitor anesthetic delivery, optimizing drug dosage and enhancing patient safety. Patients undergoing cardiopulmonary bypass (CPB) are at particular high risk for excessive or inadequate anesthetic doses. During CPB, traditional physiological indicators such as heart rate and blood pressure can be significantly altered. These abnormalities are compounded by rapid changes in anesthetic concentration from hemodilution, circuit absorption, and altered pharmacokinetics. Method: This narrative highlights the use of processed EEG with spectral analysis for anesthetic management during CPB. Conclusion: We emphasize that neuromonitoring using processed EEG during CPB can assess adequacy of anesthesia delivery and monitor for pathologic conditions that can compromise brain function such as inadequate cerebral blood flow, emboli, and seizures. This information is highly valuable for the clinical team including the perfusionist, who regularly diagnose and manage these pathological conditions.

Cerebral Oxygen Saturation Associates with Changes in Oxygen Transport Parameters during Cardiopulmonary Bypass

(1) Background: Adequate organ perfusion during cardiopulmonary bypass (CPB) requires accurate estimation and adjustment of flow rates which conventional methods may not always achieve. Perioperative monitoring of cerebral oxygen saturation (ScO2) may detect changes in oxygen transport. This study aims to compare estimated and measured perfusion flow rates and assess the capacity of ScO2 to detect subtle changes in oxygen transport during CPB. (2) Methods: This observational study included 50 patients scheduled for elective coronary artery bypass grafting (CABG) surgery, all of whom provided written informed consent. Perfusion flow rates were estimated using the DuBois formula and measured using echocardiography and a flow probe in the arterial line of the CPB system. ScO2 was continuously monitored, alongside intermittent measurements of oxygen delivery and extraction ratios. (3) Results: Significant discrepancies were found between estimated flow rates (5.2 [4.8-5.5] L/min) and those measured at the start of the surgery (4.6 [4.0-5.0] L/min). These discrepancies were flow rate-dependent, being more pronounced at lower perfusion rates and diminishing as rates increased. Furthermore, ScO2 showed a consistent correlation with both oxygen delivery (r = 0.48) and oxygen extraction ratio (r = 0.45). (4) Conclusions: This study highlights discrepancies between estimated and actual perfusion flow rates during CPB and underscores the value of ScO2 monitoring as a continuous, noninvasive tool for maintaining adequate organ perfusion, suggesting a need for improved, patient-tailored perfusion strategies.

Changes in SedLine-derived processed electroencephalographic parameters during hypothermia in patients undergoing cardiac surgery with cardiopulmonary bypass

Objective

Processed electroencephalography (pEEG) is used to monitor depth-of-anesthesia during cardiopulmonary bypass (CPB). The SedLine device has been recently introduced for pEEG monitoring. However, the effect of hypothermia on its parameters during CPB is unknown. Accordingly, we aimed to investigate temperature-induced changes in SedLine-derived pEEG parameters during CPB.

Design

Prospective observational study.

Setting

Cardiac surgery operating theatre.

Participants

28 patients undergoing elective cardiac surgery with CPB.

Interventions

We continuously measured patient state index (PSI), suppression ratio (SR), bilateral spectral edge frequency (SEF) and temperature. We used linear mixed modelling with fixed and random effects to study the interactions between pEEG parameters and core temperature.

Measurements and main results

During CPB maintenance, the median temperature was 32.1°C [interquartile range (IQR): 29.8-33.6] at the end of cooling and 32.8°C (IQR: 30.1-34.0) at rewarming initiation. For each degree Celsius change in temperature during cooling and rewarming the PSI either decreased by 0.8 points [95% confidence interval (CI): 0.7-1.0; p < 0.001] or increased by 0.7 points (95% CI: 0.6-0.8; p < 0.001). The SR increased by 2.9 (95% CI: 2.3-3.4); p < 0.001) during cooling and decreased by 2.2 (95% CI: 1.7-2.7; p < 0.001) during rewarming. Changes in the SEF were not related to changes in temperature.

Conclusions

During hypothermic CPB, temperature changes led to concordant changes in the PSI. The SR increased during cooling and decreased during rewarming. Clinicians using SedLine for depth-of-anesthesia monitoring should be aware of these effects when interpreting the PSI and SR values.

A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children

The major therapeutic end points of general anesthesia include hypnosis, amnesia, and immobility. There is a complex relationship between general anesthesia, responsiveness, hemodynamic stability, and reaction to noxious stimuli. This complexity is compounded in pediatric anesthesia, where clinicians manage children from a wide range of ages, developmental stages, and body sizes, with their concomitant differences in physiology and pharmacology. This renders anesthetic requirements difficult to predict based solely on a child's age, body weight, and vital signs. Electroencephalogram (EEG) monitoring provides a window into children's brain states and may be useful in guiding clinical anesthesia management. However, many clinicians are unfamiliar with EEG monitoring in children. Young children's EEGs differ substantially from those of older children and adults, and there is a lack of evidence-based guidance on how and when to use the EEG for anesthesia care in children. This narrative review begins by summarizing what is known about EEG monitoring in pediatric anesthesia care. A key knowledge gap in the literature relates to a lack of practical information illustrating the utility of the EEG in clinical management. To address this gap, this narrative review illustrates how the EEG spectrogram can be used to visualize, in real time, brain responses to anesthetic drugs in relation to hemodynamic stability, surgical stimulation, and other interventions such as cardiopulmonary bypass. This review discusses anesthetic management principles in a variety of clinical scenarios, including infants, children with altered conscious levels, children with atypical neurodevelopment, children with hemodynamic instability, children undergoing total intravenous anesthesia, and those undergoing cardiopulmonary bypass. Each scenario is accompanied by practical illustrations of how the EEG can be visualized to help titrate anesthetic dosage to avoid undersedation or oversedation when patients experience hypotension or other physiological challenges, when surgical stimulation increases, and when a child's anesthetic requirements are otherwise less predictable. Overall, this review illustrates how well-established clinical management principles in children can be significantly complemented by the addition of EEG monitoring, thus enabling personalized anesthesia care to enhance patient safety and experience.

Pharmacokinetics of dexmedetomidine in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass

BACKGROUND

Cardiopulmonary bypass can affect the pharmacokinetics of anesthetic agents.

