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Wigmore GJ, Deane AM, Presneill JJ, Eastwood G, Serpa Neto A, Maiden MJ, Bihari S, Baker RA, Bennetts JS, Ghanpur R, Anstey JR, Raman J, Bellomo R. Twenty percent human albumin solution fluid bolus administration therapy in patients after cardiac surgery-II: a multicentre randomised controlled trial. Intensive Care Med 2024; 50:1075-1085. [PMID: 38953926 PMCID: PMC11245445 DOI: 10.1007/s00134-024-07488-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/10/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE After cardiac surgery, fluid bolus therapy (FBT) with 20% human albumin may facilitate less fluid and vasopressor administration than FBT with crystalloids. We aimed to determine whether, after cardiac surgery, FBT with 20% albumin reduces the duration of vasopressor therapy compared with crystalloid FBT. METHODS We conducted a multicentre, parallel-group, open-label, randomised clinical trial in six intensive care units (ICUs) involving cardiac surgery patients deemed to require FBT. We randomised 240 patients to receive up to 400 mL of 20% albumin/day as FBT, followed by 4% albumin for any subsequent FBT on that day, or to crystalloid FBT for at least the first 1000 mL, with use of crystalloid or 4% albumin FBT thereafter. The primary outcome was the cumulative duration of vasopressor therapy. Secondary outcomes included fluid balance. RESULTS Of 480 randomised patients, 466 provided consent and contributed to the primary outcome (mean age 65 years; median EuroSCORE II 1.4). The cumulative median duration of vasopressor therapy was 7 (interquartile range [IQR] 0-19.6) hours with 20% albumin and 10.8 (IQR 0-22.8) hours with crystalloids (difference - 3.8 h, 95% confidence interval [CI] - 8 to 0.4; P = 0.08). Day one fluid balance was less with 20% albumin FBT (mean difference - 701 mL, 95% CI - 872 to - 530). CONCLUSIONS In patients after cardiac surgery, when compared to a crystalloid-based FBT, 20% albumin FBT was associated with a reduced positive fluid balance but did not significantly reduce the duration of vasopressor therapy.
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Affiliation(s)
- Geoffrey J Wigmore
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
- Department of Anaesthesia and Pain Medicine, Western Health, Melbourne, VIC, Australia.
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jeffrey J Presneill
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Matthew J Maiden
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Intensive Care Unit, Barwon Health, Geelong, VIC, Australia
| | - Shailesh Bihari
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of ICCU, Flinders Medical Centre, Adelaide, SA, Australia
| | - Robert A Baker
- Flinders Medical Centre and College of Medicine and Public Health Flinders University, Cardiothoracic Quality and Outcomes, Adelaide, SA, Australia
| | - Jayme S Bennetts
- Flinders Medical Centre and College of Medicine and Public Health Flinders University, Cardiothoracic Quality and Outcomes, Adelaide, SA, Australia
| | - Rashmi Ghanpur
- Department of Intensive Care, Warringal Private Hospital, Melbourne, VIC, Australia
| | - James R Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jaishankar Raman
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, VIC, Australia
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Keller SP, Whitman GJR, Grant MC. Temporary Mechanical Circulatory Support after Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00387-2. [PMID: 38955616 DOI: 10.1053/j.jvca.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024]
Abstract
Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.
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Affiliation(s)
- Steven P Keller
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael C Grant
- Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Divisions of Cardiac Anesthesia and Surgical Critical, The Johns Hopkins University School of Medicine, Baltimore, MD.
