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Chiari P, Fellahi JL. Myocardial protection in cardiac surgery: a comprehensive review of current therapies and future cardioprotective strategies. Front Med (Lausanne) 2024; 11:1424188. [PMID: 38962735 PMCID: PMC11220133 DOI: 10.3389/fmed.2024.1424188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 05/23/2024] [Indexed: 07/05/2024] Open
Abstract
Cardiac surgery with cardiopulmonary bypass results in global myocardial ischemia-reperfusion injury, leading to significant postoperative morbidity and mortality. Although cardioplegia is the cornerstone of intraoperative cardioprotection, a number of additional strategies have been identified. The concept of preconditioning and postconditioning, despite its limited direct clinical application, provided an essential contribution to the understanding of myocardial injury and organ protection. Therefore, physicians can use different tools to limit perioperative myocardial injury. These include the choice of anesthetic agents, remote ischemic preconditioning, tight glycemic control, optimization of respiratory parameters during the aortic unclamping phase to limit reperfusion injury, appropriate choice of monitoring to optimize hemodynamic parameters and limit perioperative use of catecholamines, and early reintroduction of cardioprotective agents in the postoperative period. Appropriate management before, during, and after cardiopulmonary bypass will help to decrease myocardial damage. This review aimed to highlight the current advancements in cardioprotection and their potential applications during cardiac surgery.
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Affiliation(s)
- Pascal Chiari
- Service d’Anesthésie Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Luc Fellahi
- Service d’Anesthésie Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
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Kelava M, Milam AJ, Mi J, Alfirevic A, Grady P, Unai S, Elgharably H, McCurry K, Koprivanac M, Duncan A. Arterial Hyperoxemia During Cardiopulmonary Bypass Was Not Associated With Worse Postoperative Pulmonary Function: A Retrospective Cohort Study. Anesth Analg 2024; 138:1003-1010. [PMID: 37733624 PMCID: PMC10994185 DOI: 10.1213/ane.0000000000006627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Arterial hyperoxemia may cause end-organ damage secondary to the increased formation of free oxygen radicals. The clinical evidence on postoperative lung toxicity from arterial hyperoxemia during cardiopulmonary bypass (CPB) is scarce, and the effect of arterial partial pressure of oxygen (Pa o2 ) during cardiac surgery on lung injury has been underinvestigated. Thus, we aimed to examine the relationship between Pa o2 during CPB and postoperative lung injury. Secondarily, we examined the relationship between Pa o2 and global (lactate), and regional tissue malperfusion (acute kidney injury). We further explored the association with regional tissue malperfusion by examining markers of cardiac (troponin) and liver injury (bilirubin). METHODS This was a retrospective cohort study including patients who underwent elective cardiac surgeries (coronary artery bypass, valve, aortic, or combined) requiring CPB between April 2015 and December 2021 at a large quaternary medical center. The primary outcome was postoperative lung function defined as the ratio of Pa o2 to fractional inspired oxygen concentration (F io2 ); P/F ratio 6 hours following surgery or before extubation. The association between CPB in-line sample monitor Pa o2 and primary, secondary, and exploratory outcomes was evaluated using linear or logistic regression models adjusting for available baseline confounders. RESULTS A total of 9141 patients met inclusion and exclusion criteria, and 8429 (92.2%) patients had complete baseline variables available and were included in the analysis. The mean age of the sample was 64 (SD = 13), and 68% were men (n = 6208). The time-weighted average (TWA) of in-line sample monitor Pa o2 during CPB was weakly positively associated with the postoperative P/F ratio. With a 100-unit increase in Pa o2 , the estimated increase in postoperative P/F ratio was 4.61 (95% CI, 0.71-8.50; P = .02). Our secondary analysis showed no significant association between Pa o2 with peak lactate 6 hours post CPB (geometric mean ratio [GMR], 1.01; 98.3% CI, 0.98-1.03; P = .55), average lactate 6 hours post CPB (GMR, 1.00; 98.3% CI, 0.97-1.03; P = .93), or acute kidney injury by Kidney Disease Improving Global Outcomes (KDIGO) criteria (odds ratio, 0.91; 98.3% CI, 0.75-1.10; P = .23). CONCLUSIONS Our investigation found no clinically significant association between Pa o2 during CPB and postoperative lung function. Similarly, there was no association between Pa o2 during CPB and lactate levels, postoperative renal function, or other exploratory outcomes.
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Affiliation(s)
- Marta Kelava
- From the Departments of Cardiothoracic Anesthesiology
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Adam J. Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Junhui Mi
- Departments of Quantitative Health Sciences
| | | | | | - Shinya Unai
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Kenneth McCurry
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Andra Duncan
- From the Departments of Cardiothoracic Anesthesiology
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Begashvili I, Kiladze M, Ejibishvili C, Grigolia G. Minimal fixed flow anesthesia for off-pump coronary artery bypass surgery: A parallel randomized trail. Heliyon 2023; 9:e22181. [PMID: 38034715 PMCID: PMC10685267 DOI: 10.1016/j.heliyon.2023.e22181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/23/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives The aim of the present study was to test a safety of a fixed minimal (0.5 l/min) fresh gas flow (FGF) anesthesia as a method ensuring adequate oxygenation during off-pump coronary artery bypass grafting operations. Design A randomized, prospective study. Setting Single-center clinical hospital affiliated with a university. Participants 208 patients underwent off-pump coronary artery bypass surgery. Interventions All patients received endotracheal inhalational anesthesia with fixed minimal FGF. Half of them were anesthetized by sevoflurane and another half by isoflurane. The fresh (carrier) gas was pure oxygen in the control groups and a mixture of medical air and oxygen (FiO2 0.8) in the trial groups. Measurements and main results In the control groups inhaled oxygen concentration changed minimally during the operation. In the trial groups in 28.8 % of cases inhaled oxygen concentration dropped below preliminary margin (0.4). Body surface area (BSA) (B = 38.7; p = 0.002) and patient's age (B = -0.47; p = 0.004) were retained into final logistic regression model as independent predictors. We divided BSA into subcategories and analyzed data by survival cox regression with Forward LR method. Patients with BSA>2.3 (Exp.B = 183) and BSA [2.2-2.3] (Exp.B = 59) had high chance to get less than 0.4 of inhaled oxygen concentration compared to the patients with BSA <2.0 (p < 0.001).Exp(B) or OR for the patients' age as independent predictor tested in multiple logistic regression was 0.628 In other words, for every year less the patient had 1/0.628 = 1.6 times more chance to reach the preliminary low margin (0.4) of oxygenation. Conclusions Fixed minimal FGF 0.5 l/min with FiO2 0.8 may not be sufficient for the younger patients with BSA >2.0 to maintain inhaled oxygen concentration above 0.4. Using pure oxygen as a carrier gas during fixed minimal flow long term anesthesia is much safer and more reliable.