AIMS

We aimed to evaluate the pharmacokinetics of dexmedetomidine for infants and small children undergoing cardiac surgery with cardiopulmonary bypass based on population pharmacokinetics.

METHODS

We enrolled 30 pediatric cardiac surgical patients in this study. After anesthetic induction with atropine (0.02 mg/kg), thiopental sodium (5 mg/kg), and fentanyl (2-3 μg/kg), we administered 1 μg/kg of dexmedetomidine for 10 min, followed by administration of 0.5 μg/kg of dexmedetomidine per hour during surgery. At the initiation of cardiopulmonary bypass, 1 μg/kg of dexmedetomidine was infused over 5 min. Arterial blood was obtained at predefined time points. A pharmacokinetic model was developed using NONMEM. Theory-based allometric scaling with fixed exponents was applied. Weight, age, post-menstrual age, fat-free mass, whether to implement cardiopulmonary bypass and temperature were explored as covariates.

RESULTS

A total of 376 blood samples were obtained from 29 children (age: 20.3 ± 19.3 months, weight: 9.7 ± 4.1 kg). A two-compartment mammillary model with third compartment associated cardiopulmonary bypass procedure best explained the pharmacokinetics of dexmedetomidine. The pharmacokinetic parameter estimates (95% CI) standardized to a 70-kg person were as follows: V₁ (L) = 31.6 (17.9-39.5), V₂ (L) = 90.1 (44.0-330), Cl (L/min) = 1.08 (0.70-1.25), Q (L/min) = 2.0 (1.05-3.46). Volume for third compartment associated cardiopulmonary bypass procedure (L) = 39.4 (19.3-50.9). Clearance was not influenced by the presence of cardiopulmonary bypass in this model.

CONCLUSION

When cardiopulmonary bypass is applied, the plasma concentration of dexmedetomidine decreases due to an increase in the volume of distribution, so a loading dose is required to maintain the previous concentration.

Anesthetic Preferences for Cardiac Anesthesia: A Survey of the Society of Cardiovascular Anesthesiologists

BACKGROUND

Volatile anesthetics have been historically preferred for cardiac anesthesia, but the evidence for their superiority to intravenous agents is mixed. We conducted a survey to better understand the current state of practice and the rationale behind provider preferences for anesthesia for cardiac surgery with cardiopulmonary bypass. We hypothesized that anesthetic preference would vary considerably among surveyed providers without a clear majority, as would the rationale behind those preferences.

METHODS

Email invitations were sent to members of the Society of Cardiovascular Anesthesiologists, who were asked to identify the anesthetics or sedatives they typically prefer to administer during induction, prebypass, bypass, postbypass, and postoperative periods and why they prefer those agents. Members' beliefs regarding the importance of anesthetics on postoperative outcomes were also assessed.

RESULTS

Invitations were sent on 2 separate dates to 3328 and 3274 members, of whom 689 (21%) responded. The median (interquartile range [IQR]) respondent age was 45 (37-56) years, 79% were men, and 75% were fellowship trained. The most frequently chosen drug for induction was propofol (80%). Isoflurane was the most frequently selected primary agent for the prebypass (57%), bypass (62%), and postbypass periods (50%). Sevoflurane was the second most frequently selected (30%; 17%, and 24%, respectively). Propofol was the third most frequently selected agent for the bypass (14%) and postbypass periods (17%). Ease of use was the most frequently selected reason for administering isoflurane and sevoflurane for each period. During bypass, the second most frequently selected rationale for using isoflurane and sevoflurane was institutional practice. A total of 76% responded that the perfusionist typically delivers the bypass anesthetic. Ischemic preconditioning, organ protection, and postoperative cognitive function were infrequently selected as rationales for preferring the volatile anesthetics. Most respondents (73%) think that anesthetics have organ-protective properties, especially isoflurane (74%) and sevoflurane (59%), and 72% believed that anesthetic choice contributes to patient outcome. The median (IQR) agreement (0 = strongly disagree to 100 = strongly agree) was 72 (63-85) for the statement that "inhaled anesthetics are an optimal maintenance anesthetic for cardiac surgery."

CONCLUSIONS

In a survey of cardiac anesthesiologists, a majority of respondents indicated that they prefer volatile anesthetics for maintenance of anesthesia, that anesthetic selection impacts patient outcomes, and that volatile anesthetics have organ-protective properties. The members' rationales for preferring these agents possibly reflect that practical considerations, such as ease of use, effectiveness, and institutional practice, also influence anesthetic selection during cardiac surgery in addition to considerations such as organ protection.

Bispectral Index (BIS) Monitoring and Postoperative Delirium in Elderly Patients Undergoing Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

OBJECTIVE

To examine the effect of bispectral index (BIS)-guided anesthesia on the incidence of postoperative delirium (POD) in elderly patients undergoing surgery.

DESIGN

A systematic review, meta-analysis, and trial sequential analysis (TSA).

SETTING

In the operating room, postoperative anesthesia care units (PACU), and ward.

PARTICIPANTS

Elderly patients (>60 years old) undergoing surgery.

INTERVENTIONS

The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until December 2020 for randomized controlled trials comparing BIS and usual care or blinded BIS.

MEASUREMENTS AND MAIN RESULTS

Ten trials (N = 3,891) were included for quantitative meta-analysis. In comparison to the control group, there was no significant difference in the incidence of POD in elderly patients randomized to BIS-guided anesthesia (odds ratio [OR] 0.71, 95% CI 0.47-1.08, I² = 76%, p = 0.11, level of evidence = very low, TSA = inconclusive). The authors' review demonstrated that elderly patients with BIS-guided anesthesia were significantly associated with a lower incidence of postoperative cognitive dysfunction (POCD) (OR 0.64, 95% CI 0.46-0.88, p = 0.006), extubation time (mean difference [MD] -3.38 minutes, 95% CI -4.38 to -2.39, p < 0.00001), time to eye opening (MD -2.17 minutes, 95% CI -4.21 to -0.14, p = 0.04), and time to discharge from the PACU (MD -10.77 minutes, 95% CI -11.31 to - 10.23, p < 0.00001).

CONCLUSION

The authors' meta-analysis demonstrated that BIS-guided anesthesia was not associated with a reduced incidence of POD, but it was associated with a reduced incidence of POCD and improved recovery parameters.