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3
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Yoshida T, Goto A, Shinoda S, Kotani Y, Mihara T. The epidemiology of postoperative dobutamine and phosphodiesterase inhibitors after adult elective cardiac surgery and its impact on the length of hospital stay: a post hoc analysis from the multicenter retrospective observational study. Heart Vessels 2024; 39:438-445. [PMID: 38197915 DOI: 10.1007/s00380-023-02349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024]
Abstract
The optimal administration of inotrope after cardiac surgery is unknown. This study aimed to investigate the impact of postoperative inotrope on clinical outcomes in adult elective cardiac surgery patients. Data from the Blood Pressure and Relative Optimal Target after Heart Surgery in Epidemiologic Registry study were analyzed, employing propensity score considering the hospital of admission. The primary outcome was the length of hospital stay evaluated using quantile regression. Secondary outcomes were kidney injury progression, renal replacement therapy, atrial fibrillation, mortality, mechanical ventilation duration, and length of intensive care unit (ICU) stay. Among 870 patients from 14 ICUs in Japan, 535 received inotropes within 24 h of ICU admission, with usage rates ranging from 40 to 100% among facilities. After propensity score matching, 218 patients were included in each group. The inotrope group had a significantly longer hospital stay compared to the control group (16 days vs. 14 days; median difference 1.78 [95% confidence interval [CI] 0.31-3.24]; p = 0.018). However, no significant differences were observed in the secondary outcomes, except for mechanical ventilation duration. The results of the sensitivity analysis using a mixed-effects quantile regression analysis considering the hospital of admission for length of hospital stay in the original cohort were consistent with the results of the propensity analyses (median difference in days, 2.35 [95% CI, 0.35-4.36]; p = 0.022). The use of inotropes within 24 h of ICU admission in adult elective cardiac surgery patients was associated with an extended hospitalization period of approximately 2 days, without offering any prognostic benefit. Clinical trial registration: UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.
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Affiliation(s)
- Takuo Yoshida
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, 236-0027, Japan.
- Intensive Care Unit, Department of Emergency Medicine, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi Minato-ku, Tokyo, 105-8471, Japan.
| | - Atsushi Goto
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, 236-0027, Japan
| | - Satoru Shinoda
- Department of Biostatistics, School of Medicine, Yokohama City University, Yokohama City, Kanagawa, 236-0004, Japan
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
- Department of Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan, Italy
| | - Takahiro Mihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, 236-0027, Japan
- Department of Anesthesiology, Yokohama City University School of Medicine, Yokohama, Japan
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Vail EA, Bosch NA, Law AC, Gershengorn HB, Wunsch H, Walkey AJ. Adoption of a Novel Vasopressor Agent in Critically Ill Adults. Ann Am Thorac Soc 2023; 20:1662-1667. [PMID: 37590119 DOI: 10.1513/annalsats.202306-540rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/17/2023] [Indexed: 08/19/2023] Open
Affiliation(s)
- Emily A Vail
- University of Pennsylvania Philadelphia, Pennsylvania
- Penn Center for Perioperative Outcomes Research and Transformation Philadelphia, Pennsylvania
| | | | | | - Hayley B Gershengorn
- University of Miami Miami, Florida
- Albert Einstein College of Medicine Bronx, New York
| | - Hannah Wunsch
- Sunnybrook Health Sciences Centre Toronto, Ontario, Canada
- University of Toronto Toronto, Ontario, Canada
| | - Allan J Walkey
- Boston University Boston, Massachusetts
- Center for Implementation and Improvement Sciences Boston, Massachusetts
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5
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Juhl-Olsen P, Berg-Hansen K, Nørskov J, Enevoldsen J, Hermansen JL. The haemodynamic effects of phenylephrine after cardiac surgery. Acta Anaesthesiol Scand 2023. [PMID: 37186094 DOI: 10.1111/aas.14256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Phenylephrine increases systemic- and pulmonary resistances and therefore may increase blood pressures at the expense of blood flow. Cardio-pulmonary bypass alters vasoreactivity and many patients exhibit chronotropic insufficiency after cardiac surgery. We aimed to describe the haemodynamic effects of phenylephrine infusion after cardiac surgery. METHODS Patients in steady state after low-risk cardiac surgery received incremental infusion rates of phenylephrine up to 1.0 μg/kg/min with the aim of increasing systemic mean arterial blood pressure 20 mmHg. Invasive haemodynamic parameters, including pulmonary wedge pressures, were captured along with echocardiographic measures of biventricular function before, during phenylephrine infusion at target systemic blood pressure, and 20 min after phenylephrine discontinuation. RESULTS Thirty patients were included. Phenylephrine increased mean arterial pressure increased from 78 (±9) mmHg to 98 (±10) mmHg with phenylephrine infusion. Also, pulmonary blood pressure as well as systemic- and pulmonary resistances increased. The ratio between systemic- and pulmonary artery resistances did not change statistically significantly (p = .59). Median cardiac output was 4.35 (interquartile range [IQR] 3.6-5.4) L/min at baseline and increased significantly with phenylephrine infusion (median Δcardiac output was 0.25 [IQR 0.1-0.6] L/min) (p = .012). Pulmonary artery wedge pressure increased from 10.2 (±3.0) mmHg to 11.9 (±3.4) mmHg (p < .001). This was accompanied by significant increases in central venous pressure. Phenylephrine infusion increased left ventricular end-diastolic volume from 105 (±46) mL to 119 (±44) mL (p < .001). All results of phenylephrine infusion were reversed with discontinuation. CONCLUSION In haemodynamically stable patients after cardiac surgery, phenylephrine increased PVR and SVR, but did not change the PVR/SVR ratio. Phenylephrine increased biventricular filling pressures and left ventricular end-diastolic area. Consequently, CO increased as ejection fraction was maintained. These findings do not discourage the use of phenylephrine after low-risk cardiac surgery. REGISTRATION clinicaltrial.gov (identifier NCT04419662).