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Affiliation(s)
- Ioseb Begashvili
- Tbilisi 5th clinical hospital, Department of cardiac anesthesia and intensive care. PhD student of Ivane Javakhishvili Tbilisi state university. Address: Temqa - XI, I Quarter, 5th clinical hospital “Open Heart”, 0102 Tbilisi, Georgia
| | - Merab Kiladze
- Professor of Ivane Javakhishvili Tbilisi state university, Chief of the department of surgery at American hospital Tbilisi, Georgia
| | - Christina Ejibishvili
- Tbilisi 5th clinical hospital, Department of cardiac anesthesia and intensive care, PhD student of Ivane Javakhishvili Tbilisi state university, Georgia
| | - George Grigolia
- Tbilisi 5th clinical hospital, Head of the department of cardiac anesthesia and intensive care, Georgia
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Turra J, Riesterer D, Eisner C, Wenzel F, Möbius A, Karck M, Arif R, Lichtenstern C, Fischer D. Prospective clinical study testing the efficacy and safety of a new formula to increase the precision of oxygen therapy in the initiation phase of cardiopulmonary bypass. Perfusion 2023; 38:1203-1212. [PMID: 35608437 PMCID: PMC10466968 DOI: 10.1177/02676591221100743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION During cardiopulmonary bypass (CPB), supranormal concentrations of oxygen are routinely administered with the intention to prevent cellular hypoxia. However, hyperoxemia may have adverse effects on patient outcome. Oxygen settings are based on the perfusionist's individual work experience rather than profound recommendations and studies analyzing the effect of oxygen levels are in need of methodological improvement. We aimed to advance perfusion technique by developing and clinically applying a formula for tailored oxygen therapy in CPB. METHODS A formula to precalculate the oxygenator setting before CPB was developed. The newly-derived formula was then evaluated in a prospective, single-center pilot study to test whether a predefined arterial partial oxygen pressure (PaO2) of 150-250 mmHg could be reached. 80 patients were enrolled in the study between April and September 2021. RESULTS The mean oxygen fraction calculated for the setting of the gas blender was 52% ±0,12. The mean PaO2 after initiation of the CPB was 193 ± 99 mmHg (min-max: 61-484, median 163 mmHg). 38.75% of the values were in the desired PaO2 corridor of 150 to 250 mmHg. 8.75% of all PaO2 values were below <79.9 mmHg, 31.25% between 80 and 149.9 mmHg, 38.75% between 150 and 249.9 mmHg and 21.25%>250 mmHg. CONCLUSIONS Conceptually, perfusion technique should be goal-directed, guided by objective parameters and formulas. Although the optimal CPB oxygenation target remains unknown, it is nevertheless important to develop strategies to tailor oxygen therapy to aid in creating evidence as to what level of oxygen is best for patients during CPB. The formula we derived needs further adjustments to increase results in the target range.
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Affiliation(s)
- Jan Turra
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - David Riesterer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Eisner
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Folker Wenzel
- Furtwangen University, University Schwenningen, Schwenningen, Germany
| | - Andreas Möbius
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Dania Fischer
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
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Nam K, Nam JS, Kim HB, Chung J, Hwang IE, Ju JW, Bae J, Lee S, Cho YJ, Shim JK, Kwak YL, Chin JH, Choi IC, Lee EH, Jeon Y. Effects of intraoperative inspired oxygen fraction (FiO 2 0.3 vs 0.8) on patients undergoing off-pump coronary artery bypass grafting: the CARROT multicenter, cluster-randomized trial. Crit Care 2023; 27:286. [PMID: 37443130 PMCID: PMC10339585 DOI: 10.1186/s13054-023-04558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND To maintain adequate oxygenation is of utmost importance in intraoperative care. However, clinical evidence supporting specific oxygen levels in distinct surgical settings is lacking. This study aimed to compare the effects of 30% and 80% oxygen in off-pump coronary artery bypass grafting (OPCAB). METHODS This multicenter trial was conducted in three tertiary hospitals from August 2019 to August 2021. Patients undergoing OPCAB were cluster-randomized to receive either 30% or 80% oxygen intraoperatively, based on the month when the surgery was performed. The primary endpoint was the length of hospital stay. Intraoperative hemodynamic data were also compared. RESULTS A total of 414 patients were cluster-randomized. Length of hospital stay was not different in the 30% oxygen group compared to the 80% oxygen group (median, 7.0 days vs 7.0 days; the sub-distribution hazard ratio, 0.98; 95% confidence interval [CI] 0.83-1.16; P = 0.808). The incidence of postoperative acute kidney injury was significantly higher in the 30% oxygen group than in the 80% oxygen group (30.7% vs 19.4%; odds ratio, 1.94; 95% CI 1.18-3.17; P = 0.036). Intraoperative time-weighted average mixed venous oxygen saturation was significantly higher in the 80% oxygen group (74% vs 64%; P < 0.001). The 80% oxygen group also had a significantly greater intraoperative time-weighted average cerebral regional oxygen saturation than the 30% oxygen group (56% vs 52%; P = 0.002). CONCLUSIONS In patients undergoing OPCAB, intraoperative administration of 80% oxygen did not decrease the length of hospital stay, compared to 30% oxygen, but may reduce postoperative acute kidney injury. Moreover, compared to 30% oxygen, intraoperative use of 80% oxygen improved oxygen delivery in patients undergoing OPCAB. Trial registration ClinicalTrials.gov (NCT03945565; April 8, 2019).
