Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

[Anaesthesia for Hybrid Procedures]

The development and implementation of the hybrid operating theatre over the last decade is one of the most innovative advancements in the field of medical interdisciplinary treatment options. The hybrid operating theatre allows the combination of minimally invasive surgery and interventional procedures using the benefits of modern imaging technologies. Therefore, it will be of increasing interest for different kinds of surgical disciplines in the future. In Germany, the hybrid operating theatre is mainly used in the field of transcatheter based heart valve procedures and in the field of vascular surgery cooperating with interventional radiology. Managing this special patient population is a highly challenging task for all players in this setting, especially for the cardiac surgeon, the cardiologist, and the anaesthesiologist. Only close interdisciplinary cooperation ensures optimal treatment. The impact of recent developments in the field of transcatheter based heart valve procedures on anaesthesia management will be addressed in this article.

Biomarkers and longitudinal changes in lumbar spine degeneration and low back pain: the Johnston County Osteoarthritis Project

OBJECTIVE

To determine if baseline biomarkers are associated with longitudinal changes in the worsening of disc space narrowing (DSN), vertebral osteophytes (OST), and low back pain (LBP).

DESIGN

Paired baseline (2003-2004) and follow-up (2006-2010) lumbar spine radiographs from the Johnston County Osteoarthritis Project were graded for severity of DSN and OST. LBP severity was self-reported. Concentrations of analytes (cytokines, proteoglycans, and neuropeptides) were quantified by immunoassay. Pressure-pain threshold (PPT), a marker of sensitivity to pressure pain, was measured with a standard dolorimeter. Binary logistic regression models were used to estimate odd ratios (OR) and 95% confidence intervals (CI) of biomarker levels with DSN, OST, or LBP. Interactions were tested between biomarker levels and the number of affected lumbar spine levels or LBP.

RESULTS

We included participants (n = 723) with biospecimens, PPT, and paired lumbar spine radiographic data. Baseline Lumican, a proteoglycan reflective of extracellular matrix changes, was associated with longitudinal changes in DSN worsening (OR = 3.19 [95% CI 1.22, 8.01]). Baseline brain-derived neuropathic factor, a neuropeptide, (OR = 1.80 [95% CI 1.03, 3.16]) was associated with longitudinal changes in OST worsening, which may reflect osteoclast genesis. Baseline hyaluronic acid (OR = 1.31 [95% CI 1.01, 1.71]), indicative of systemic inflammation, and PPT (OR = 1.56 [95% CI 1.02, 2.31]) were associated with longitudinal increases in LBP severity.

CONCLUSION

These findings suggest that baseline biomarkers are associated with longitudinal changes occurring in structures of the lumbar spine (DSN vs OST). Markers of inflammation and perceived pressure pain sensitivity were associated with longitudinal worsening of LBP.

[Hemodynamic Monitoring in the ICU: the More Invasive, the Better?]

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. However, the invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution technologies are still the clinical gold standard in terms of advanced haemodynamic monitoring, especially in the treatment of critically ill patients. The current data situation regarding the early use of continuous haemodynamic monitoring in this patient population, specifically flow-based variables such as stroke volume to prevent occult hypoperfusion, is overwhelming. However, the effective implementation of these technologies in daily clinical routine is remarkably low. Given the fact that perioperative morbidity and mortality are higher than anticipated, anaesthesiologists and intensivists are in charge to deal with this problem. The recent advances in minimally invasive and non-invasive haemodynamic monitoring technologies may facilitate a more widespread use in the operating theatre and in critical care patients. This review evaluates the significance of invasive, minimally- and non-invasive monitoring devices and their specific haemodynamic variables in this particular field of perioperative medicine.

Comparison of oscillometric, non-invasive and invasive arterial pressure monitoring in patients undergoing laparoscopic bariatric surgery – a secondary analysis of a prospective observational study

Background

Oscillometric, non-invasive blood pressure measurement (NIBP) is the first choice of blood pressure monitoring in the majority of low and moderate risk surgeries. In patients with morbid obesity, however, it is subject to several limitations. The aim was to compare arterial pressure monitoring by NIBP and a non-invasive finger-cuff technology (Nexfin®) with the gold-standard invasive arterial pressure (IAP).

Methods

In this secondary analysis of a prospective observational, single centre cohort study, systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP) were measured at 16 defined perioperative time points including posture changes, fluid bolus administration and pneumoperitoneum (PP) in patients undergoing laparoscopic bariatric surgery. Absolute arterial pressures by NIBP, Nexfin® and IAP were compared using correlation and Bland Altman analyses. Interchangeability was defined by a mean difference ≤ 5 mmHg (SD ≤8 mmHg). Percentage error (PE) was calculated as an additional statistical estimate. For hemodynamic trending, concordance rates were analysed according to the Critchley criterion.

Results

Sixty patients (mean body mass index of 49.2 kg/m²) were enrolled and data from 56 finally analysed. Pooled blood pressure values of all time points showed a significant positive correlation for both NIPB and Nexfin® versus IAP. Pooled PE for NIBP versus IAP was 37% (SAP), 35% (DAP) and 30% (MAP), for Nexfin versus IAP 23% (SAP), 26% (DAP) and 22% (MAP). Correlation of MAP was best and PE lowest before induction of anesthesia for NIBP versus IAP (r = 0.72; PE 24%) and after intraoperative fluid bolus administration for Nexfin® versus IAP (r = 0.88; PE: 17.2%). Concordance of MAP trending was 90% (SAP 85%, DAP 89%) for NIBP and 91% (SAP 90%, DAP 86%) for Nexfin®. MAP trending was best during intraoperative ATP positioning for NIBP (97%) and at induction of anesthesia for Nexfin® (97%).