Volatile Anaesthesia versus Total Intravenous Anaesthesia for Cardiac Surgery-A Narrative Review

Recent research has contested the previously accepted paradigm that volatile anaesthetics improve outcomes in cardiac surgery patients when compared to intravenous anaesthesia. In this review we summarise the mechanisms of myocardial ischaemia/reperfusion injury and cardioprotection in cardiac surgery. In addition, we make a comprehensive analysis of evidence comparing outcomes in patients undergoing cardiac surgery under volatile or intravenous anaesthesia, in terms of mortality and morbidity (cardiac, neurological, renal, pulmonary).

Mitochondrial Oxygenation During Cardiopulmonary Bypass: A Pilot Study

Objective

Adequate oxygenation is essential for the preservation of organ function during cardiac surgery and cardiopulmonary bypass (CPB). Both hypoxia and hyperoxia result in undesired outcomes, and a narrow window for optimal oxygenation exists. Current perioperative monitoring techniques are not always sufficient to monitor adequate oxygenation. The non-invasive COMET® monitor could be a tool to monitor oxygenation by measuring the cutaneous mitochondrial oxygen tension (mitoPO2). This pilot study examines the feasibility of cutaneous mitoPO2 measurements during cardiothoracic procedures. Cutaneous mitoPO2 will be compared to tissue oxygenation (StO2) as measured by near-infrared spectroscopy.

Design and Method

This single-center observational study examined 41 cardiac surgery patients requiring CPB. Preoperatively, patients received a 5-aminolevulinic acid plaster on the upper arm to enable mitoPO2 measurements. After induction of anesthesia, both cutaneous mitoPO2 and StO2 were measured throughout the procedure. The patients were observed until discharge for the development of acute kidney insufficiency (AKI).

Results

Cutaneous mitoPO2 was successfully measured in all patients and was 63.5 [40.0-74.8] mmHg at the surgery start and decreased significantly (p < 0.01) to 36.4 [18.4-56.0] mmHg by the end of the CPB run. StO2 at the surgery start was 80.5 [76.8-84.3]% and did not change significantly. Cross-clamping of the aorta and the switch to non-pulsatile flow resulted in a median cutaneous mitoPO2 decrease of 7 mmHg (p < 0.01). The cessation of the aortic cross-clamping period resulted in an increase of 4 mmHg (p < 0.01). Totally, four patients developed AKI and had a lower preoperative eGFR of 52 vs. 81 ml/min in the non-AKI group. The AKI group spent 32% of the operation time with a cutaneous mitoPO2 value under 20 mmHg as compared to 8% in the non-AKI group.

Conclusion

This pilot study illustrated the feasibility of measuring cutaneous mitoPO2 using the COMET® monitor during cardiothoracic procedures. Moreover, in contrast to StO2, mitoPO2 decreased significantly with the increasing CPB run time. Cutaneous mitoPO2 also significantly decreased during the aortic cross-clamping period and increased upon the release of the clamp, but StO2 did not. This emphasized the sensitivity of cutaneous mitoPO2 to detect circulatory and microvascular changes.

Safe sedation management using volatile anesthetics during cardiopulmonary bypass

Several pieces of evidence suggest that volatile anesthetics (VAs), which were originally used as sedatives, have myocardial protective effects against cardiac ischemia-reperfusion injury. In Europe and the United States, the use of VAs during cardiopulmonary bypass (CPB) is widespread, as 2019 European Association for Cardio-Thoracic Surgery (EACTS)/European Association of Cardiothoracic Anaesthesiology/European Board of Cardiovascular Perfusion, 2011 American College of Cardiology/American Heart Association, and 2017 EACTS guidelines recommend their use in cardiovascular surgery, based on their potential myocardial protective effects. In other countries, including Japan, the use of VAs is gradually increasing. Therefore, it is important to be aware of the risks and possible adverse events associated with VA use during CPB to ensure safe sedation management. Herein, we describe in detail issues such as intraoperative awareness, air pollution, and damage to oxygenators due to VA use and propose precautions.

Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass

Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.

Remimazolam benzenesulfonate anesthesia effectiveness in cardiac surgery patients under general anesthesia

BACKGROUND

Sedation with propofol injections is associated with a risk of addiction, but remimazolam benzenesulfonate is a comparable anesthetic with a short elimination half-life and independence from cell P450 enzyme metabolism. Compared to remimazolam, remimazolam benzenesulfonate has a faster effect, is more quickly metabolized, produces inactive metabolites and has weak drug interactions. Thus, remimazolam benzenesulfonate has good effectiveness and safety for diagnostic and operational sedation.

AIM

To investigate the clinical value of remimazolam benzenesulfonate in cardiac surgery patients under general anesthesia.

METHODS

A total of 80 patients who underwent surgery in the Department of Cardiothoracic Surgery from August 2020 to April 2021 were included in the study. Using a random number table, patients were divided into two anesthesia induction groups of 40 patients each: remimazolam (0.3 mg/kg remimazolam benzenesulfonate) and propofol (1.5 mg/kg propofol). Hemodynamic parameters, inflammatory stress response indices, respiratory function indices, perioperative indices and adverse reactions in the two groups were monitored over time for comparison.

RESULTS

At pre-anesthesia induction, the remimazolam and propofol groups did not differ regarding heart rate, mean arterial pressure, cardiac index or volume per wave index. After endotracheal intubation and when the sternum was cut off, mean arterial pressure and volume per wave index were significantly higher in the remimazolam group than in the propofol group (P < 0.05). After endotracheal intubation, the oxygenation index and the respiratory index did not differ between the groups. After endotracheal intubation and when the sternum was cut off, the oxygenation index values were significantly higher in the remimazolam group than in the propofol group (P < 0.05). Serum interleukin-6 and tumor necrosis factor-α levels 12 h after surgery were significantly higher than before surgery in both groups (P < 0.05). The observation indices were re-examined 2 h after surgery, and the epinephrine, cortisol and blood glucose levels were significantly higher in the remimazolam group than in the propofol group (P < 0.05). The recovery and extubation times were significantly lower in the remimazolam group than in the propofol group (P < 0.05); there were significantly fewer adverse reactions in the remimazolam group (10.00%) than in the propofol group (30.00%; P < 0.05).