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Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hye-Bin Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jaeyeon Chung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Medical Service Corps of the First Logistics Support Command, Wonju, Gangwon State, Republic of Korea
| | - In Eob Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Gyeonggi Province, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
- Hana Anesthesia Clinic, Seoul, Republic of Korea.
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Ju JW, Choe HW, Bae J, Lee S, Cho YJ, Nam K, Jeon Y. Intraoperative mild hyperoxia may be associated with improved survival after off-pump coronary artery bypass grafting: a retrospective observational study. Perioper Med (Lond) 2022; 11:27. [PMID: 35851431 PMCID: PMC9295444 DOI: 10.1186/s13741-022-00259-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 03/28/2022] [Indexed: 01/28/2023] Open
Abstract
Background The effect of hyperoxia due to supplemental oxygen administration on postoperative outcomes in patients undergoing cardiac surgery remains unclear. This retrospective study aimed to evaluate the relationship between intraoperative oxygen tension and mortality after off-pump coronary artery bypass grafting (OPCAB). Methods The study included adult patients who underwent isolated OPCAB between July 2010 and June 2020. Patients were categorised into three groups based on their intraoperative time-weighted average arterial oxygen partial pressure (PaO2): normoxia/near-normoxia (< 150 mmHg), mild hyperoxia (150–250 mmHg), and severe hyperoxia (> 250 mmHg). The risk of in-hospital mortality was compared using weighted logistic regression analysis. Restricted cubic spline analysis was performed to analyse intraoperative PaO2 as a continuous variable. The risk of cumulative all-cause mortality was compared using Cox regression analysis. Results The normoxia/near-normoxia, mild hyperoxia, and severe hyperoxia groups included 229, 991, and 173 patients (n = 1393), respectively. The mild hyperoxia group had a significantly lower risk of in-hospital mortality than the normoxia/near-normoxia (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.06–0.22) and severe hyperoxia groups (OR, 0.06; 95% CI, 0.03–0.14). Intraoperative PaO2 exhibited a U-shaped relationship with in-hospital mortality in the non-hypoxic range. The risk of cumulative all-cause mortality was significantly lower in the mild hyperoxia group (hazard ratio, 0.72; 95% CI, 0.52–0.99) than in the normoxia/near-normoxia group. Conclusions Maintaining intraoperative PaO2 at 150–250 mmHg was associated with a lower risk of mortality after OPCAB than PaO2 at < 150 mmHg and at > 250 mmHg. Future randomised trials are required to confirm if mildly increasing arterial oxygen tension during OPCAB to 150–250 mmHg improves postoperative outcomes.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Hyun Woo Choe
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea.
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
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Shen Y, Ru W, Cao L, Jiang R, Xu X. Impact of partial pressure of oxygen trajectories on the incidence of acute kidney injury in patients undergoing cardiopulmonary bypass. J Cardiol 2021; 79:545-550. [PMID: 34799218 DOI: 10.1016/j.jjcc.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/01/2021] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND To investigate the impact of the dynamic oxygenation status on the incidence of acute kidney injury (AKI) in patients undergoing cardiopulmonary bypass. METHODS This retrospective study was performed using data extracted from the Medical Information Mart for Intensive Care III database. A group-based trajectory approach was used to identify partial pressure of oxygen (PaO2) trajectories using dynamic change in PaO2 within 48 hours after intensive care unit admission. RESULTS In total, 5,824 patients were included. Four PaO2 trajectories were identified: Trajectory 1 (Traj-1), hyperoxia and rapid decrease; Trajectory 2 (Traj-2), hyperoxia and rapid decrease similar to that of Traj-1; Trajectory 3 (Traj-3), normoxemia and rapid increase in PaO2; and Trajectory 4 (Traj-4), hyperoxia and gradual decrease. Compared with the Traj-1 group, the Traj-3 group had a significantly lower initial Sequential Organ Failure Assessment score, similar vasopressor use rate, and a higher fraction of inspired oxygen. However, the risk of developing AKI was significantly higher in the Traj-3 [adjusted odds ratio (OR): 1.7, 95% confidence interval (CI): 1.1-2.7] and Traj-4 groups (OR: 1.9, 95% CI: 1.4-2.5) than in the Traj-1 group. CONCLUSIONS Patients with persistent hyperoxia had a higher incidence of AKI than those with transient hyperoxia. Further studies are required to determine potential underlying mechanisms.
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Affiliation(s)
- Yanfei Shen
- Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Weizhe Ru
- Cixi People's Hospital, Cixi, Zhejiang, China
| | - Lingyong Cao
- Zhejiang University of Traditional Chinese Medicine, Hangzhou, Zhejiang, China
| | - Ronglin Jiang
- Zhejiang Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, China
| | - Xiaoming Xu
- Zhejiang Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, China.
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Grocott BB, Kashani HH, Maakamedi H, Dutta V, Hiebert B, Rakar M, Grocott HP. Oxygen Management During Cardiopulmonary Bypass: A Single-Center, 8-Year Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:100-105. [PMID: 32921614 DOI: 10.1053/j.jvca.2020.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 08/05/2020] [Accepted: 08/12/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To characterize the institutional oxygen management practices during cardiopulmonary bypass (CPB) in patients undergoing cardiac surgery, including any potential changes during an 8-year study period. DESIGN A retrospective cohort study. SETTING A tertiary care cardiac surgical program. PARTICIPANTS Patients who underwent cardiac surgery involving CPB, with or without hypothermic circulatory arrest (HCA), between January 1, 2010, and December 31, 2017. MEASUREMENTS AND MAIN RESULTS In addition to baseline patient characteristics, the authors recorded the partial pressures of arterial oxygen (Pao2), fraction of inspired oxygen, and mixed venous oxygen saturation during CPB of 696 randomly selected patients during an 8-year study period. The overall mean Pao2 was 255 ± 48 mmHg, without any significant change during the 8-year study period (p = 0.30). The mean Pao2 of HCA patients was significantly higher than in patients without HCA (327 ± 93 mmHg v 252 ± 45 mmHg, respectively; p < 0.001). CONCLUSIONS The current approach to oxygen management during CPB at the authors' institution is within the range of hyperoxemic levels, and these practices have not changed over time. The impact of these practices on patients' outcomes is not fully understood, and additional studies are needed to establish firm evidence to guide optimal oxygen management practice during CPB.