Conclusion

As compared with IAP, interchangeability of absolute pressure values could neither be shown for NIBP nor Nexfin®, however, NIBP showed poorer overall correlation and precision. Overall trending ability was generally high with Nexfin® surpassing NIBP. Nexfin® may likely render individualized decision-making in the management of different hemodynamic stresses during laparoscopic bariatric surgery, particularly where NIBP cannot be reliably established.

Trial registration

The non-interventional, observational study was registered retrospectively at (NCT03184285) on June 12, 2017.

Feasibility and beneficial effects of an early goal directed therapy after cardiac arrest: evaluation by conductance method

Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids (P < 0.05) and less epinephrine administration (P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.

[Enhanced recovery after surgery (ERAS): less is more : What must be considered from an anesthesiological perspective?]

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multidisciplinary treatment model with the aim of guaranteeing a reduction of postoperative complications by the maintenance or early restoration of the patient-specific homoeostasis. From the anesthesiologist's perspective in all three areas of the perioperative phases there are important aspects that need to be addressed in the sense of a holistic treatment concept in order to achieve the highest possible benefit for the patient.

OBJECTIVE

In the perioperative period there is a bundle of anesthesiological measures, which make the ERAS concept into what it is now. At this point the focus is on the preoperative preparation and optimization of the patient and on the intraoperative and postoperative fluid management.

MATERIAL AND METHODS

A selective literature search was carried out in the Medline and Cochrane Library databases including consideration of national and international guidelines.

RESULTS

From an anesthesiological perspective there are relevant aspects in all three pillars of the perioperative phase, the adherence of which will improve the outcome of the patient: a comprehensive risk evaluation in the preoperative period and the avoidance of any sedative drugs; intraoperative individualized fluid management in the sense of a target-oriented optimization; early postoperative enteral nutrition and the avoidance of intravenous fluid administration, whenever justifiable.

CONCLUSION

Implementing the ERAS concept in the daily clinical routine in combination with maintaining a high compliance with the protocols is a demanding interdisciplinary challenge that urgently needs to be continued.

Continuous noninvasive monitoring of arterial pressure using the vascular unloading technique in comparison to the invasive gold standard in elderly comorbid patients: A prospective observational study

BACKGROUND AND AIMS

Elderly patients aged ≥65 years represent a growing population in the perioperative field, particularly orthopedic and vascular surgery. The higher degree of age-related or comorbid-dependent vascular alterations renders these patients at risk for hemodynamic complications and likely denote a possible limitation for modern, non-invasive arterial pressure monitoring devices. The aim was to compare vascular unloading technique-derived to invasive measurements of systolic (SAP), diastolic (DAP), and mean arterial pressure (MAP) in elderly perioperative patients.

METHODS

This prospective observational study included patients aged ≥65 years scheduled for orthopedic and patients ≥50 years with peripheral artery disease Fontaine stage ≥ II scheduled for vascular surgery, respectively. Invasive radial artery and non-invasive finger-cuff (Nexfin system) arterial pressures were recorded before and after induction of general anesthesia and during surgery. Correlation, Bland-Altman, and concordance analyses were performed. Measurements of arterial pressure were also compared during intraoperative hypotension (MAP <70 mm Hg) and hypertension (MAP >105 mm Hg).

RESULTS

Sixty patients with orthopedic (N = 25, mean (SD) age 77 (5) years) and vascular surgery (N = 35, age 69 [10] years) were enrolled. Seven hundred data pairs of all patients were analysed and pooled bias and percentage error were: SAP: 14.43 mm Hg, 43.79%; DAP: -2.40 mm Hg, 53.78% and MAP: 1.73 mm Hg, 45.05%. Concordance rates were 84.01% for SAP, 77.87% for DAP, and 86.47% for MAP. Predefined criteria for interchangeability of absolute and trending values could neither be reached in the overall nor in the subgroup analyses orthopedic vs vascular surgery. During hypertension, percentage error was found to be lowest for all pressure values, still not reaching predefined criteria.

CONCLUSION

Arterial pressure monitoring with the vascular unloading technique did not reach criteria of interchangeability for absolute and trending values. Nevertheless, the putatively beneficial use of noninvasive arterial pressure measurements should be further evaluated in the elderly perioperative patient.

Perioperative non-invasive versus semi-invasive cardiac index monitoring in patients with bariatric surgery - a prospective observational study

Background

In morbidly obese patients undergoing laparoscopic bariatric surgery, the combination of obesity-related comorbidities, pneumoperitoneum and extreme posture changes constitutes a high risk of perioperative hemodynamic complications. Thus, an advanced hemodynamic monitoring including continuous cardiac index (CI) assessment is desirable. While invasive catheterization may bear technical difficulties, transesophageal echocardiography is contraindicated due to the surgical procedure. Evidence on the clinical reliability of alternative semi- or non-invasive cardiac monitoring devices is limited. The aim was to compare the non-invasive vascular unloading to a semi-invasive pulse contour analysis reference technique for continuous CI measurements in bariatric surgical patients.

Methods

This prospective observational study included adult patients scheduled for elective, laparoscopic bariatric surgery after obtained institutional ethics approval and written informed consent. CI measurements were performed using the vascular unloading technique (Nexfin®) and semi-invasive reference method (FloTrac™). At 10 defined measurement time points, the influence of clinically indicated body posture changes, passive leg raising, fluid bolus administration and pneumoperitoneum was evaluated pre- and intraoperatively. Correlation, Bland-Altman and concordance analyses were performed.