CONCLUSION

Compared with propofol, remimazolam benzenesulfonate benefited cardiac surgery patients under general anesthesia by reducing hemodynamic fluctuations. Remimazolam benzenesulfonate influenced the surgical stress response and respiratory function, thereby reducing anesthesia-related adverse reactions.

Plasma from patients undergoing coronary artery bypass graft surgery does not activate endothelial cells under shear stress in vitro

Background:

Cardiac surgery with cardiopulmonary bypass (CPB) is commonly associated with acute kidney injury, and microvascular endothelial inflammation is a potential underlying mechanism. We hypothesized that pro-inflammatory components of plasma from patients who underwent coronary artery bypass graft surgery with CPB induce endothelial adhesion molecule expression when incorporating altered shear stress in the in vitro model.

Methods:

The clinical characteristics and markers of systemic inflammation and kidney injury were analyzed pre and postoperatively in 29 patients undergoing coronary artery bypass grafting with CPB. The effects of tumor necrosis factor (TNF)-α and patient plasma on the expression of endothelial inflammation and adhesion markers were analyzed in vitro.

Results:

Plasma TNF-α was elevated 6 h postoperation (median: 7.3 pg/ml (range: 2.5–94.8 pg/ml)). Neutrophil gelatinase-associated lipocalin in plasma peaked 6 h (99.8 ng/ml (52.6–359.1 ng/ml)) and in urine 24 h postoperation (1.6 ng/mg (0.2–6.4 ng/mg)). Urinary kidney injury molecule-1 concentration peaked 24 h postoperation (0.5 ng/mg (0.2–1.2 ng/mg). In vitro, the expression of E-selectin was induced by 20 pg/ml TNF-α. In addition, the expression of interleukin-8, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 was induced by 100 pg/ml TNF-α. Compared to healthy control plasma exposure, postoperative plasma did not increase the expression of markers of endothelial inflammation and adhesion under shear stress in vitro.

Conclusion:

Patients undergoing CPB surgery showed mild systemic inflammation and kidney injury. However, the plasma components did not stimulate endothelial inflammation and adhesion molecule expression in vitro.

Volatile Versus Intravenous Anesthetics in Cardiac Anesthesia: a Narrative Review

Purpose of the Review

The present review addresses clinicians and gives an overview about the experimental rationale for pharmacological conditioning associated with volatile anesthetics, opioids, and propofol; the current clinical data; and the technical considerations regarding the clinical routine in cardiac anesthesia.

Recent Findings

Volatile anesthetics have been standard of care for general anesthesia for cardiac surgery, especially while using cardiopulmonary bypass. The 2019 published MYRIAD trial was not able to show a difference in mortality or cardiac biomarkers for volatile anesthetics compared to total intravenous anesthesia (TIVA), raising the question of equivalence with respect to patient outcome.

Summary

Reviewing the literature, the scientific foundation for the belief of clinically relevant conditioning by uninterrupted administration of a volatile anesthetic is weak. TIVA can also be performed safely in patients undergoing cardiac surgery.

Managing the coagulopathy associated with cardiopulmonary bypass

Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.

Esmolol in Cardiac Surgery: A Randomized Controlled Trial

OBJECTIVE

To assess whether the administration of the ultra-short-acting β-blocker esmolol in cardiac surgery could have a cardioprotective effect that translates into improved postoperative outcomes.

DESIGN

Single-center, double-blinded, parallel-group randomized controlled trial.

SETTING

A tertiary care referral center.

PARTICIPANTS

Patients undergoing elective cardiac surgery with preoperative evidence of left ventricular end-diastolic diameter >60 mm and/or left ventricular ejection fraction <50%.

INTERVENTIONS

Patients were assigned randomly to receive either esmolol (1 mg/kg as a bolus before aortic cross-clamping and 2 mg/kg mixed in the cardioplegia solution) or placebo in a 1:1 allocation ratio.

MEASUREMENTS AND MAIN RESULTS

The primary composite endpoint of prolonged intensive care unit stay and/or in-hospital mortality occurred in 36/98 patients (36%) in the placebo group versus 27/102 patients (27%) in the esmolol group (p = 0.13). In the esmolol group, a reduction in the maximum inotropic score during the first 24 postoperative hours was observed (10 [interquartile range 5-15] v 7 [interquartile range 5-10.5]; p = 0.04), as well as a trend toward a reduction in postoperative low-cardiac-output syndrome (13/98 v 6/102; p = 0.08) and the rate of hospital admission at one year (26/95 v 16/96; p = 0.08). A trend toward an increase in the number of patients with ejection fraction ≥60% at hospital discharge also was observed (4/95 v 11/92; p = 0.06).

CONCLUSIONS

In the present trial, esmolol as a cardioplegia adjuvant enhanced postoperative cardiac performance but did not reduce a composite endpoint of prolonged intensive care unit stay and/or mortality.

Role of Anaesthetic Choice in Improving Outcome after Cardiac Surgery

Clinical background

Volatile anaesthetics (VAs) have been shown to protect cardiomyocytes against ischaemia and reperfusion injury in cardiac surgery.

Clinical problems

VAs have been shown in multiple trials and meta-analyses to be associated with better outcomes when compared to intravenous anaesthesia in cardiac surgery. However, recent data from a large randomised controlled trial do not confirm the superiority of VA as compared to total intravenous anaesthesia in this population.

Review objectives

This mini review presents the VA cardioprotective effects, their clinical use in cardiac surgery and the most recent evidence that compares VA to intravenous anaesthesia for reducing perioperative morbidity. At present, there is no clear superiority of VA over intravenous anaesthesia in improving the outcome after cardiac surgery.

The Future Directions of Research in Cardiac Anesthesiology

This article provides an overview of knowledge gaps that need to be addressed in cardiac anesthesia, including mitigating the inflammatory effects of cardiopulmonary bypass, defining myocardial infarction after cardiac surgery, improving perioperative neurologic outcomes, and the optimal management of patients undergoing valve replacement. In addition, emerging approaches to research conduct are discussed, including the use of new analytical techniques like machine learning, pragmatic trials, and adaptive designs.

Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass

BACKGROUND

Corticosteroids are routinely given to children undergoing cardiac surgery with cardiopulmonary bypass (CPB) in an attempt to ameliorate the inflammatory response. Their use is still controversial and the decision to administer the intervention can vary by centre and/or by individual doctors within that centre.

OBJECTIVES

This review is designed to assess the benefits and harms of prophylactic corticosteroids in children between birth and 18 years of age undergoing cardiac surgery with CPB.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Conference Proceedings Citation Index-Science in June 2020. We also searched four clinical trials registers and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included studies of prophylactic administration of corticosteroids, including single and multiple doses, and all types of corticosteroids administered via any route and at any time-point in the perioperative period. We excluded studies if steroids were administered therapeutically. We included individually randomised controlled trials (RCTs), with two or more groups (e.g. multi-drug or dose comparisons with a control group) but not 'head-to-head' trials without a placebo or a group that did not receive corticosteroids. We included studies in children, from birth up to 18 years of age, including preterm infants, undergoing cardiac surgery with the use of CPB. We also excluded studies in patients undergoing heart or lung transplantation, or both; studies in patients already receiving corticosteroids; in patients with abnormalities of the hypothalamic-pituitary-adrenal axis; and in patients given steroids at the time of cardiac surgery for indications other than cardiac surgery.

DATA COLLECTION AND ANALYSIS

We used the Covidence systematic review manager to extract and manage data for the review. Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We resolved disagreements by consensus or by consultation with a third review author. We assessed the certainty of evidence with GRADE.

MAIN RESULTS

We found 3748 studies, of which 888 were duplicate records. Two studies had the same clinical trial registration number, but reported different populations and interventions. We therefore included them as separate studies. We screened titles and abstracts of 2868 records and reviewed full text reports for 84 studies to determine eligibility. We extracted data for 13 studies. Pooled analyses are based on eight studies. We reported the remaining five studies narratively due to zero events for both intervention and placebo in the outcomes of interest. Therefore, the final meta-analysis included eight studies with a combined population of 478 participants. There was a low or unclear risk of bias across the domains. There was moderate certainty of evidence that corticosteroids do not change the risk of in-hospital mortality (five RCTs; 313 participants; risk ratio (RR) 0.83, 95% confidence interval (CI) 0.33 to 2.07) for children undergoing cardiac surgery with CPB. There was high certainty of evidence that corticosteroids reduce the duration of mechanical ventilation (six RCTs; 421 participants; mean difference (MD) 11.37 hours lower, 95% CI -20.29 to -2.45) after the surgery. There was high-certainty evidence that the intervention probably made little to no difference to the length of postoperative intensive care unit (ICU) stay (six RCTs; 421 participants; MD 0.28 days lower, 95% CI -0.79 to 0.24) and moderate-certainty evidence that the intervention probably made little to no difference to the length of the postoperative hospital stay (one RCT; 176 participants; mean length of stay 22 days; MD -0.70 days, 95% CI -2.62 to 1.22). There was moderate certainty of evidence for no effect of the intervention on all-cause mortality at the longest follow-up (five RCTs; 313 participants; RR 0.83, 95% CI 0.33 to 2.07) or cardiovascular mortality at the longest follow-up (three RCTs; 109 participants; RR 0.40, 95% CI 0.07 to 2.46). There was low certainty of evidence that corticosteroids probably make little to no difference to children separating from CPB (one RCT; 40 participants; RR 0.20, 95% CI 0.01 to 3.92). We were unable to report information regarding adverse events of the intervention due to the heterogeneity of reporting of outcomes. We downgraded the certainty of evidence for several reasons, including imprecision due to small sample sizes, a single study providing data for an individual outcome, the inclusion of both appreciable benefit and harm in the confidence interval, and publication bias.

AUTHORS' CONCLUSIONS

Corticosteroids  probably do not change the risk of mortality for children having heart surgery using CPB at any time point. They probably reduce the duration of postoperative ventilation in this context, but have little or no effect on the total length of postoperative ICU stay or total postoperative hospital stay. There was inconsistency in the adverse event outcomes reported which, consequently, could not be pooled. It is therefore impossible to provide any implications and policy-makers will be unable to make any recommendations for practice without evidence about adverse effects. The review highlighted the need for well-conducted RCTs powered for clinical outcomes to confirm or refute the effect of corticosteroids versus placebo in children having cardiac surgery with CPB. A core outcome set for adverse event reporting in the paediatric major surgery and intensive care setting is required.

Multicenter International Survey on Cardiopulmonary Bypass Perfusion Practices in Adult Cardiac Surgery

OBJECTIVES

To assess current practice in adult cardiac surgery during cardiopulmonary bypass (CPB) across European and non-European countries.

DESIGN

International, multicenter, web-based survey including 28 multiple choice questions addressing hemodynamic and tissue oxygenation parameters, organ protection measures, and the monitoring and usage of anesthetic drugs as part of the anesthetic and perfusion practice during CPB.

SETTING

Online survey endorsed by the European Association of Cardiothoracic Anesthesiologists.

PARTICIPANTS

Representatives of anesthesiology departments in European and non-European adult cardiac surgical centers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The survey was distributed via e-mail to European Association of Cardiothoracic Anesthesiologists members (n = 797) and kept open for 1 month. The response rate was 34% (n = 271). After exclusion of responses from the same centers and of incomplete answers, data from 202 cardiac centers in 56 countries, of which 67% of centers were university hospitals, were analyzed. Optimization of pump flows and tissue oxygenation parameters during CPB were applied by the majority of centers, with target flow rates of >2.2 L/min/m² in 93% (n = 187) of centers and mean arterial blood pressures between 51 and 90 mmHg in 85% (n = 172). Hemoglobin transfusion triggers were either individualized or between 7 and 8 g/dL in 92% (n = 186) of centers. Mixed venous oxyhemoglobin saturations were assessed routinely in 59% (n = 120) and lactate in 88% (n = 178) of cardiac surgery units. Noninvasive cerebral saturation monitoring was used in a subgroup of patients or routinely in 84% (n = 169) of sites, and depth-of-anesthesia monitoring was used routinely in 53% (n = 106). Transesophageal echocardiography and pulmonary artery catheters were used routinely or in subgroups of patients in 97% (n = 195) and 71% (n = 153) of centers, respectively. The preferred site for temperature monitoring was the nasopharynx in 66% (n = 134) of centers. Anesthetic techniques were variable, with 26% of centers (n = 52) using low-tidal-volume ventilation and 28% (n = 57) using continuous positive airway pressure during CPB. Volatile agents were used routinely as the only agent during CPB in 36% sites (n = 73) and propofol in 47% (n = 95). Other drugs routinely administered included magnesium in 45% (n = 91), steroids in 18% (n = 37), tranexamic acid in 88% (n = 177), and aprotinin in 15% (n = 30) of the centers.

