Dexmedetomidine for adult cardiac surgery: a systematic review, meta-analysis and trial sequential analysis

The effects of dexmedetomidine in adults undergoing cardiac surgery are inconsistent. We conducted a systematic review and meta-analysis to analyse the effects of peri-operative dexmedetomidine in adults undergoing cardiac surgery. We searched MEDLINE via Pubmed, EMBASE, Scopus and Cochrane for relevant randomised controlled trials between 1 January 1990 and 1 March 2022. We used the Joanna Briggs Institute methodology checklist to assess study quality and the GRADE approach to certainty of evidence. We assessed the sensitivity of results to false data. We used random-effects meta-analyses to analyse the primary outcomes: durations of intensive care and tracheal intubation. We included 48 trials of 6273 participants. Dexmedetomidine reduced the mean (95%CI) duration of intensive care by 5.0 (2.2-7.7) h, p = 0.001, and tracheal intubation by 1.6 (0.6-2.7) h, p = 0.003. The relative risk (95%CI) for postoperative delirium was 0.58 (0.43-0.78), p = 0.001; 0.76 (0.61-0.95) for atrial fibrillation, p = 0.015; and 0.49 (0.25-0.97) for short-term mortality, p = 0.041. Bradycardia and hypotension were not significantly affected. Trial sequential analysis was consistent with the primary meta-analysis. Adjustments for possible false data reduced the mean (95%CI) reduction in duration of intensive care and tracheal intubation by dexmedetomidine to 3.6 (1.8-5.4) h and 0.8 (0.2-1.4) h, respectively. Binary adjustment for methodological quality at a Joanna Briggs Institute score threshold of 10 did not alter the results significantly. In summary, peri-operative dexmedetomidine reduced the durations of intensive care and tracheal intubation and the incidence of short-term mortality after adult cardiac surgery. The reductions in intensive care stay and tracheal intubation may or may not be considered clinically useful, particularly after adjustment for possible false data.

Analyzing white blood cell subpopulation for quick and simple predictors for autologous stem cell collection

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Background: For patients undergoing peripheral stem cell harvesting, the current standard predictor for successful harvest is the peripheral blood (PB)CD34 count, which may have a slow turn-around time. Daily monitoring of CD34 count may not be cost-effective. This study aims to identify simple hematological parameters that can be used to predict for a single day CD 34+ stem cell yield of at least 1 x 10(6)/kg. Methods: 57 patients with lymphoproliferative malignancies who underwent autologous stem cell (ASC) harvesting were studied following DHAP, ICE or ESHAP chemotherapy. Eight main parameters were investigated to predict for a single day CD34 stem cell yield above 1x10(6)/kg: PB CD34+ cells, absolute monocyte count (AMC), AMC ratio, total white count (WBC), absolute lymphocyte count (ALC), ALC ratio, immature granulocyte count (IMC), IMC ratio and non-neutrophil cells (NNC). NNC was calculated by subtracting absolute neutrophil count from the total white count. The ratios were calculated by dividing the respective values on the first day of harvest with the values on the day before mobilizing chemotherapy started. Results: Linear regression showed a strong correlation between stem cell yield and CD34+ cells (R2=0.79, p<0.001), IMC ratio (R2=0.51, p<0.001) and AMC ratio (R2= 0.46, P<0.001). WBC and AMC showed a wide dispersion of results and were not reliable predictors of CD34 yield. On multivariate analysis, an IMC > 1 (p=0.03) and AMC ratio > 1 (p=0.002), ALC ratio > 1 (p=0.03) were independently predictive of a single day CD34 stem cell yield exceeding 1x10(6)/kgConclusions: Incorporating simple, routine hematolgic indices such as ALC and AMC ratio into a simple formula can be used to predict for ASC collection in addition to CD34+ count. This may be particularly useful when the turn-around-time to attain enumeration of CD34+ cells is slow or delayed on the same day of collection.

No significant financial relationships to disclose.

Unanticipated admission after day surgery

Day surgery is becoming more common due to its cost effectiveness as well as patient acceptance. With increasing caseloads, there is a need to maintain quality of care. The purpose of this study is to identify the reasons for unanticipated admissions in our day surgical population, with the aim of improving efficiency of day surgical services, yet maintaining a high standard of patient care. A retrospective review of records of patients who were admitted over the two-year study period was conducted. Unanticipated admission was defined as unplanned admission after a day surgical procedure. Data relating to physical status, perioperative complications and reasons for hospital admission were recorded. A total of 10,801 procedures were done, and 163 patients were admitted. The unanticipated admission rate was 1.5%. Most of the admissions were surgically related (62.8%), followed by anaesthesia (12.2%), social (9.5%) and medical reasons (8.1%). Seventy-five percent of these admissions were potentially preventable. The majority were due to common problems like postoperative pain, admission for surgical observation and for social reasons. Non preventable causes (25%) were mainly due to unrelated medical problems.