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Affiliation(s)
- Bronwen B Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hessam H Kashani
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Vikas Dutta
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Martin Rakar
- Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Hilary P Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada.
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Topcu AC, Bolukcu A, Ozeren K, Kavasoglu T, Kayacioglu I. Normoxic management of cardiopulmonary bypass reduces myocardial oxidative stress in adult patients undergoing coronary artery bypass graft surgery. Perfusion 2020; 36:261-268. [PMID: 32755372 DOI: 10.1177/0267659120946733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION We aimed to investigate whether normoxic cardiopulmonary bypass would limit myocardial oxidative stress in adults undergoing coronary artery bypass grafting. METHODS Patients scheduled to undergo elective isolated on-pump coronary artery bypass grafting were randomized to normoxia and hyperoxia groups. The normoxia group received 35% oxygen during anesthetic induction, 35% during hypothermic bypass, and 45% during rewarming. The hyperoxia group received 70%, 50%, and 70% oxygen, respectively. Coronary sinus blood samples were taken prior to initiation of cardiopulmonary bypass and after reperfusion for myocardial total oxidant and antioxidant status measurements. The primary endpoint was myocardial total oxidant status. Secondary endpoints were myocardial total antioxidant status and length of intensive care unit and hospital stay. RESULTS Forty-eight patients were included. Twenty-two received normoxic management. Mean ± standard deviation of age was 58 ± 9.07 years. Groups were balanced in terms of demographics, risk factors, and operative data. Myocardial total oxidant status was significantly lower in the normoxia group following reperfusion (p = 0.03). There was no statistically significant difference regarding myocardial total antioxidant status and length of intensive care unit and hospital stay (p = 0.08, p = 0.82, and p = 0.54, respectively). CONCLUSIONS Normoxic cardiopulmonary bypass is associated with reduced myocardial oxidative stress compared to hyperoxic cardiopulmonary bypass in adult coronary artery bypass patients.
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Affiliation(s)
- Ahmet Can Topcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Bolukcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Kamile Ozeren
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tugba Kavasoglu
- Department of Anesthesiology and Reanimation, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ilyas Kayacioglu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Abou-Arab O, Huette P, Martineau L, Beauvalot C, Beyls C, Josse E, Touati G, Bouchot O, Bouhemad B, Diouf M, Lorne E, Guinot PG. Hyperoxia during cardiopulmonary bypass does not decrease cardiovascular complications following cardiac surgery: the CARDIOX randomized clinical trial. Intensive Care Med 2019; 45:1413-1421. [PMID: 31576438 DOI: 10.1007/s00134-019-05761-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 08/20/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Data on the benefit or or harmful effects of oxygen level on ischemic reperfusion injuries in cardiac surgery are insufficient. We hypothesized that hyperoxia during cardiopulmonary bypass decreases the incidence of postoperative atrial fibrillation (POAF) and ventricular fibrillation, and therefore decreases cardiovascular morbidity (CARDIOX study). METHODS An open-label, randomized clinical trial including adults undergoing elective cardiac surgery, i.e. cardiopulmonary bypass (CPB) randomized 1:1 to an intervention group or standard group at two French University Hospitals from June 2016 to October 2018. The intervention consisted in delivering of an inspired fraction of oxygen of one to one during CPB. The standard care consisted in delivering oxygen to achieve a partial arterial blood pressure less than 150 mmHg. The primary endpoint was the occurrence of POAF and/or ventricular tachycardia/ventricular fibrillation (VT/VF) within the 15 days following cardiac surgery. The secondary endpoint was the occurrence of major adverse cardiovascular events (MACCE: in-hospital mortality, stroke, cardiac arrest, acute kidney injury, and mesenteric ischemia). RESULTS 330 patients were randomly assigned to either the intervention group (n = 161) or the standard group (n = 163). Mean PaO2 was 447 ± 98 mmHg and 161 ± 60 mmHg during CPB, for the intervention and standard group (p < 0.0001) respectively. The incidence of POAF or VT/VF were similar in the intervention group and the standard group (30% [49 of 161 patients] and 30% [49 of 163 patients], absolute risk reduction 0.4%; 95% CI, - 9.6-10.4; p = 0.94). MACCE was similar between groups with, an occurrence of 24% and 21% for the intervention group and the standard groups (absolute risk reduction 3.4%; 95% CI, - 5.7-12.5; p = 0.47) respectively. After adjustment, the primary and secondary endpoints remained similar for both groups. CONCLUSION Hyperoxia did not decrease POAF and cardiovascular morbidity following cardiac surgery with CPB. CLINICALTRIAL. GOV IDENTIFIER NCT02819739.