Results

Sixty patients (mean BMI 49.2 kg/m²) were enrolled into the study and data from 54 patients could be entered in the final analysis. Baseline CI was 3.2 ± 0.9 and 3.3 ± 0.8 l/min/m², respectively. Pooled absolute CI values showed a positive correlation (r_s = 0.76, P < 0.001) and mean bias of of − 0.16 l/min/m² (limits of agreement: − 1.48 to 1.15 l/min/m²) between the two methods. Pooled percentage error was 56.51%, missing the criteria of interchangeability (< 30%). Preoperatively, bias ranged from − 0.33 to 0.08 l/min/m² with wide limits of agreement. Correlation of CI was best (r_s = 0.82, P < 0.001) and percentage error lowest (46.34%) during anesthesia and after fluid bolus administration. Intraoperatively, bias ranged from − 0.34 to − 0.03 l/min/m² with wide limits of agreement. CI measurements correlated best during pneumoperitoneum and after fluid bolus administration (r_s = 0.77, P < 0.001; percentage error 35.95%). Trending ability for all 10 measurement points showed a concordance rate of 85.12%, not reaching the predefined Critchley criterion (> 92%).

Conclusion

Non-invasive as compared to semi-invasive CI measurements did not reach criteria of interchangeability for monitoring absolute and trending values of CI in morbidly obese patients undergoing bariatric surgery.

Trial registration

The study was registered retrospectively on June 12, 2017 with the registration number NCT03184272.

Outcomes of Patients after Implantation of the Pericardial All-Biological Valve No-React Aortic Conduit (BioIntegral) for Root Replacement in Complex Surgical Procedures

OBJECTIVE

Therapy of complex aortic root pathologies remains a great surgical challenge. Though different graft materials are available to replace the often-destroyed aortic root, long durability and freedom from reoperation of the latter are still under debate. The aim of our study was to investigate patients' postoperative outcome after implantation of the BioIntegral conduit in complex aortic root pathologies.

METHODS

From February 2014 to May 2017, 33 consecutive patients (69.7% male) with a median age of 73 (57.5; 76.2) years underwent aortic root replacement with the BioIntegral conduit at our institution. Severe aortic valve endocarditis (78.8%) was the predominant indication for surgery. In 28 patients (84.9%), implantation was performed as redo or in 87.8% as urgent and emergent surgery. Primary end-point was the 30-day survival time, evaluated by Cox regression analysis. Secondary midterm outcome and graft-related reoperation were analyzed.

RESULTS

Median follow-up for all patients was 178 (8; 659) days. Median EuroScore II was 19.9% (13.4; 29.9). Freedom from reoperation was 97%. The overall 30-day mortality rate was 33% mainly caused by multiorgan failure in six (18.2%) patients and cardiac failure in five (15.1%) patients. One further death occurred during follow-up at day 156. None was directly conduit-related. Graft reinfection after the 4th surgery with basal abscess formation occurred in only one patient (3%). Early echocardiographic assessment of the valve revealed good functional results. A higher EuroScore II was significantly associated with a poorer 30-day survival time (hazard ratio, 1.039; 95% confidence interval, 1.015-1.063, p = 0.001).

CONCLUSION

Aortic root replacement for complex pathologies is associated with substantial 30-day mortality, but survival of patients after discharge from hospital was stable. Early functional status of the BioIntegral valve was good. Though freedom from re-operation was low, long-term outcome and long-term functional status have to be further evaluated.

Genome-wide association study of myocardial infarction, atrial fibrillation, acute stroke, acute kidney injury and delirium after cardiac surgery - a sub-analysis of the RIPHeart-Study

Background

The aim of our study was the identification of genetic variants associated with postoperative complications after cardiac surgery.

Methods

We conducted a prospective, double-blind, multicenter, randomized trial (RIPHeart). We performed a genome-wide association study (GWAS) in 1170 patients of both genders (871 males, 299 females) from the RIPHeart-Study cohort. Patients undergoing non-emergent cardiac surgery were included. Primary endpoint comprises a binary composite complication rate covering atrial fibrillation, delirium, non-fatal myocardial infarction, acute renal failure and/or any new stroke until hospital discharge with a maximum of fourteen days after surgery.

Results

A total of 547,644 genotyped markers were available for analysis. Following quality control and adjustment for clinical covariate, one SNP reached genome-wide significance (PHLPP2, rs78064607, p = 3.77 × 10^− 8) and 139 (adjusted for all other outcomes) SNPs showed promising association with p < 1 × 10^− 5 from the GWAS.

Conclusions

We identified several potential loci, in particular PHLPP2, BBS9, RyR2, DUSP4 and HSPA8, associated with new-onset of atrial fibrillation, delirium, myocardial infarction, acute kidney injury and stroke after cardiac surgery.

Trial registration

The study was registered with ClinicalTrials.gov NCT01067703, prospectively registered on 11 Feb 2010.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1002-x) contains supplementary material, which is available to authorized users.

A retrospective study of conscious sedation versus general anaesthesia in patients scheduled for transfemoral aortic valve implantation: A single center experience

OBJECTIVES

The current 2017 ESC/EACTS guidelines recommend transcatheter aortic valve implantations (TAVIs) as the therapy of choice for inoperable patients with severe symptomatic aortic stenosis. Most of the TAVIs worldwide are performed under general anaesthesia (GA). Although conscious sedation (CS) concepts are increasingly applied in Europe, it is still a matter of debate which concept is associated with highest amount of safety for this high-risk patient population. The aim of this single center, before-and-after study was to investigate feasibility and safety of CS compared with GA with respect to peri-procedural complications and 30-day mortality in patients scheduled for transfemoral TAVI (TF-TAVI).