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Affiliation(s)
- Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kristoffer Berg-Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Nørskov
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
| | - Johannes Enevoldsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johan Lyngklip Hermansen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Guerci P, Leone M, Lorne E, Mongardon N. Norepinephrine in cardiac surgery: The love-hate story. Anaesth Crit Care Pain Med 2023; 42:101210. [PMID: 36870666 DOI: 10.1016/j.accpm.2023.101210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy, F-54000 Vandoeuvre-les Nancy, France; INSERM U1116, DCAC, University of Lorraine, Nancy, France.
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Assistance Publique-Hôpitaux Universitaires de Marseille, Aix Marseille Université, Hôpital Nord, F-13015 Marseille, France
| | - Emmanuel Lorne
- Département d'Anesthésie-Réanimation (Akomé), Clinique du Millénaire, F-34000 Montpellier, France
| | - Nicolas Mongardon
- Service d'Anesthésie-Réanimation chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Université Paris Est Créteil, Faculté de Santé, F-94010 Créteil, France; U955-IMRB, Equipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", Inserm, Univ Paris Est Créteil (UPEC)
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7
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Guinot PG, Durand B, Besnier E, Mertes PM, Bernard C, Nguyen M, Berthoud V, Abou-Arab O, Bouhemad B, Martin A, Duclos V, Spitz A, Constandache T, Grosjean S, Radhouani M, Anciaux JB, Missaoui A, Morgant MC, Bouchot O, Jazayeri S, Demailly Z, Huette P, Guilbart M, Besserve P, Beyls C, Dupont H, Kindo M, Wpiff T. Epidemiology, risk factors and outcomes of norepinephrine use in cardiac surgery with cardiopulmonary bypass: a multicentric prospective study. Anaesth Crit Care Pain Med 2023; 42:101200. [PMID: 36758855 DOI: 10.1016/j.accpm.2023.101200] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND The present study was designed to describe the prevalence of norepinephrine use, the factors associated with its use, and the incidence of postoperative complications according to norepinephrine use, in patients undergoing cardiac surgery with cardiopulmonary bypass. METHOD We performed a prospective, multicenter, observational study in 4 University-affiliated medico-surgical cardiovascular units. We analyzed all patients treated with cardiac surgery after excluding pre-ECMO surgery, LVAD implantation, heart transplantation and intra-operative hemorrhage. RESULTS Of 9316 patients screened during the study period, 2862 were included and 2510 were analyzed. Among them, 1549 (61%) were treated with norepinephrine with a median maximal dose of 0.11 [0.06-0.2] μg.kg-1.min-1 and a median duration of 10 h [2-24]. Norepinephrine was most often started in the operating room before cardiopulmonary bypass. The multiple regression logistic analysis identified several modifiable (haematocrit, maintenance of beta-blocker, cardiopulmonary bypass time, glucose-insulin-potassium, Custodiol cardioplegia, Delnido cardioplegia, and fibrinogen transfusion) and non-modifiable factors (age, ASA score, chronic high blood pressure, coronary disease, dyslipidemia, right ventricular dysfunction, left ventricular dysfunction, active endocarditis, and valvular aortic surgery) associated with norepinephrine use. Mortality, morbidity (neurological and renal complications, death) and length of stay in the ICU were higher in patients treated with norepinephrine. CONCLUSION Norepinephrine is often used in cardiac surgical patients but for <24 h with a low dose. Many preoperative and surgical factors are associated with norepinephrine use. Patients supported by norepinephrine have a higher incidence of major postoperative events.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France.