CONCLUSION

This international CPB survey revealed that techniques for optimization of pump flow and oxygenation during CPB usually were applied. Furthermore, cerebral and hemodynamic monitoring devices were frequently used during CPB. However, most CPB-related anesthetic techniques and medications were more variable. More high-quality randomized controlled trials are needed to assess anesthetic techniques and organ protection.

A survey of practices during cardiopulmonary bypass in India: An Indian association of cardiovascular and thoracic anesthesiologist endeavor

Context:

Cardiac anesthesiologists play a key role during the conduct of cardiopulmonary bypass (CPB). There are variations in the practice of CPB among extracorporeal technologists in India.

Aims:

The aim of this survey is to gather information on variations during the conduct of CPB in India.

Settings and Design:

This was an online conducted survey by Indian College of Cardiac Anaesthesia, which is the research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists.

Subjects and Methods:

Senior consultants heading cardiac anesthesia departments in both teaching and nonteaching centers (performing at least 15 cases a month) were contacted using an online questionnaire fielded using SurveyMonkey™ software. There were 33 questions focusing on institute information, perfusion practices, blood conservation on CPB; monitoring and anesthesia practices.

Results:

The response rate was 74.2% (187/252). Fifty-one (26%) centers were teaching centers; 18% centers performed more than 1000 cases annually. Crystalloid solution was the most common priming solution used. Twenty-three percent centers used corticosteroids routinely; methylprednisone was the most commonly used agent. The cardioplegia solution used by most responders was the one available commercially containing high potassium St. Thomas solution (55%), followed by Del Nido cardioplegia (33%). Majority of the responders used nasopharyngeal site to monitor intraoperative patient temperature. Antifibrinolytics were commonly used only in patients who were at high risk for bleeding by 51% of responders, while yet, another 39% used them routinely, and 11% never did. About 59% of the centers insist on only fresh blood (<7 days old) when blood transfusion was indicated. The facility to use vaporizer on CPB was available in 62% of the centers. All the teaching centers or high volume centers in India had access to transesophageal echocardiography probe and echo machine, with 51% using them routinely and 38% using them at least sometimes.

Conclusions:

There is a wide heterogeneity in CPB management protocols among various Indian cardiac surgery centers. The survey suggests that adherence to evidence-based and internationally accepted practices appears to be more prevalent in centers that have ongoing teaching programs and/or have high volumes, strengthening the need to devise guidelines by appropriate body to help bring in uniformity in CPB management to ensure patient safety and high quality of clinical care for best outcomes.

Volatile Anesthesia Versus Total Intravenous Anesthesia During Cardiopulmonary Bypass: A Narrative Review on the Technical Challenges and Considerations

The Mortality in Cardiac Surgery Randomized Controlled Trial of Volatile Anesthetics (MYRIAD) demonstrated that cardiac surgery with either volatile anesthesia or intravenous anesthesia techniques can be comparable with respect to morbidity and mortality. Maintaining anesthesia during cardiopulmonary bypass (CPB) with either approach requires appreciation of the nuances that are unique to each. This narrative review addresses these technical challenges and other considerations.

Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options

Vasoplegia syndrome in the cardiac surgical intensive care unit and postoperative period has been an area of interest to clinicians because of its prevalence and effects on morbidity and mortality. However, there is a paucity of evidence regarding the treatment of vasoplegia syndrome during cardiopulmonary bypass (on-CPB VS). This review aims to detail the incidence, outcomes, and possible treatment options for patients who develop vasoplegia during bypass. The pharmacologic rescue agents discussed are used in cases in which vasoplegia during CPB is refractory to standard catecholamine agents, such as norepinephrine, epinephrine, and phenylephrine. Methods to improve vasoplegia during CPB can be both pharmacologic and nonpharmacologic. In particular, optimization of CPB parameters plays an important nonpharmacologic role in vasoplegia during CPB. Pharmacologic agents that have been demonstrated as being effective in vasoplegia include vasopressin, terlipressin, methylene blue, hydroxocobalamin, angiotensin II (Giapreza), vitamin C, flurbiprofen (Ropion), and hydrocortisone. Although these agents have not been specifically evaluated for vasoplegia during CPB, they have shown signs of effectiveness for vasoplegia postoperatively to varying degrees. Understanding the evidence for, dosing, and side effects of these agents is crucial for cardiac anesthesiologists when treating vasoplegia during CPB bypass.

The use of data science to analyse physiology of oxygen delivery in the extracorporeal circulation

Background

Recent scientific reports have brought into light a new concept of goal-directed perfusion (GDP) that aims to recreate physiological conditions in which the risk of end-organ malperfusion is minimalized. The aim of our study was to analyse patients’ interim physiology while on cardiopulmonary bypass based on the haemodynamic and tissue oxygen delivery measurements. We also aimed to create a universal formula that may help in further implementation of the GDP concept.

Methods

We retrospectively analysed patients operated on at the Wroclaw University Hospital between June 2017 and December 2018. Since our observations provided an extensive amount of data, including the patients’ demographics, surgery details and the perfusion-related data, the Data Science methodology was applied.

Results

A total of 272 (mean age 62.5 ± 12.4, 74% male) cardiac surgery patients were included in the study. To study the relationship between haemodynamic and tissue oxygen parameters, the data for three different values of DO₂i (280 ml/min/m², 330 ml/min/m² and 380 ml/min/m²), were evaluated. Each set of those lines showed a descending function of CI in Hb concentration for the set DO₂i.

Conclusions

Modern calculation tools make it possible to create a common data platform from a very large database. Using that methodology we created models of haemodynamic compounds describing tissue oxygen delivery. The obtained unique patterns may both allow the adaptation of the flow in relation to the patient’s unique morphology that changes in time and contribute to wider and safer implementation of perfusion strategy which has been tailored to every patient’s individual needs.