METHODS

From March 2012 until September 2014, patients scheduled for the TF-TAVI procedure were included in a prospective, observational manner. From the 200 patients finally included, 107 procedures were performed under GA, using either an endotracheal tube or a laryngeal mask, and balanced anaesthesia. CS was performed in 93 patients using low-dose propofol and remifentanil.

RESULTS

Conversion to GA was needed 4 times due to procedural-related complications (4.3%), in one patient due to ongoing agitation (1.1%). The CS-group showed significantly shorter key time courses: anaesthesia time (105 [95-120] minutes vs 115 [105-140] minutes, P-value = 0.009, Mann-Whitney-U-test) and length of stay in the intensive care unit (1.6 [1.0-1.5] d vs 2.1 [1.0-2.0] d, P-value = 0.002, Mann-Whitney-U-test). The lowest mean arterial pressure was significantly higher in the CS-group compared with the GA-group (74.3 mmHg vs 55.2 mmHg, P-value <0.0001, t-test). CS was associated with less requirements of norepinephrine (0.1 μg/kg vs 2.3 μg/kg, P-value <0.0001, Mann-Whitney-U-test).

CONCLUSIONS

Our single-center data demonstrate that CS is a feasible and safe alternative, especially with respect to a higher degree of intra-procedural haemodynamic stability, and a reduced length of stay in the intensive care unit.

Non-invasive assessment of fluid responsiveness using CNAP™ technology is interchangeable with invasive arterial measurements during major open abdominal surgery

BACKGROUND

Dynamic variables of fluid responsiveness (FR), such as pulse pressure variation (PPV), have been shown to predict the response to a fluid challenge accurately. A recently introduced non-invasive technology based on the volume-clamp method (CNAP™) offers the ability to measure PPV continuously (PPV_CNAP). However, the accuracy regarding the prediction of FR in the operating room has to be proved.

METHODS

We compared PPV_CNAP with an invasive approach measuring PPV using the PiCCO technology (PPV_PiCCO). We studied 47 patients undergoing major open abdominal surgery before and after a passive leg-raising manoeuvre and i.v. fluid resuscitation. A positive response to a volume challenge was defined as ≥15% increase in stroke volume index obtained with transpulmonary thermodilution. Bootstrap methodology was used with the grey zone approach to determine the area of inconsistency regarding the ability of PPV_PiCCO and PPV_CNAP to predict FR.

RESULTS

In response to the passive leg-raising manoeuvre, PPV_PiCCO predicted FR with a sensitivity of 81% and a specificity of 72% [area under the curve (AUC) 0.86] compared with a sensitivity of 76% and a specificity of 72% (AUC 0.78) for PPV_CNAP Regarding the volume challenge in the operating room, PPV_PiCCO predicted FR with a sensitivity of 87% and a specificity of 100% (AUC 0.97) compared with a sensitivity of 91% and specificity of 93% (AUC 0.97) for PPV_CNAP The grey zone approach identified a range of PPV_PiCCO values (11-13%) and PPV_CNAP values (7-11%) for which FR could not be predicted reliably.

CONCLUSIONS

Non-invasive assessment of FR using PPV_CNAP seems to be interchangeable with PPV_PiCCO in patients undergoing major open abdominal surgery.

CLINICAL TRIAL REGISTRATION

NCT02166580.

[Cardiac Anaesthesia: Anaesthesiological Management]

The anaesthesiological management of patients scheduled for cardiac surgery has been refined distinctively over the last decade due to different reasons. The continuing growth of the elderly patient population and the increasing number of combined cardiac surgery procedures in octogenarians on the one hand are one aspect. The rapid development of minimally invasive cardiac surgery and the enhancements in mechanical, artificial heart assist devices on the other hand can be seen as additional decisive factors. All of these innovations in the field of cardiac surgery implicate further enhancements regarding the anaesthesiological management. This review article addresses the following subareas of cardiac anaesthesia: significance of pharmacological myocardial protection, anaesthetic management during cardiopulmonary bypass, importance of "Enhanced Recovery After Cardiac Surgery"-protocols as well as innovations in the field of minimally invasive cardiac surgery like transcatheter aortic valve implantation.

Demonstration of Single-Barium-Ion Sensitivity for Neutrinoless Double-Beta Decay Using Single-Molecule Fluorescence Imaging

A new method to tag the barium daughter in the double-beta decay of ^{136}Xe is reported. Using the technique of single molecule fluorescent imaging (SMFI), individual barium dication (Ba^{++}) resolution at a transparent scanning surface is demonstrated. A single-step photobleach confirms the single ion interpretation. Individual ions are localized with superresolution (∼2  nm), and detected with a statistical significance of 12.9σ over backgrounds. This lays the foundation for a new and potentially background-free neutrinoless double-beta decay technology, based on SMFI coupled to high pressure xenon gas time projection chambers.

RIPHeart (Remote Ischemic Preconditioning for Heart Surgery) Study: Myocardial Dysfunction, Postoperative Neurocognitive Dysfunction, and 1 Year Follow-Up

BACKGROUND

Remote ischemic preconditioning (RIPC) has been suggested to protect against certain forms of organ injury after cardiac surgery. Previously, we reported the main results of RIPHeart (Remote Ischemic Preconditioning for Heart Surgery) Study, a multicenter trial randomizing 1403 cardiac surgery patients receiving either RIPC or sham-RIPC.