| | - Bastien Durand
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Emmanuel Besnier
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Paul-Michel Mertes
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Chloe Bernard
- Department of Cardiac Surgery, Dijon University Medical Centre, 21000 Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, 80000 Amiens, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Audrey Martin
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Valerian Duclos
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Alexandra Spitz
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Tiberiu Constandache
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Sandrine Grosjean
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Mohamed Radhouani
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Jean-Baptiste Anciaux
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Anis Missaoui
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Marie-Catherine Morgant
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Olivier Bouchot
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Saed Jazayeri
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Zoe Demailly
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Pierre Huette
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Mathieu Guilbart
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Patricia Besserve
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Christophe Beyls
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Hervé Dupont
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Thibaut Wpiff
- Department of Cardiac Surgery, Dijon University Medical Centre, 21000 Dijon, France
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Du W, Lv M, Chen T, Sun X, Wang J, Zhang H, Wei C, Liu Y, Qiao C, Wang Y. The effect of topical airway anesthesia on hemodynamic profiles during the induction period in patients undergoing cardiac surgery: Study protocol for a randomized controlled trial. Front Cardiovasc Med 2022; 9:992534. [PMID: 36299870 PMCID: PMC9589145 DOI: 10.3389/fcvm.2022.992534] [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: 07/12/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patients scheduled for cardiac surgery are often accompanied by cardiac dysfunction and hemodynamic instability. However, the conventional induction strategy for anesthesia using high-dose intravenous anesthetics is often associated with persistent and recurrent hypotension after tracheal intubation. The purpose of this study is to investigate the effects of topical airway anesthesia on the hemodynamic profile of patients undergoing cardiac surgery during the induction period. Methods This is a superiority, single-blind, randomized controlled study with two parallel groups. Participants scheduled to undergo elective cardiac surgery will be allocated into two blocks according to the New York Heart Association (NYHA) classification and then randomly assigned to the following two groups at a 1:1 ratio: the conventional induction group and the combined topical airway anesthesia induction group. The combined topical airway anesthesia induction strategy includes aerosol inhalation airway anesthesia, subglottic airway anesthesia, and general anesthesia induction using low-dose intravenous anesthetics. The primary outcome is the area under the curve (AUC) of blood pressure below baseline mean arterial pressure (MAP) from 3 to 15 min after endotracheal intubation. Secondary outcomes include the AUC above baseline MAP and below baseline MAP at other time points, the highest and lowest arterial blood pressure values during the induction period, type and dose of vasoactive drugs, incidence of arrhythmias, cardiac function, and the incidence of postoperative hoarseness and sore throat. Discussion The study will explore whether aerosol inhalation airway anesthesia and subglottic airway anesthesia could reduce the incidence and duration of hypotension during the induction period in patients undergoing cardiac surgery. Clinical Trial Registration This trial was registered on www.ClinicalTrials.gov (NCT05323786).