The Future Directions of Research in Cardiac Anesthesiology

This article provides an overview of knowledge gaps that need to be addressed in cardiac anesthesia, including mitigating the inflammatory effects of cardiopulmonary bypass, defining myocardial infarction after cardiac surgery, improving perioperative neurologic outcomes, and the optimal management of patients undergoing valve replacement. In addition, emerging approaches to research conduct are discussed, including the use of new analytical techniques like machine learning, pragmatic trials, and adaptive designs.

Anesthetic Management of Total Aortic Arch Replacement in a Myasthenia Gravis Patient under Deep Hypothermic Circulatory Arrest

The anesthetic management of myasthenia gravis patients undergoing cardiac or aortic surgery under cardiopulmonary bypass, especially with deep hypothermic circulatory arrest, is challenging. We describe a case of successful anesthetic management of a myasthenia gravis patient undergoing total arch replacement with deep hypothermic circulatory arrest under neuromuscular monitoring and complete reversal of the action of neuromuscular blocking drugs by sugammadex. The present case suggests that patients with well-controlled myasthenia gravis might be safely managed in cardiac or aortic surgery under cardiopulmonary bypass with deep hypothermic circulatory arrest.

The effect of SANGUINATE® (PEGylated carboxyhemoglobin bovine) on cardiopulmonary bypass functionality using a bovine whole blood model of normovolemic hemodilution

Background:

Cardiac surgery using cardiopulmonary bypass carries a high risk of bleeding and need for blood transfusion. Blood administration is associated with increased rates of morbidity and mortality. Perioperatively, strategies are often employed to reduce blood transfusions in high-risk patients or in situations where blood transfusion is contraindicated. Normovolemic hemodilution is a blood conservation technique used during cardiac surgery that involves replacement of blood with fluids. SANGUINATE® (PEGylated carboxyhemoglobin bovine) is a novel hemoglobin-based oxygen carrier that can deliver oxygen effectively to tissues in the presence of severe hypoxia. The use of a hemoglobin-based oxygen carrier during hemodilution may augment tissue oxygen delivery and reduce blood transfusion.

Methods:

Six standardized cardiopulmonary bypass runs simulating normovolemic hemodilution using varying proportions of bovine whole blood and SANGUINATE were performed. Pump speed, flow rate, line pressures, hemoglobin concentration, oxygenation, and degree of anticoagulation were assessed at regular intervals. Membrane oxygenators and arterial line filters were inspected for evidence of clotting following each run.

Results:

Increases in the pressure drop across the membrane oxygenator were detected during runs 5 and 6. Median activated clotting time values were able to be maintained at goal during the runs, and SANGUINATE did not appear to be thrombogenic. Hemoglobin concentration decreased following the addition of SANGUINATE. Oxygenation was maintained during all runs that included SANGUINATE.

Conclusion:

SANGUINATE does not impact the performance of the cardiopulmonary bypass circuit in a bovine whole blood model. The results support further evaluation of SANGUINATE in the setting of normovolemic hemodilution and cardiopulmonary bypass.

Effective Dose of Landiolol, an Ultra-Short-Acting β-Blocker, to Decrease Heart Rate During On-Pump, Beating Coronary Artery Bypass Grafting

OBJECTIVE

Decreasing the heart rate (HR) using landiolol, an ultra-short-acting β-blocker, is helpful for completing a meticulous distal anastomosis during on-pump or off-pump, beating coronary artery bypass grafting (CABG) surgery. We determine the effectiveness of landiolol to decrease the HR because the most effective dose has not been established.

DESIGN

Observational open-label pharmacodynamics cohort study.

SETTING

Single center, Hamamatsu University Hospital.

PARTICIPANTS

28 patients undergoing on-pump, beating CABG.

INTERVENTIONS

Landiolol 5 μg/kg/min was started (time 0) and then increased to 15, 25, and 35 μg/kg/min at 10-min intervals during left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis.

MEASUREMENTS AND MAIN RESULTS

Pharmacodynamics were characterized using a sigmoidal inhibitory maximum effect model to determine the percent decrease in HR according to the landiolol dose. Baseline (mean  ±  SD) HR (85 ± 10 beats/min) decreased to 81 ± 9, 71 ± 10, 67 ± 9, and 67 ± 9 beats/min, respectively, at the four landiolol infusion points evaluated. Estimated maximum percent decrease in HR from the baseline effective dose value (ED0) was -21.5 (-25.3 to -17.8) [mean (95% confidence interval)]%. ED50, ED90, and ED95 were 9.5 (9.0-10.1), 25.0 (22.5-27.6), and 35.2 (30.3-40.1) μg/kg/min, respectively.

CONCLUSIONS

Landiolol maximally decreased HR just over 20% of the baseline HR. Hence, landiolol 25 μg/kg/min is likely a sufficient dose during LITA-LAD anastomosis during on-pump, beating CABG.

The triple variable index combines information generated over time from common monitoring variables to identify patients expressing distinct patterns of intraoperative physiology

Background

Mean arterial pressure (MAP), bispectral index (BIS), and minimum alveolar concentration (MAC) represent valuable, yet dynamic intraoperative monitoring variables. They provide information related to poor outcomes when considered together, however their collective behavior across time has not been characterized.

Methods

We have developed the Triple Variable Index (TVI), a composite variable representing the sum of z-scores from MAP, BIS, and MAC values that occur together during surgery. We generated a TVI expression profile, defined as the sequential TVI values expressed across time, for each surgery where concurrent MAP, BIS, and MAC monitoring occurred in an adult patient (≥18 years) at the University of Pittsburgh Medical Center between January and July 2014 (n = 5296). Patterns of TVI expression were identified using k-means clustering and compared across numerous patient, procedure, and outcome characteristics. TVI and the triple low state were compared as prediction models for 30-day postoperative mortality.