METHODS AND RESULTS

In this follow-up paper, we present 1-year follow-up of the composite primary end point and its individual components (all-cause mortality, myocardial infarction, stroke and acute renal failure), in a sub-group of patients, intraoperative myocardial dysfunction assessed by transesophageal echocardiography and the incidence of postoperative neurocognitive dysfunction 5 to 7 days and 3 months after surgery. RIPC neither showed any beneficial effect on the 1-year composite primary end point (RIPC versus sham-RIPC 16.4% versus 16.9%) and its individual components (all-cause mortality [3.4% versus 2.5%], myocardial infarction [7.0% versus 9.4%], stroke [2.2% versus 3.1%], acute renal failure [7.0% versus 5.7%]) nor improved intraoperative myocardial dysfunction or incidence of postoperative neurocognitive dysfunction 5 to 7 days (67 [47.5%] versus 71 [53.8%] patients) and 3 months after surgery (17 [27.9%] versus 18 [27.7%] patients), respectively.

CONCLUSIONS

Similar to our main study, RIPC had no effect on intraoperative myocardial dysfunction, neurocognitive function and long-term outcome in cardiac surgery patients undergoing propofol anesthesia.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01067703.

Long-term outcome and quality of life following emergency surgery for acute aortic dissection type A: a comparison between young and elderly adults

Objectives

Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients.

Methods

We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n  = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n  = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery.

Results

The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P  = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P  = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P  = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P  = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P  = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P  = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P  = 0.12).

Conclusions

Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

Iatrogenic Catheter-Induced Acute Aortic Dissection Type A after Coronary Angiography-A Retrospective Consecutive Case Series

Background Acute aortic dissection type A (AADA) is one of the most life-threatening situations and surgical demanding procedures even today. Usually AADA develops spontaneously, but it can be related also to interventional procedures. Methods We analyzed the data of 14 patients surgically treated in our institution with catheter-induced AADA (ciAADA) during coronary angiography between January 2004 and December 2014. Data were compared with overall AADA patients in this time period (n = 288). Results Nine of the 14 patients were female. Subjects were significantly older compared to the AADA patients (69 ± 11 vs. 62 ± 11; p = 0.021). At admission, ciAADA patients were more often hemodynamically instable and mechanically ventilated. Twelve patients underwent replacement of the ascending aorta and two patients received a modified Bentall operation. Cardiopulmonary bypass time (210 ± 92 vs. 172 ± 51 min) and cross-clamp time (122 ± 63 vs. 92 ± 40 min) were significantly longer due to additional coronary artery bypass grafts in 71.4 versus 3.1% due to myocardial ischemia. Operative mortality (7.1 vs. 2.1%, p = 0.29) and 30-day mortality (50.0 vs. 10.7%, p < 0.001) were higher in the ciAADA group. Conclusion Coronary angiography-induced AADA is a rare but severe complication. Due to additional myocardial ischemia and preoperative hemodynamic instability, patients with ciAADA have adverse outcome compared to overall AADA patients.

Non-invasive hemodynamic optimization in major abdominal surgery: a feasibility study

BACKGROUND

Today, most of the pre-emptive hemodynamic optimization algorithms are based on variables associated with invasive techniques like arterial cannulation. The non-invasive Nexfin™ technology is able to estimate continuous Cardiac Index (CI) and pulse pressure variation (PPV). However, the efficiency of an early goal directed therapy (EGDT) algorithm based on non-invasive variables has to be proven. The aim of our study was to investigate the feasibility of a non-invasive driven EGDT protocol and its impact on patient's outcome.

METHODS

Seventy-nine patients (ASA II-III) undergoing elective major abdominal surgery were randomized to either study group (SG, N.=39) or control group (CG, N.=40). The SG was treated according to an algorithm based on non-invasive CI and PPV, whereas the CG received standard of care. Postoperative complications up to 28 days and length of hospital stay (LOS) in both groups were recorded.

RESULTS

There was no significant difference between the groups regarding demographics, hemodynamic variables, preoperative risk scores and duration of surgery. The total amount of complications was higher in the CG (SG 94 vs. CG 132 complications, P=0.22) without reaching statistical significance. LOS revealed no difference between both groups (SG, 9 [7-15] vs. CG, 9 [7-15.25] days, P=0.82). We have seen no impact of the non-invasive optimization protocol with respect to postoperative mortality.

CONCLUSIONS

In this patient collective, we could demonstrate the feasibility of a non-invasive approach for hemodynamic optimization. However, EGDT based on non-invasive variables was not able to significantly improve outcome.

[Transcatheter aortic valve implantation – What does the anaesthetist need to know and pay attention to?]

Recent advancements in the field of cardiovascular surgery have been dominated by 3 aspects that comparably challenge a sophisticated cardiological, surgical and anaesthesiological management of this patient population. The proportion of elderly patients with relevant comorbidities increases steadily, and the number of combined cardiac surgical procedures is rising in this elderly population. A very important innovation in the last decade pertaining to the treatment of elderly patients at high risk suffering from significant aortic stenosis is the minimally invasive transcatheter aortic valve implantation (TAVI). Over the last 7 years this interventional-surgical "hybrid-procedure" has increased in numbers from almost 0 to 10,500 procedures in 2013 in Germany, performed at more than 80 centers. These patients relevant comorbidities accounting for a high risk of perioperative complications and moreover for a high mortality. The combination of a patient at high risk with the specific characteristics of the TAVI procedure necessitates to update the required skills of anaesthetists responsible for providing care for this kind of procedure.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Dynamic Variables Fail to Predict Fluid Responsiveness in an Animal Model With Pericardial Effusion

OBJECTIVES

The reliability of dynamic and volumetric variables of fluid responsiveness in the presence of pericardial effusion is still elusive. The aim of the present study was to investigate their predictive power in a porcine model with hemodynamic relevant pericardial effusion.