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Affiliation(s)
- Wenya Du
- Shandong First Medical University, Taian, China
| | - Meng Lv
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | | | - Xiaxuan Sun
- Shandong First Medical University, Taian, China
| | - Jihua Wang
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Haixia Zhang
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Chuansong Wei
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yi Liu
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Changlong Qiao
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yuelan Wang
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China,*Correspondence: Yuelan Wang
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Huette P, Moussa MD, Beyls C, Guinot PG, Guilbart M, Besserve P, Bouhlal M, Mounjid S, Dupont H, Mahjoub Y, Michaud A, Abou-Arab O. Association between acute kidney injury and norepinephrine use following cardiac surgery: a retrospective propensity score-weighted analysis. Ann Intensive Care 2022; 12:61. [PMID: 35781575 PMCID: PMC9250911 DOI: 10.1186/s13613-022-01037-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Excess exposure to norepinephrine can compromise microcirculation and organ function. We aimed to assess the association between norepinephrine exposure and acute kidney injury (AKI) and intensive care unit (ICU) mortality after cardiac surgery. Methods This retrospective observational study included adult patients who underwent cardiac surgery under cardiopulmonary bypass from January 1, 2008, to December 31, 2017, at the Amiens University Hospital in France. The primary exposure variable was postoperative norepinephrine during the ICU stay and the primary endpoint was the presence of AKI. The secondary endpoint was in-ICU mortality. As the cohort was nonrandom, inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalances in the pre- and intra-operative characteristics. Results Among a population of 5053 patients, 1605 (32%) were exposed to norepinephrine following cardiac surgery. Before weighting, the prevalence of AKI was 25% and ICU mortality 10% for patients exposed to norepinephrine. Exposure to norepinephrine was estimated to be significantly associated with AKI by a factor of 1.95 (95% confidence interval, 1.63–2.34%; P < 0.001) in the IPW cohort and with in-ICU mortality by a factor of 1.54 (95% confidence interval, 1.19–1.99%; P < 0.001). Conclusion Norepinephrine was associated with AKI and in-ICU mortality following cardiac surgery. While these results discourage norepinephrine use for vasoplegic syndrome in cardiac surgery, prospective investigations are needed to substantiate findings and to suggest alternative strategies for organ protection. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01037-1.
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Affiliation(s)
- Pierre Huette
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Mouhamed Djahoum Moussa
- Anesthesia and Critical Care Department, Institut Coeur-Poumon, Lille Hospital University, 59000, Lille, France
| | - Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, 21000, Dijon, France
| | - Mathieu Guilbart
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Patricia Besserve
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Mehdi Bouhlal
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Sarah Mounjid
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Audrey Michaud
- Department of Biostatistics, Amiens Picardy University Hospital, 80054, Amiens, France
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens Picardy University Hospital, 80054, Amiens, France.
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10
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Ravaux JM, Van Kuijk SMJ, Di Mauro M, Vernooy K, Bidar E, Mariani S, Dato GA, Van′t Hof AW, Veenstra L, Kats S, Houterman S, Maessen JG, Lorusso R. Incidence and predictors of permanent pacemaker implantation after surgical aortic v alve replacement: Data of the Netherlands Heart Registration (NHR). J Card Surg 2021; 36:3519-3527. [PMID: 34250647 PMCID: PMC8518121 DOI: 10.1111/jocs.15803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Permanent pacemaker implantation (PPI) after surgical aortic valve replacement (SAVR) remains a frequent complication. Predictors, however, have been mainly investigated in single-center studies. Therefore, nationwide data were used to identify patients-and procedural risk factors for postoperative PPI. MATERIALS AND METHODS Data were retrospectively collected from the Netherlands Heart Registration (NHR). Patients enrolled in the NHR undergoing isolated SAVR from 2013 to 2019 were analyzed. Primary endpoint was in-hospital PPI during hospitalization after SAVR. RESULTS From the NHR database, 5600 patients with symptomatic aortic valve stenosis were included in the study. Crude incidence of post-SAVR PPI was 4.0%. Backward regression analysis identified previous cardiac surgery (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.18-2.76), extra-corporeal circulation time (OR: 1.01; 95% CI: 1.00-1.01), vasopressor use (OR: 2.66; 95% CI: 1.79-3.96) and in-hospital cardiac conduction abnormalities (OR: 4.48; 95% CI: 3.36-5.98) as potential predictors for PPI. Across the time, PPI after SAVR significantly increased (OR: 1.11; 95% CI: 1.03-1.21). CONCLUSIONS From this nationwide analysis, PPI after SAVR remains a low but increasingly frequent complication. Several predictive factors for postoperative PPI after SAVR have been identified and might be useful for patient informed consent about potential adverse event rate.