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Affiliation(s)
- Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 1, Rue du Professeur Christian Cabrol, 80054, Amiens, France. .,MP3CV, EA7517, CURS, Jules Verne University of Picardy, 80054, Amiens, France.
| | - Pierre Huette
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 1, Rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Lucie Martineau
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 1, Rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Clémence Beauvalot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, 14033, Dijon, France
| | - Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 1, Rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Estelle Josse
- Department of Clinical Research, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Gilles Touati
- Department of Cardiac Surgery, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Olivier Bouchot
- Department of Cardiac Surgery, Dijon University Hospital, 14033, Dijon, France
| | - Belaïd Bouhemad
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, 14033, Dijon, France
| | - Momar Diouf
- Department of Clinical Research, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Emmanuel Lorne
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 1, Rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, 14033, Dijon, France
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Roberts SM, Cios TJ. Con: Hyperoxia Should Not Be Used Routinely in the Management of Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2019; 33:2075-2078. [PMID: 30890393 DOI: 10.1053/j.jvca.2019.02.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/11/2022]
Affiliation(s)
- S Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA.
| | - Theodore J Cios
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
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12
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The impact of hyperoxia on outcomes after cardiac surgery: a systematic review and narrative synthesis. Can J Anaesth 2018; 65:923-935. [DOI: 10.1007/s12630-018-1143-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 01/05/2023] Open
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13
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Heinrichs J, Grocott HP. Pro: Hyperoxia Should Be Used During Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:2070-2074. [PMID: 29567040 DOI: 10.1053/j.jvca.2018.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Jeffrey Heinrichs
- Department of Anesthesia, Pain, and Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hilary P Grocott
- Department of Anesthesia, Pain, and Perioperative Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Effects of Hyperoxia During Resuscitation From Hemorrhagic Shock in Swine With Preexisting Coronary Artery Disease. Crit Care Med 2017; 45:e1270-e1279. [PMID: 29028763 DOI: 10.1097/ccm.0000000000002767] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Investigation of the effects of hyperoxia during resuscitation from hemorrhagic shock in swine with preexisting coronary artery disease. DESIGN Prospective, controlled, randomized trial. SETTING University animal research laboratory. SUBJECTS Nineteen hypercholesterolemic pigs with preexisting coronary artery disease. INTERVENTIONS Anesthetized, mechanically ventilated, and surgically instrumented pigs underwent 3 hours of hemorrhagic shock (removal of 30% of the calculated blood volume and subsequent titration of mean arterial blood pressure ≈40 mm Hg). Postshock resuscitation (48 hr) comprised retransfusion of shed blood, crystalloids (balanced electrolyte solution), and norepinephrine support. Pigs were randomly assigned to "control" (FIO2 0.3, adjusted for arterial oxygen saturation ≥ 90%) and "hyperoxia" (FIO2 1.0 for 24 hr) groups. MEASUREMENTS AND MAIN RESULTS Before, at the end of shock and every 12 hours of resuscitation, datasets comprising hemodynamics, calorimetry, blood gases, cytokines, and cardiac and renal function were recorded. Postmortem, organs were sampled for immunohistochemistry, western blotting, and mitochondrial high-resolution respirometry. Survival rates were 50% and 89% in the control and hyperoxia groups, respectively (p = 0.077). Apart from higher relaxation constant τ at 24 hours, hyperoxia did not affect cardiac function. However, troponin values were lower (2.2 [0.9-6.2] vs 6.9 [4.8-9.8] ng/mL; p < 0.05) at the end of the experiment. Furthermore, hyperoxia decreased cardiac 3-nitrotyrosine formation and increased inducible nitric oxide synthase expression. Plasma creatinine values were lower in the hyperoxia group during resuscitation coinciding with significantly improved renal mitochondrial respiratory capacity and lower 3-nitrotyrosine formation. CONCLUSIONS Hyperoxia during resuscitation from hemorrhagic shock in swine with preexisting coronary artery disease reduced renal dysfunction and cardiac injury, potentially resulting in improved survival, most likely due to increased mitochondrial respiratory capacity and decreased oxidative and nitrosative stress. Compared with our previous study, the present results suggest a higher benefit of hyperoxia in comorbid swine due to an increased susceptibility to hemorrhagic shock.
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Jakutis G, Norkienė I, Ringaitienė D, Jovaiša T. Severity of hyperoxia as a risk factor in patients undergoing on-pump cardiac surgery. Acta Med Litu 2017; 24:153-158. [PMID: 29217969 PMCID: PMC5709054 DOI: 10.6001/actamedica.v24i3.3549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background. Hyperoxia has long been perceived as a desirable or at least an inevitable part of cardiopulmonary bypass. Recent evidence suggest that it might have multiple detrimental effects on patient homeostasis. The aim of the study was to identify the determinants of supra-physiological values of partial oxygen pressure during on-pump cardiac surgery and to assess the impact of hyperoxia on clinical outcomes. Materials and methods. Retrospective data analysis of the institutional research database was performed to evaluate the effects of hyperoxia in patients undergoing elective cardiac surgery with cardiopulmonary bypass, 246 patients were included in the final analysis. Patients were divided in three groups: mild hyperoxia (MHO, PaO2 100–199 mmHg), moderate hyperoxia (MdHO, PaO2 200–299 mmHg), and severe hyperoxia (SHO, PaO2 >300 mmHg). Postoperative complications and outcomes were defined according to standardised criteria of the Society of Thoracic Surgeons. Results. The extent of hyperoxia was more immense in patients with a lower body mass index (p = 0.001) and of female sex (p = 0.005). A significant link between severe hyperoxia and a higher incidence of infectious complications (p – 0.044), an increased length of hospital stay (p – 0.044) and extended duration of mechanical ventilation (p < 0.001) was confirmed. Conclusions. Severe hyperoxia is associated with an increased incidence of postoperative infectious complications, prolonged mechanical ventilation, and increased hospital stay.