DESIGN

A single-center animal investigation.

PARTICIPANTS

Twelve German domestic pigs.

INTERVENTIONS

Pigs were studied before and during pericardial effusion. Instrumentation included a pulmonary artery catheter and a transpulmonary thermodilution catheter in the femoral artery. Hemodynamic variables like cardiac output (COPAC) and stroke volume (SVPAC) derived from pulmonary artery catheter, global end-diastolic volume (GEDV), stroke volume variation (SVV), and pulse-pressure variation (PPV) were obtained.

MEASUREMENTS AND MAIN RESULTS

At baseline, SVV, PPV, GEDV, COPAC, and SVPAC reliably predicted fluid responsiveness (area under the curve 0.81 [p = 0.02], 0.82 [p = 0.02], 0.74 [p = 0.07], 0.74 [p = 0.07], 0.82 [p = 0.02]). After establishment of pericardial effusion the predictive power of dynamic variables was impaired and only COPAC and SVPAC and GEDV allowed significant prediction of fluid responsiveness (area under the curve 0.77 [p = 0.04], 0.76 [p = 0.05], 0.83 [p = 0.01]) with clinically relevant changes in threshold values.

CONCLUSIONS

In this porcine model, hemodynamic relevant pericardial effusion abolished the ability of dynamic variables to predict fluid responsiveness. COPAC, SVPAC, and GEDV enabled prediction, but their threshold values were significantly changed.

Over Ten Years of Experience with a Modified Right Atrial Anastomosis in Orthotopic Heart Transplantation: Follow-up and Comparison with the Biatrial and Bicaval Technique

BACKGROUND

In 1997, a modified right atrial anastomosis (cavoatrial technique) for orthotopic heart transplantation (oHTx) was first developed in our institution. The purpose of this study is to report our long-term experience with this technique compared with biatrial and bicaval technique.

METHODS

Retrospectively, 202 consecutive oHTx between 1997 and 2013 were analyzed. The applied transplantation techniques were biatrial (n = 108), bicaval (n = 22), and cavoatrial (n = 72).

RESULTS

Demographic data were similar in all groups. The cardiopulmonary bypass and cross-clamp time were significantly shorter in the biatrial group. Follow-up echocardiographic examination showed excellent results in all groups with no relevant differences. After 1 year, occurrence of severe tricuspid regurgitation (biatrial 1.9% vs bicaval 0.0% vs cavoatrial 1.4%) was low in all groups. Rate of permanent pacemaker implantations was also low (12.0% vs 5.0% vs 11.1%). There were no significant differences in survival between the groups.

CONCLUSION

The cavoatrial technique can be a safe and simple alternative for heart transplantation. Easy handling and similar reduced postoperative complications encourage the use of this technique.

[Study of the 21 cases of thromboembolism from the 4th report of national confidential enquiry into maternal death in France in 2007-2009]

OBJECTIVES

The Confidential National Enquiry on Maternal Mortality identified 254 deaths in France from 2007 to 2009. Thromboembolism venous disease led to 31 deaths, becoming the 3rd cause of maternal mortality. This study analyses the 21 enquiry files obtained by the National Expert Committee on Maternal Mortality (CNEMM).

MATERIALS AND METHODS

Clinical characteristics, arising circumstances and imaging exams were collected in the 20 patients deceased by pulmonary embolism (PE). After excluding two incomplete files, we looked for the PE Risk Factors (RF) in order to sort patients out according to 4 levels of risk (low, moderate, high and major).

RESULTS

The main RF were: non-Caucasian ethnic origin (n=8), age over 35years (n=7), diabetes (n=6) and emergency or unplanned caesarean section (n=6). The average number of RF was 3.7: 73% were low, 18% moderate. Among 7 autopsies performed, 6 resulted in PE diagnostic. Only 67% of eligible patients had an imaging exam.

CONCLUSION

The search for the RF of thromboembolism accidents, in particular the low RF, should be improved to establish an adapted prophylactic therapy. Autopsy or even post-mortem imaging should be implemented when diagnosis is uncertain in order to avoid over-/under-estimating death incidence caused by PE.

Monitoring high-risk patients: minimally invasive and non-invasive possibilities

Over the past decades, there has been considerable progress in the field of less invasive haemodynamic monitoring technologies. Substantial evidence has accumulated, which supports the continuous measurement and optimization of flow-based variables such as stroke volume, that is, cardiac output, in order to prevent occult hypoperfusion and consequently to improve patients' outcome in the perioperative setting. However, there is a striking gap between the developments in haemodynamic monitoring and the increasing evidence to implement defined treatment protocols based on the measured variables, and daily clinical routine. Recent trials have shown that perioperative morbidity and mortality is higher than anticipated. This emphasizes the need for the anaesthesia community to address this issue and promotes the implementation of proven concepts into clinical practice in order to improve patients' outcome, especially in high-risk patients. The advances in minimally invasive and non-invasive monitoring techniques can be seen as a driving force in this respect, as the degree of invasiveness of any monitoring tool determines the frequency of its application, especially in the operating room (OR). From this point of view, we are very confident that some of these minimally invasive and non-invasive haemodynamic monitoring technologies will become an inherent part of our monitoring armamentarium in the OR and in the intensive care unit (ICU).