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Affiliation(s)
- Justine M. Ravaux
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Sander MJ Van Kuijk
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Michele Di Mauro
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Kevin Vernooy
- Department of CardiologyMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht University Medical CenterMaastrichtThe Netherlands
- Department of CardiologyRadboud University Medical Center (Radboudumc)Nijmegenthe Netherlands
| | - Elham Bidar
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Silvia Mariani
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Giulia Actis Dato
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Arnoud W Van′t Hof
- Department of CardiologyMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht University Medical CenterMaastrichtThe Netherlands
| | - Leo Veenstra
- Department of CardiologyMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Suzanne Kats
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | | | - Jos G Maessen
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht University Medical CenterMaastrichtThe Netherlands
| | - Roberto Lorusso
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht University Medical CenterMaastrichtThe Netherlands
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11
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Koutroumpakis E, Hashmi SS, Powell C, Fatakdawala M, Pang J, Patel R, Thannoun T, Grable C, Damaraju S, Badruddin Mawji S, Lin K, Folivi M, Chauhan S, Shabbir MA, Hughes K, Peters TK, Lyubarova R, Damaraju S, Palaskas N, Deswal A, Garcia-Sayan E, Taegtmeyer H. Geographical Differences in Cardiovascular Comorbidities and Outcomes of COVID-19 Hospitalized Patients in the USA. Cardiology 2021; 146:481-488. [PMID: 33902039 PMCID: PMC8247800 DOI: 10.1159/000515064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/04/2021] [Indexed: 11/25/2022]
Abstract
Introduction Cardiovascular comorbidities may predispose to adverse outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19). However, across the USA, the burden of cardiovascular comorbidities varies significantly. Whether clinical outcomes of hospitalized patients with COVID-19 differ between regions has not yet been studied systematically. Here, we report differences in underlying cardiovascular comorbidities and clinical outcomes of patients hospitalized with COVID-19 in Texas and in New York state. Methods We established a multicenter retrospective registry including patients hospitalized with COVID-19 between March 15 and July 12, 2020. Demographic and clinical data were manually retrieved from electronic medical records. We focused on the following outcomes: mortality, need for pharmacologic circulatory support, need for mechanical ventilation, and need for hemodialysis. Univariate and multivariate logistic regression analyses were performed. Results Patients in the Texas cohort (n = 296) were younger (57 vs. 63 years, p value <0.001), they had a higher BMI (30.3 kg/m<sup>2</sup> vs. 28.5 kg/m<sup>2</sup>, p = 0.015), and they had higher rates of diabetes mellitus (41 vs. 30%; p = 0.014). In contrast, patients in the New York state cohort (n = 218) had higher rates of coronary artery disease (19 vs. 10%, p = 0.005) and atrial fibrillation (11 vs. 5%, p = 0.012). Pharmacologic circulatory support, mechanical ventilation, and hemodialysis were more frequent in the Texas cohort (21 vs. 13%, p = 0.020; 30 vs. 12%, p < 0.001; and 11 vs. 5%, p = 0.009, respectively). In-hospital mortality was similar between the 2 cohorts (16 vs. 18%, p = 0.469). After adjusting for differences in underlying comorbidities, only the use of mechanical ventilation remained significantly higher in the participating Texas hospitals (odds ratios [95% CI]: 3.88 [1.23, 12.24]). Median time to pharmacologic circulatory support was 8 days (interquartile range: 2, 13.8) in the Texas cohort compared to 1 day (0, 3) in the New York state cohort, while median time to in-hospital mortality was 16 days (10, 25.5) and 7 days (4, 14), respectively (both p < 0.001). In-hospital mortality was higher in the late versus the early study phase in the New York state cohort (24 vs. 14%, p = 0.050), while it was similar between the 2 phases in the Texas cohort (16 vs. 15%, p = 0.741). Conclusions Geographical differences, including practice pattern variations and the impact of disease burden on provision of health care, are important for the evaluation of COVID-19 outcomes. Unadjusted data may cause bias affecting future regulatory policies and proper allocation of resources.