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Affiliation(s)
- Gabrielius Jakutis
- Clinic of Anaesthesiology and Reanimatology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ieva Norkienė
- Clinic of Anaesthesiology and Reanimatology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Donata Ringaitienė
- Clinic of Anaesthesiology and Reanimatology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Jovaiša
- Clinic of Anaesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Toraman F, Evrenkaya S, Senay S, Karabulut H, Alhan C. Adjusting Oxygen Fraction to Avoid Hyperoxemia during Cardiopulmonary Bypass. Asian Cardiovasc Thorac Ann 2016; 15:303-6. [PMID: 17664202 DOI: 10.1177/021849230701500407] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although an adverse influence of hyperoxemia during cardiopulmonary bypass is well documented, there is a wide range of oxygen settings during cardiopulmonary bypass, based mostly on trial and error. The aim of this study was to determine the optimal inspired oxygen fraction during cardiopulmonary bypass. Ninety patients undergoing isolated coronary artery bypass operations were randomly allocated to one of 3 groups of 30 each. In group 1, cardiopulmonary bypass was started with an inspired oxygen fraction of 0.40, increased to 0.60 during rewarming. These settings were 0.40 and 0.50 in group 2, and 0.35 and 0.45 in group 3. Samples for blood gas analysis were collected at defined time periods during the operation. PaO2 was significantly higher in groups 1 and 2 compared to group 3. All patients in group 1 and 88% of patients in group 2 suffered at least one episode of hyperoxemia during cardiopulmonary bypass, compared to 30% of patients in group 3. The differences were significant, and we concluded that to avoid hyperoxemia, inspired oxygen fraction should be kept at 0.35 during cardiopulmonary bypass and increased to 0.45 during rewarming.
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Affiliation(s)
- Fevzi Toraman
- Department of Cardiovascular Surgery, Acibadem Kadikoy Hospital, Istanbul, Turkey
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18
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Cardiac surgery, a right target for hyperoxia? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:162. [PMID: 27306619 PMCID: PMC4910213 DOI: 10.1186/s13054-016-1347-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In perioperative cardiac surgery period, supra-physiological arterial oxygen partial pressures is common practice, although there is no clear evidence of any benefit. Smit et al. have shown that a “conservative” approach did not improve hemodynamics, decrease oxidative stress or myocardial tissue damage, but was not associated with major deleterious event either. Here, we outline major oxygen friend or foes properties, which may partly explain the study results, and place the clinical trial from Smit et al. in a global context.
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Smit B, Smulders YM, de Waard MC, Boer C, Vonk ABA, Veerhoek D, Kamminga S, de Grooth HJS, García-Vallejo JJ, Musters RJP, Girbes ARJ, Oudemans-van Straaten HM, Spoelstra-de Man AME. Moderate hyperoxic versus near-physiological oxygen targets during and after coronary artery bypass surgery: a randomised controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:55. [PMID: 26968380 PMCID: PMC4788916 DOI: 10.1186/s13054-016-1240-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/10/2016] [Indexed: 01/21/2023]
Abstract
Background The safety of perioperative hyperoxia is currently unclear. Previous studies in patients undergoing coronary artery bypass surgery suggest reduced myocardial damage when avoiding extreme perioperative hyperoxia (>400 mmHg). In this study we investigated whether an oxygenation strategy from moderate hyperoxia to a near-physiological oxygen tension reduces myocardial damage and improves haemodynamics, organ dysfunction and oxidative stress. Methods This was a single-blind, single-centre, open-label, randomised controlled trial in patients undergoing elective coronary artery bypass surgery. Fifty patients were randomised to a partial pressure of oxygen in arterial blood (PaO2) target of 200–220 mmHg during cardiopulmonary bypass and 130–150 mmHg during intensive care unit (ICU) admission (control group) versus lower targets of 130–150 mmHg during cardiopulmonary bypass and 80–100 mmHg at the ICU (conservative group). Primary outcome was myocardial injury (CK-MB and Troponin-T) at ICU admission and 2, 6 and 12 hours thereafter. Results Weighted PaO2 during cardiopulmonary bypass was 220 mmHg (interquartile range (IQR) 211–233) vs. 157 (151–162) in the control and conservative group, respectively (P < 0.0001). During ICU admission, weighted PaO2 was 107 mmHg (86–141) vs. 90 (84–98) (P = 0.03), respectively. Area under the curve of CK-MB was median 23.5 μg/L/h (IQR 18.4–28.1) vs. 21.5 (15.8–26.6) (P = 0.35) and 0.30 μg/L/h (0.25–0.44) vs. 0.39 (0.24–0.43) (P = 0.81) for Troponin-T. Cardiac index, systemic vascular resistance index, creatinine, lactate and F2-isoprostane levels were not different between groups. Conclusions Compared to moderate hyperoxia, a near-physiological oxygen strategy does not reduce myocardial damage in patients undergoing coronary artery bypass surgery. Conservative oxygen administration was not associated with increased lactate levels or hypoxic events. Trial registration Netherlands Trial Registry NTR4375, registered on 30 January 2014 Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1240-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bob Smit
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
| | - Yvo M Smulders
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Monique C de Waard
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anaesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Dennis Veerhoek
- Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Suzanne Kamminga
- Department of Anaesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm-Jan S de Grooth
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Juan J García-Vallejo
- Department of Molecular Cell Biology & Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Rene J P Musters
- Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
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Spoelstra-de Man AME, Smit B, Oudemans-van Straaten HM, Smulders YM. Cardiovascular effects of hyperoxia during and after cardiac surgery. Anaesthesia 2015; 70:1307-19. [PMID: 26348878 DOI: 10.1111/anae.13218] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 12/23/2022]
Abstract
During and after cardiac surgery with cardiopulmonary bypass, high concentrations of oxygen are routinely administered, with the intention of preventing cellular hypoxia. We systematically reviewed the literature addressing the effects of arterial hyperoxia. Extensive evidence from pre-clinical experiments and clinical studies in other patient groups suggests predominant harm, caused by oxidative stress, vasoconstriction, perfusion heterogeneity and myocardial injury. Whether these alterations are temporary and benign, or actually affect clinical outcome, remains to be demonstrated. In nine clinical cardiac surgical studies in low-risk patients, higher oxygen targets tended to compromise cardiovascular function, but did not affect clinical outcome. No data about potential beneficial effects of hyperoxia, such as reduction of gas micro-emboli or post-cardiac surgery infections, were reported. Current evidence is insufficient to specify optimal oxygen targets. Nevertheless, the safety of supraphysiological oxygen suppletion is unproven. Randomised studies with a variety of oxygen targets and inclusion of high-risk patients are needed to identify optimal oxygen targets during and after cardiac surgery.