Results

The median frequency MAP, BIS, and MAC were recorded was one measurement every 3, 5, and 5 min. Three expression patterns were identified: elevated, mixed, and depressed. The elevated pattern displayed the highest average MAP, BIS, and MAC values (86.5 mmHg, 45.3, and 0.98, respectively), while the depressed pattern displayed the lowest values (76.6 mmHg, 38.0, 0.66). Patterns (elevated, mixed, depressed) were distinct across the following characteristics: average patient age (52, 53, 54 years), American Society of Anesthesiologists Physical Status 4 (6.7, 16.1, 27.3%) and 5 (0.1, 0.6, 1.6%) categories, cardiac (2.2, 6.5, 16.1%) and emergent (5.8, 10.5, 12.8%) surgery, cardiopulmonary bypass use (0.3, 2.6, 9.8%), intraoperative medication administration including etomidate (3.0, 7.3, 12.6%), hydromorphone (47.6, 26.3, 25.2%), ketamine (11.2, 4.6, 3.0%), dexmedetomidine (18.4, 16.6, 13.6%), phenylephrine (74.0, 74.8, 83.0), epinephrine (2.0, 6.0, 18.0%), norepinephrine (2.4, 7.5, 21.2%), vasopressin (3.4, 7.6, 21.0%), succinylcholine (74.0, 69.0, 61.9%), intraoperative hypotension (28.8, 33.0, 52.3%) and the triple low state (9.4, 30.3, 80.0%) exposure, and 30-day postoperative mortality (0.8, 2.7, 5.6%). TVI was a better predictor of patients that died or survived in the 30 days following surgery compared to cumulative triple low state exposure (AUC 0.68 versus 0.62, p < 0.05).

Conclusions

Surgeries that share similar patterns of TVI expression display distinct patient, procedure, and outcome characteristics.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0660-9) contains supplementary material, which is available to authorized users.

The depth of anaesthesia associated with the administration of isoflurane 2.5% during cardiopulmonary bypass

BACKGROUND

Administering isoflurane 2.5% into the oxygenator during cardiopulmonary bypass results in no patient movement. However, doing so may result in an excessive depth of anaesthesia particularly, when hypothermia is induced. Bispectral index and arterial blood and oxygenator exhaust concentrations of volatile anaesthetics should be related to depth of anaesthesia. The primary aim of this study was to measure the depth of anaesthesia using bispectral index, resulting from administering isoflurane 2.5% into the oxygenator during cardiopulmonary bypass, and secondary aims were to examine the relationships between blood and oxygenator exhaust isoflurane concentrations and bispectral index.

METHODS

Arterial and mixed-venous blood samples were aspirated at three time points during cardiopulmonary bypass and measured for isoflurane concentration using mass spectrometry. Simultaneously, oxygenator exhaust isoflurane concentration, nasopharyngeal temperature and bispectral index were recorded.

RESULTS

When averaged across the three time points, all patients had a bispectral index score below 40 (binomial test, p < 0.001). There were no significant correlations between bispectral index score and arterial or mixed-venous blood isoflurane concentrations (r = -0.082, p = 0.715; r = -0.036, p = 0.874) and oxygenator exhaust gas concentration of isoflurane (r = -0.369, p = 0.091).

CONCLUSION

When 2.5% isoflurane was administered into the sweep gas supply to the oxygenator during cardiopulmonary bypass, all patients experienced a bispectral index score less than 40 and no significant relationship was found between either arterial or mixed-venous blood or oxygenator exhaust concentrations of isoflurane and bispectral index.

Evaluation of the use of the fourth version FloTrac system in cardiac output measurement before and after cardiopulmonary bypass

The FloTrac system is a system for cardiac output (CO) measurement that is less invasive than the pulmonary artery catheter (PAC). The purposes of this study were to (1) compare the level of agreement and trending abilities of CO values measured using the fourth version of the FloTrac system (CCO-FloTrac) and PAC-originated continuous thermodilution (CCO-PAC) and (2) analyze the inadequate CO-discriminating ability of the FloTrac system before and after cardiopulmonary bypass (CPB). Fifty patients were included. After exclusion, 32 patients undergoing cardiac surgery with CPB were analyzed. All patients were monitored with a PAC and radial artery catheter connected to the FloTrac system. CO was assessed at 10 timing points during the surgery. In the Bland-Altman analysis, the percentage errors (bias, the limits of agreement) of the CCO-FloTrac were 61.82% (0.16, - 2.15 to 2.47 L min) and 51.80% (0.48, - 1.97 to 2.94 L min) before and after CPB, respectively, compared with CCO-PAC. The concordance rates in the four-quadrant plot were 64.10 and 62.16% and the angular concordance rates (angular mean bias, the radial limits of agreement) in the polar-plot analysis were 30.00% (17.62°, - 70.69° to 105.93°) and 38.63% (- 10.04°, - 96.73° to 76.30°) before and after CPB, respectively. The area under the receiver operating characteristic curve for CCO-FloTrac was 0.56, 0.52, 0.52, and 0.72 for all, ≥ ± 5, ≥ ± 10, and ≥ ± 15% CO changes (ΔCO) of CCO-PAC before CPB, respectively, and 0.59, 0.55, 0.49, and 0.46 for all, ≥ ± 5, ≥ ± 10, and ≥ ± 15% ΔCO of CCO-PAC after CPB, respectively. When CO < 4 L/min was considered inadequate, the Cohen κ coefficient was 0.355 and 0.373 before and after CPB, respectively. The accuracy, trending ability, and inadequate CO-discriminating ability of the fourth version of the FloTrac system in CO monitoring are not statistically acceptable in cardiac surgery.

Performance of the Minto model for the target-controlled infusion of remifentanil during cardiopulmonary bypass

We studied the predictive performance of the Minto pharmacokinetic model during cardiopulmonary bypass in patients undergoing cardiac surgery. Patients received remifentanil target-controlled infusion using the Minto model during total intravenous anaesthesia with propofol. From 56 patients, 275 arterial blood samples were drawn before, during and after bypass to determine the plasma concentration of remifentanil, and the predicted concentrations were recorded at each time. For pooled data, the median prediction error and median absolute prediction error were 21.3% and 21.8%, respectively, and 22.1% and 22.3% during bypass. Both were 148.4% during hypothermic circulatory arrest and measured concentrations were more than three times greater than predicted (26.9 (17.0) vs. 7.1 (1.6) ng.ml^-1 ). The Minto model showed considerable bias but overall acceptable precision during bypass. The target concentration of remifentanil should be reduced when using the Minto model during hypothermic circulatory arrest.