Accuracy of an autocalibrated pulse contour analysis in cardiac surgery patients: a bi-center clinical trial

BACKGROUND

Less-invasive and easy to install monitoring systems for continuous estimation of cardiac index (CI) have gained increasing interest, especially in cardiac surgery patients who often exhibit abrupt haemodynamic changes. The aim of the present study was to compare the accuracy of CI by a new semi-invasive monitoring system with transpulmonary thermodilution before and after cardiopulmonary bypass (CPB).

METHODS

Sixty-five patients (41 Germany, 24 Spain) scheduled for elective coronary surgery were studied before and after CPB, respectively. Measurements included CI obtained by transpulmonary thermodilution (CITPTD) and autocalibrated semi-invasive pulse contour analysis (CIPFX). Percentage changes of CI were also calculated.

RESULTS

There was only a poor correlation between CITPTD and CIPFX both before (r (2) = 0.34, p < 0.0001) and after (r (2) = 0.31, p < 0.0001) CPB, with a percentage error (PE) of 62 and 49 %, respectively. Four quadrant plots revealed a concordance rate over 90 % indicating an acceptable correlation of trends between CITPTD and CIPFX before (concordance: 93 %) and after (concordance: 94 %) CPB. In contrast, polar plot analysis showed poor trending before and an acceptable trending ability of changes in CI after CPB.

CONCLUSIONS

Semi-invasive CI by autocalibrated pulse contour analysis showed a poor ability to estimate CI compared with transpulmonary thermodilution. Furthermore, the new semi-invasive device revealed an acceptable trending ability for haemodynamic changes only after CPB.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02312505 Date: 12.03.2012.

A mechanical model for dissolution–precipitation creep based on the minimum principle of the dissipation potential

In contrast to previous approaches that consider dissolution–precipitation creep as a multi-stage process and only simulate its governing subprocess, the present model treats this phenomenon as a single continuous process. The applied strategy uses the minimum principle of the dissipation potential according to which a Lagrangian consisting of elastic power and dissipation is minimized. Here, the elastic part has a standard form while the assumption for dissipation stipulates the driving forces to be proportional to two kinds of velocities: the material-transport velocity and the boundary-motion velocity. A Lagrange term is included to impose mass conservation. Two ways of solution are proposed. The strong form of the problem is solved analytically for a simple case. The weak form of the problem is used for a finite-element implementation and for simulating more complex cases.

Evaluation of remote ischaemic post-conditioning in a pig model of cardiac arrest: A pilot study

BACKGROUND

Remote ischaemic post-conditioning (RIPoC) in which transient episodes of ischaemia (e.g. by inflation and deflation of a blood pressure cuff) are applied after a prolonged ischaemia/reperfusion injury, may have the potential to improve patient outcome and survival following cardiac arrest. In this study we employed a pig model of cardiac arrest and successful cardiopulmonary resuscitation to evaluate the effects of RIPoC on haemodynamics, cardiac tissue damage and neurologic deficit.

MATERIALS AND METHODS

A total of 22 pigs were subjected to ventricular fibrillation, cardiopulmonary resuscitation and randomly assigned to Control or RIPoC treatment consisting of 4 cycles of 5 min femoral artery occlusion followed by 5 min of reperfusion starting 10min after return of spontaneous circulation (ROSC). Post-resuscitation was evaluated by haemodynamics using left ventricular conductance catheters, quantification of cardiac troponin T (cTnT), lactate dehydrogenase (LDH) and creatine kinase (CK). Neurological testing was performed 24h after return of spontaneous circulation (ROSC).

RESULTS

RIPoC resulted in a statistically significant reduction of serum cTnT levels 4h after ROSC (P ≤ 0.01). LDH and CK concentrations were significantly lower in RIPoC treated pigs 24h after ROSC (P ≤ 0.001), suggesting tissue and/or cardioprotective effects of RIPoC. End-systolic pressure volume relationship was significantly increased in RIPoC treated animals 4h after ROSC (P ≤ 0.05). Neurological testing revealed a trend towards an improved outcome in RIPoC treated animals.

CONCLUSIONS

We propose that RIPoC applied immediately after ROSC reduces serum concentrations of markers for cell damage and improves end-systolic pressure volume relationship 4h after ROSC.

[Can anaesthetic management improve the outcome?]

Despite anaesthesia-specific pharmacological and technological innovations in the last decades we are definitely aware that anaesthesia per se has the potential to induce changes in the balance of human physiology that in turn may have relevant consequences, i.e. an increase in postoperative morbidity and mortality. Today anaesthesia appears to be extremely safe, with the number of deaths solely attributed to anaesthesia having reached its lowest point in history (0.055 per 10 000 anaesthetics). However, the available data regarding anaesthesia-related mortality, solely or contributory, are not consistent and the interpretation and legibility is limited. Fortunately, the issue of "patient safety in anaesthesiology" has gained increasing interest in the last few years, yielding some very promising projects. Since most of the ideas are focused on intraoperative safety improvement strategies, it seems to be reasonable in the near future to expand to the complete perioperative period, especially the postoperative care on the ward in high-risk patients. This knowledge, combined with an ongoing promotion of patient safety in anaesthesiology and provision of adequate resources definitely will increase patient safety. Hopefully, in the end, our efforts will contribute to integrate the "patient safety in anaesthesiology concept" in daily clinical routine.