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Affiliation(s)
| | - B Smit
- Department of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - Y M Smulders
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
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21
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Abstract
Cell-free hemoglobin (Hb) has been blamed for a spectrum of problems, including vasoconstriction pancreatitis, myocardial infarction, and pulmonary hypertension in hemolytic anemia, malaria, and sickle cell anemia, and from Hb-based oxygen carriers (HBOCs). Toxicities have been attributed to scavenging of nitric oxide (NO). However, while NO scavenging may explain many in vitro effects, and some effects in animal models and clinical trials with HBOCs, key inconsistencies in the theory require alternative explanations. This review considers the hypothesis that cell-free Hb oversupplies oxygen to tissues, leading to oxygen-related toxicity, possibly through formation of reactive oxygen species and local destruction of NO. Evidence for this hypothesis comes from various sources, establishing that tissue oxygen levels are maintained over very narrow (and low) levels, even at high oxygen consumption. Tissue is normally protected from excessive oxygen by its extremely low solubility in plasma, but introduction of cell-free Hb, even at low concentration, greatly augments oxygen supply, engaging protective mechanisms that include vasoconstriction and ischemia. The requirement to limit oxygen supply by cell-free Hb suggests novel ways to modify it to overcome vasoconstriction, independent of the intrinsic reaction of Hb with NO. This control is essential to the design of a safe and effective cell-free HBOC.
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Affiliation(s)
- Robert M Winslow
- Department of Bioengineering, University of California, San Diego, USA
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22
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Mariero LH, Rutkovskiy A, Stensløkken KO, Vaage J. Hyperoxia during early reperfusion does not increase ischemia/reperfusion injury. Eur J Cardiothorac Surg 2012; 41:149-53. [PMID: 21636285 DOI: 10.1016/j.ejcts.2011.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Oxygen is routinely administered to patients undergoing acute myocardial infarction as well as during revascularization procedures and cardiac surgery. Because reactive oxygen species are mediators of ischemia/reperfusion injury, increased oxygen availability might theoretically aggravate myocardial injury during reperfusion. We hypothesized that ventilation with a hyperoxic gas at start of reperfusion might increase ischemia/reperfusion injury. METHODS Rats were anesthetized with isoflurane and ventilated with 40% oxygen. The animals were subjected to 40 min of regional myocardial ischemia and 120 min of reperfusion. In the test group, rats (n=11) were ventilated with a normobaric hyperoxic gas (95% O2) during the last 10 min of ischemia and the first 10 min of reperfusion. Control rats (n=14) were ventilated with 40% O2 throughout the experiments. Due to irreversible reperfusion arrhythmias, one animal in the hyperoxia group and six animals in the control group were excluded. Hearts (n=8 in the control group and n=10 in the test group) were harvested for measurement of infarct size. RESULTS The incidence of lethal arrhythmias was 1/11 in the test group and 6/14 in the control group (p=0.06). Reperfusion with normobaric hyperoxia did not influence infarct size (20±8% of area at risk) compared with the normoxia group (24±8% and of area at risk), respectively (mean±SD, p>0.2). CONCLUSION Normobaric hyperoxia during early reperfusion did not increase ischemia/reperfusion injury.
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Affiliation(s)
- Lars Henrik Mariero
- Faculty of Medicine, Department of Molecular Biosciences, University of Oslo, and Institute for Experimental Medical Research, Department of Surgery, Oslo University Hospital, Oslo, Norway.
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23
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Lee JS, Kim JC, Chung JY, Hong SW, Choi KH, Kwak YL. Effect of arterial oxygen tension during reperfusion on myocardial recovery in patients undergoing valvular heart surgery. Korean J Anesthesiol 2010; 58:122-8. [PMID: 20498789 PMCID: PMC2872857 DOI: 10.4097/kjae.2010.58.2.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 08/13/2009] [Accepted: 10/05/2009] [Indexed: 11/12/2022] Open
Abstract
Background Valvular heart surgery (VHS) utilizing cardiopulmonary bypass (CPB) is inevitably associated with ischemic-reperfusion injury, which is known to depend on oxygen tension during reperfusion. The aim of this study was to evaluate the effect of arterial oxygen tension during reperfusion on myocardial recovery in patients undergoing VHS. Methods Fifty-six patients undergoing isolated VHS were randomly exposed to an oxygen fraction of 0.7 (hyperoxic group, n = 28) or 0.5 (normoxic group, n = 28) during reperfusion. All patients received an oxygen fraction of 0.7 during CPB. In the normoxic group, the oxygen fraction was lowered to 0.5 from the last warm cardioplegia administration to 1 minute after aortic unclamping, and was then raised back to 0.7. Hemodynamic data were measured after induction of anesthesia, weaning from CPB, and sternum closure. The frequency of cardiotonic medications used during and after weaning from CPB, and the short-term outcomes during the hospital stay were also assessed. Results The frequency of vasopressin and milrinone use during weaning from CPB, but not norepinephrine, was significantly less in the normoxic group. The post-operative cardiac enzyme levels and short-term outcomes were not different between the groups. Conclusions Normoxic reperfusion from the last cardioplegia administration to 1 minute after aortic unclamping in patients undergoing VHS resulted in significantly less frequent use of vasopressin and inotropics during weaning from CPB than hyperoxic reperfusion, although it did not affect the post-operative myocardial enzyme release or short-term prognosis.