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Affiliation(s)
- Efstratios Koutroumpakis
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - S Shahrukh Hashmi
- Pediatrics Research Center, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher Powell
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariya Fatakdawala
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason Pang
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ritesh Patel
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Tariq Thannoun
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Cullen Grable
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sarita Damaraju
- Division of Cardiology, Coastal Cardiology, Christus Spohn Health System, Corpus Christi, Texas, USA
| | - Shamim Badruddin Mawji
- Division of Cardiology, Coastal Cardiology, Christus Spohn Health System, Corpus Christi, Texas, USA
| | - Kevin Lin
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Messan Folivi
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Siddharth Chauhan
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Muhammad Asim Shabbir
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Katherine Hughes
- Wilson Memorial Regional Medical Center, Johnson City, New York, USA.,Binghamton General Hospital, Binghamton, New York, USA.,Chenango Memorial Hospital, Norwich, New York, USA
| | - Terri K Peters
- Wilson Memorial Regional Medical Center, Johnson City, New York, USA.,Binghamton General Hospital, Binghamton, New York, USA.,Chenango Memorial Hospital, Norwich, New York, USA
| | - Radmila Lyubarova
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Srikanth Damaraju
- Division of Cardiology, Coastal Cardiology, Christus Spohn Health System, Corpus Christi, Texas, USA
| | - Nicolas Palaskas
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Enrique Garcia-Sayan
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Heinrich Taegtmeyer
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
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12
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Franco RA, de Almeida JP, Landoni G, Scheeren TWL, Galas FRBG, Fukushima JT, Zefferino S, Nardelli P, de Albuquerque Piccioni M, Arita ECTC, Park CHL, Cunha LCC, de Oliveira GQ, Costa IBSDS, Kalil Filho R, Jatene FB, Hajjar LA. Dobutamine-sparing versus dobutamine-to-all strategy in cardiac surgery: a randomized noninferiority trial. Ann Intensive Care 2021; 11:15. [PMID: 33496877 PMCID: PMC7838231 DOI: 10.1186/s13613-021-00808-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 01/13/2021] [Indexed: 12/16/2022] Open
Abstract
Background The detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach. Nevertheless, standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery to prevent low cardiac output syndrome and its implications. Randomized evidence in favor of a patient-tailored, inotrope-sparing approach is still lacking. We designed a randomized controlled noninferiority trial in patients undergoing cardiac surgery with normal ejection fraction to assess whether an dobutamine-sparing strategy (in which the use of dobutamine was guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion) was noninferior to an inotrope-to-all strategy (in which all patients received dobutamine). Results A total of 160 patients were randomized to the dobutamine-sparing strategy (80 patients) or to the dobutamine-to-all approach (80 patients). The primary composite endpoint of 30-day mortality or occurrence of major cardiovascular complications (arrhythmias, acute myocardial infarction, low cardiac output syndrome and stroke or transient ischemic attack) occurred in 25/80 (31%) patients of the dobutamine-sparing group (p = 0.74) and 27/80 (34%) of the dobutamine-to-all group. There were no significant differences between groups regarding the incidence of acute kidney injury, prolonged mechanical ventilation, intensive care unit or hospital length of stay. Discussion Although it is common practice in many centers to administer inotropes to all patients undergoing cardiac surgery, a dobutamine-sparing strategy did not result in an increase of mortality or occurrence of major cardiovascular events when compared to a dobutamine-to-all strategy. Further research is needed to assess if reducing the administration of inotropes can improve outcomes in cardiac surgery. Trial registration ClinicalTrials.gov, NCT02361801. Registered Feb 2nd, 2015. https://clinicaltrials.gov/ct2/show/NCT02361801
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Affiliation(s)
- Rafael Alves Franco
- Intensive Care Unit, Cancer Institute (ICESP), University of Sao Paulo, São Paulo, Brazil
| | | | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center, Groningen, The Netherlands
| | | | - Julia Tizue Fukushima
- Intensive Care Unit, Cancer Institute (ICESP), University of Sao Paulo, São Paulo, Brazil
| | - Suely Zefferino
- Department of Anesthesiology, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | | | | | | | - Roberto Kalil Filho
- Department of Cardiology, Heart Institute (InCor), University of Sao Paulo, São Paulo, Brazil
| | - Fabio Biscegli Jatene
- Division of Cardiovascular Surgery, Heart Institute (InCor), University of Sao Paulo, São Paulo, Brazil
| | - Ludhmila Abrahão Hajjar
- Intensive Care Unit, Cancer Institute (ICESP), University of Sao Paulo, São Paulo, Brazil. .,Department of Cardiopneumology, Instituto Do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 44-05403-900, São Paulo, SP, Brazil.
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