Monitoring cardiac function: echocardiography, pulse contour analysis and beyond

Haemodynamic monitoring has developed considerably over the last decades, nowadays comprising a wide spectrum of different technologies ranging from invasive to completely non-invasive techniques. At present, the evidence to continuously measure and optimise stroke volume, that is, cardiac output, in order to prevent occult hypoperfusion in the perioperative setting and consequently to improve patients' outcome is substantial. Surprisingly, there is a striking discrepancy between the developments in advanced haemodynamic monitoring combined with evidence-based knowledge on the one hand and daily clinical routine on the other hand. Recent trials have shown that perioperative mortality is higher than anticipated, emphasising the need for the speciality of anaesthesiology to face the problem and to translate proven concepts into clinical routine to improve patients' outcome. One basic principle of these concepts is to monitor and to optimise cardiac function by means of advanced haemodynamic monitoring, using echocardiography, pulse contour analysis and beyond.

Postoperative neurocognitive dysfunction in patients undergoing cardiac surgery after remote ischemic preconditioning: a double-blind randomized controlled pilot study

Background

Remote ischemic preconditioning (RIPC) has been shown to enhance the tolerance of remote organs to cope with a subsequent ischemic event. We hypothesized that RIPC reduces postoperative neurocognitive dysfunction (POCD) in patients undergoing complex cardiac surgery.

Methods

We conducted a prospective, randomized, double-blind, controlled trial including 180 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomized either to RIPC or to control group. Primary endpoint was postoperative neurocognitive dysfunction 5–7 days after surgery assessed by a comprehensive test battery. Cognitive change was assumed if the preoperative to postoperative difference in 2 or more tasks assessing different cognitive domains exceeded more than one SD (1 SD criterion) or if the combined Z score was 1.96 or greater (Z score criterion).

Results

According to 1 SD criterion, 52% of control and 46% of RIPC patients had cognitive deterioration 5–7 days after surgery (p = 0.753). The summarized Z score showed a trend to more cognitive decline in the control group (2.16±5.30) compared to the RIPC group (1.14±4.02; p = 0.228). Three months after surgery, incidence and severity of neurocognitive dysfunction did not differ between control and RIPC. RIPC tended to decrease postoperative troponin T release at both 12 hours [0.60 (0.19–1.94) µg/L vs. 0.48 (0.07–1.84) µg/L] and 24 hours after surgery [0.36 (0.14–1.89) µg/L vs. 0.26 (0.07–0.90) µg/L].

Conclusions

We failed to demonstrate efficacy of a RIPC protocol with respect to incidence and severity of POCD and secondary outcome variables in patients undergoing a wide range of cardiac surgery. Therefore, definitive large-scale multicenter trials are needed.

Trial Registration

ClinicalTrials.gov NCT00877305

[Labour epidural analgesia for a parturient with a factor XI deficiency: an ill-considered challenge or a reasonable risk?]

The authors report the performance of a labour epidural analgesia in a 26-year-old parturient presenting a moderate factor XI (FXI) deficiency. If haemostasis disorders usually contraindicate an epidural analgesia (with a risk of epidural haematoma), a moderate FXI deficiency is not an absolute contraindication to perform such an epidural analgesia. Desmopressin, sometimes used in surgery to reduce the bleeding, was administered to withdraw the catheter in better haemostasis conditions. No neurological signs were observed.

A comparison of continuous non-invasive arterial pressure with invasive radial and femoral pressure in patients undergoing cardiac surgery

BACKGROUND

Non-invasive continous monitoring of finger arterial pressure has gained increasing interest. The aim of the present study was to compare the accuracy of non-invasive reconstructed brachial artery pressure by the Nexfin™ device (NFAP) with invasive femoral (IFAP) and radial (IRAP) artery pressure before and after cardiopulmonary bypass (CPB).

METHODS

Fifty patients scheduled for elective coronary surgery were studied before and after CPB, respectively. Each patient was monitored with the non-invasive system, and both an indwelling femoral and radial arterial catheter. A passive leg raising maneuver was also performed before and after CPB. Measurements included mean (MAP), systolic (SAP) and diastolic (DAP) arterial pressure by NFAP (MAP,SAP,DAP(NFAP)), IFAP (MAP,SAP,DAP(IFAP)) and IRAP (MAP,SAP,DAP(IRAP)). Percentage changes of MAP for all measurement sites were also calculated.

RESULTS

There was a moderate correlation between MAP(NFAP) and MAP(IFAP) both before (r=0.64, P<0.0001) and after (r=0.57, P<0.0001) CPB, with a percentage error (PE) of 29% and 27%, respectively. Correlation coefficients between MAP(NFAP) and MAP(IRAP) were r=0.53, P<0.0001 (PE 34%) before and r=0.54, P<0.0001 (PE 29%) after CPB. There was a significant correlation in percentage changes between ∆MAP(NFAP) and ∆MAP(IFAP) before (r=0.70, P<0.0001) and after (r=0.71, P<0.0001) CPB and for ∆MAP(NFAP) and ∆MAP(IRAP) (r=0.67, P<0.0001; r=0.74, P<0.0001), respectively.

CONCLUSION

Non-invasive, reconstructed brachial artery pressure showed moderate correlation compared with both invasive femoral and radial artery pressure. Furthermore, the non-invasive monitoring system was able to reflect percentage changes in mean arterial pressure in a moderate fashion.