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Affiliation(s)
- Jeong-Soo Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Atkins JL, Johnson KB, Pearce FJ. Cardiovascular responses to oxygen inhalation after hemorrhage in anesthetized rats: hyperoxic vasoconstriction. Am J Physiol Heart Circ Physiol 2006; 292:H776-85. [PMID: 17056674 DOI: 10.1152/ajpheart.00381.2006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Oxygen inhalation is recommended for the initial care of trauma victims. The improved survival seen in early hemorrhage is normally associated with an increase in blood pressure. Although clinical use of oxygen can occur late after hemorrhage, the effects of late administration have not been specifically examined. Anesthetized rats were studied using an isobaric hemorrhage model with target pressures of either 70 or 40 mmHg. At various times after hemorrhage, the feedback control of the blood pressure was stopped and the inspired gas was changed from room air to 100% oxygen. The results show that shortly after hemorrhage to 70 mmHg, oxygen inhalation results in an increase in mean arterial blood pressure of 60 +/- 3 mmHg, which is associated with a large increase in total peripheral resistance from 0.89 +/- 0.05 to 1.25 +/- 0.1 peripheral resistance units. The blood pressure response is essentially unchanged with time, and it is not altered by a 10-min exposure to N(G)-nitro-l-arginine methyl ester. At a target pressure of 40 mmHg, the initial blood pressure response to oxygen is the same, but it gradually decreases as the animal develops a lactic acidosis. We conclude that the therapeutic value of oxygen needs to be separately evaluated for late hemorrhage.
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Affiliation(s)
- James L Atkins
- Division of Military Casualty Research, Walter Reed Army Institute of Research, 503 Robert Grant Ave., Silver Spring, MD 20910, USA.
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Thomas NJ. Myocardial protection of the donor heart and the avoidance of oxidative stress. J Heart Lung Transplant 2005; 24:1995-6. [PMID: 16297813 DOI: 10.1016/j.healun.2005.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Revised: 03/15/2005] [Accepted: 04/04/2005] [Indexed: 10/25/2022] Open
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Sun HY, Wang NP, Kerendi F, Halkos M, Kin H, Guyton RA, Vinten-Johansen J, Zhao ZQ. Hypoxic postconditioning reduces cardiomyocyte loss by inhibiting ROS generation and intracellular Ca2+ overload. Am J Physiol Heart Circ Physiol 2004; 288:H1900-8. [PMID: 15563525 DOI: 10.1152/ajpheart.01244.2003] [Citation(s) in RCA: 214] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We have shown that intermittent interruption of immediate reflow at reperfusion (i.e., postconditioning) reduces infarct size in in vivo models after ischemia. Cardioprotection of postconditioning has been associated with attenuation of neutrophil-related events. However, it is unknown whether postconditioning before reoxygenation after hypoxia in cultured cardiomyocytes in the absence of neutrophils confers protection. This study tested the hypothesis that prevention of cardiomyocyte damage by hypoxic postconditioning (Postcon) is associated with a reduction in the generation of reactive oxygen species (ROS) and intracellular Ca(2+) overload. Primary cultured neonatal rat cardiomyocytes were exposed to 3 h of hypoxia followed by 6 h of reoxygenation. Cardiomyocytes were postconditioned after the 3-h index hypoxia by three cycles of 5 min of reoxygenation and 5 min of rehypoxia applied before 6 h of reoxygenation. Relative to sham control and hypoxia alone, the generation of ROS (increased lucigenin-enhanced chemiluminescence, SOD-inhibitable cytochrome c reduction, and generation of hydrogen peroxide) was significantly augmented after immediate reoxygenation as was the production of malondialdehyde, a product of lipid peroxidation. Concomitant with these changes, intracellular and mitochondrial Ca(2+) concentrations, which were detected by fluorescent fluo-4 AM and X-rhod-1 AM staining, respectively, were elevated. Cell viability assessed by propidium iodide staining was decreased consistent with increased levels of lactate dehydrogenase after reoxygenation. Postcon treatment at the onset of reoxygenation reduced ROS generation and malondialdehyde concentration in media and attenuated cardiomyocyte death assessed by propidium iodide and lactate dehydrogenase. Postcon treatment was associated with a decrease in intracellular and mitochondrial Ca(2+) concentrations. These data suggest that Postcon treatment reduces reoxygenation-induced injury in cardiomyocytes and is potentially mediated by attenuation of ROS generation, lipid peroxidation, and intracellular and mitochondrial Ca(2+) overload.
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Affiliation(s)
- He-Ying Sun
- Cardiothoracic Research Laboratory, Carlyle Fraser Heart Center/Crawford Long Hospital, Emory University School of Medicine, 550 Peachtree St. NE, Atlanta, GA 30308-2225, USA
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Maharaj C, Laffey JG. New strategies to control the inflammatory response in cardiac surgery. Curr Opin Anaesthesiol 2004; 17:35-48. [PMID: 17021527 DOI: 10.1097/00001503-200402000-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To present and interpret data from recent clinical studies (July 2002-August 2003) of strategies to control the inflammatory response after cardiac surgery. RECENT FINDINGS Off-pump coronary artery bypass techniques, which avoid the need for extracorporeal circulation, attenuate the inflammatory response and appear to confer clinical benefit. Concerns regarding the quality of the revascularization after off-pump coronary artery bypass appear to have been allayed. At present, ventricular assist devices do not enhance the efficacy of off-pump coronary artery bypass. In patients undergoing cardiopulmonary bypass, heparin-coated circuits, hypothermic pulmonary perfusion, normoxic reperfusion after aortic unclamping, and modified ultrafiltration hold promise. Strategies to maintain perioperative haemodynamic stability, such as enoximone therapy, may be beneficial, particularly in elderly patients. Aprotinin may have important beneficial anti-inflammatory actions in higher-risk adult and paediatric patients. The therapeutic potential of corticosteroids, particularly when administered in multiple dosages is increasingly clear. Direct anti-mediator therapies that focus upon key effector molecules and pathways of the inflammatory response offer future therapeutic options. SUMMARY The potential for strategies that inhibit the inflammatory response to improve outcome after cardiac surgery is clear. Large-scale multicentre trials investigating the most promising strategies, including off-pump coronary artery bypass, heparin-coated circuits, and perioperative corticosteroid and aprotinin therapy, are urgently needed. These trials need to be restricted to the high-risk patient groups most likely to experience benefit. In the interim, the optimal strategy to minimize the inflammatory response to cardiac surgery will remain elusive.
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Affiliation(s)
- Chris Maharaj
- Department of Anaesthesia and Intensive Care, University College Hospital, Galway, Ireland
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