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Reese M, Wong MK, Cheong V, Ha CI, Cooter Wright M, Browndyke J, Moretti E, Devinney MJ, Habib AS, Moul JW, Shaw LM, Waligorska T, Whitson HE, Cohen HJ, Welsh-Bohmer KA, Plassman BL, Mathew JP, Berger M. Cognitive and Cerebrospinal Fluid Alzheimer's Disease-related Biomarker Trajectories in Older Surgical Patients and Matched Nonsurgical Controls. Anesthesiology 2024; 140:963-978. [PMID: 38324729 PMCID: PMC11003848 DOI: 10.1097/aln.0000000000004924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND Anesthesia and/or surgery accelerate Alzheimer's disease pathology and cause memory deficits in animal models, yet there is a lack of prospective data comparing cerebrospinal fluid (CSF) Alzheimer's disease-related biomarker and cognitive trajectories in older adults who underwent surgery versus those who have not. Thus, the objective here was to better understand whether anesthesia and/or surgery contribute to cognitive decline or an acceleration of Alzheimer's disease-related pathology in older adults. METHODS The authors enrolled 140 patients 60 yr or older undergoing major nonneurologic surgery and 51 nonsurgical controls via strata-based matching on age, sex, and years of education. CSF amyloid β (Aβ) 42, tau, and p-tau-181p levels and cognitive function were measured before and after surgery, and at the same time intervals in controls. RESULTS The groups were well matched on 25 of 31 baseline characteristics. There was no effect of group or interaction of group by time for baseline to 24-hr or 6-week postoperative changes in CSF Aβ, tau, or p-tau levels, or tau/Aβ or p-tau/Aβ ratios (Bonferroni P > 0.05 for all) and no difference between groups in these CSF markers at 1 yr (P > 0.05 for all). Nonsurgical controls did not differ from surgical patients in baseline cognition (mean difference, 0.19 [95% CI, -0.06 to 0.43]; P = 0.132), yet had greater cognitive decline than the surgical patients 1 yr later (β, -0.31 [95% CI, -0.45 to -0.17]; P < 0.001) even when controlling for baseline differences between groups. However, there was no difference between nonsurgical and surgical groups in 1-yr postoperative cognitive change in models that used imputation or inverse probability weighting for cognitive data to account for loss to follow up. CONCLUSIONS During a 1-yr time period, as compared to matched nonsurgical controls, the study found no evidence that older patients who underwent anesthesia and noncardiac, nonneurologic surgery had accelerated CSF Alzheimer's disease-related biomarker (tau, p-tau, and Aβ) changes or greater cognitive decline. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Melody Reese
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
| | - Megan K. Wong
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Vanessa Cheong
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- Duke University-National University of Singapore Medical School, Singapore
| | - Christine I. Ha
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Mary Cooter Wright
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Jeffrey Browndyke
- DUMC, Department of Psychiatry and Behavioral Medicine, Durham, NC, USA
| | - Eugene Moretti
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Michael J. Devinney
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Ashraf S. Habib
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Judd W. Moul
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- DUMC, Department of Surgery, Durham, NC, USA
| | - Leslie M. Shaw
- Perelman School of Medicine University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, PA, USA
| | - Teresa Waligorska
- Perelman School of Medicine University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, PA, USA
| | - Heather E. Whitson
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
- DUMC, Department of Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Harvey J. Cohen
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
- DUMC, Department of Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Kathleen A. Welsh-Bohmer
- DUMC, Department of Psychiatry and Behavioral Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Brenda L. Plassman
- DUMC, Department of Psychiatry and Behavioral Medicine, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
| | - Joseph P. Mathew
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
| | - Miles Berger
- Duke University Medical Center (DUMC), Department of Anesthesiology, Durham, NC, USA
- DUMC, Center for the Study of Aging and Human Development, Durham, NC, USA
- DUMC, Duke/UNC Alzheimer’s Disease Research Center, Durham, NC, USA
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Liu SY, Kelly-Hedrick M, Temkin N, Barber J, Komisarow J, Hatfield J, Ohnuma T, Manley G, Treggiari MM, Colton K, Vavilala MS, Grandhi R, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Goldstein B, Krishnamoorthy V. Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study. Crit Care Med 2024; 52:607-617. [PMID: 37966330 PMCID: PMC10939970 DOI: 10.1097/ccm.0000000000006106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVE To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI). DESIGN Retrospective cohort study with prospectively collected data. SETTING Eighteen Level-1 Trauma Centers, United States. PATIENTS Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20). CONCLUSION Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.
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Affiliation(s)
- Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Nancy Temkin
- Department of Biostatistics, University of Washington. Seattle, WA
- Department of Neurosurgery, University of Washington. Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington. Seattle, WA
| | | | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Miriam M. Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | | | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Daniel T. Laskowitz
- Department of Neurosurgery, Duke University. Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | | | | | - Michael L. James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
| | - Ben Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
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Kelly-Hedrick M, Liu SY, Komisarow J, Hatfield J, Ohnuma T, Treggiari MM, Colton K, Arulraja E, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Krishnamoorthy V. Early Beta-Blocker Utilization in Critically Ill Patients With Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study. J Intensive Care Med 2024:8850666241236724. [PMID: 38449336 DOI: 10.1177/08850666241236724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND There is limited evidence that beta-blockers may provide benefit for patients with moderate-severe traumatic brain injury (TBI) during the acute injury period. Larger studies on utilization patterns and impact on outcomes in clinical practice are lacking. OBJECTIVE The present study uses a large, national hospital claims-based dataset to examine early beta-blocker utilization patterns and its association with clinical outcomes among critically ill patients with moderate-severe TBI. METHODS We conducted a retrospective cohort study of the administrative claims Premier Healthcare Database of adults (≥17 years) with moderate-severe TBI admitted to the intensive care unit (ICU) from 2016 to 2020. The exposure was receipt of a beta-blocker during day 1 or 2 of ICU stay (BB+). The primary outcome was hospital mortality, and secondary outcomes were: hospital length of stay (LOS), ICU LOS, discharge to home, and vasopressor utilization. In a sensitivity analysis, we explored the association of beta-blocker class (cardioselective and noncardioselective) with hospital mortality. We used propensity weighting methods to address possible confounding by treatment indication. RESULTS A total of 109 665 participants met inclusion criteria and 39% (n = 42 489) were exposed to beta-blockers during the first 2 days of hospitalization. Of those, 42% received cardioselective only, 43% received noncardioselective only, and 14% received both. After adjustment, there was no association with hospital mortality in the BB+ group compared to the BB- group (adjusted odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.94, 1.04). The BB+ group had longer hospital stays, lower chance of discharged home, and lower risk of vasopressor utilization, although these difference were clinically small. Beta-blocker class was not associated with hospital mortality. CONCLUSION In this retrospective cohort study, we found variation in use of beta-blockers and early exposure was not associated with hospital mortality. Further research is necessary to understand the optimal type, dose, and timing of beta-blockers for this population.
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Affiliation(s)
- Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Miriam M Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Evangeline Arulraja
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Michael L James
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Liu SY, Kelly-Hedrick M, Komisarow J, Hatfield J, Ohnuma T, Treggiari MM, Colton K, Arulraja E, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Krishnamoorthy V. Association of Early Dexmedetomidine Utilization With Clinical Outcomes After Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study. Anesth Analg 2024:00000539-990000000-00741. [PMID: 38335145 DOI: 10.1213/ane.0000000000006869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is an expensive and common public health problem. Management of TBI oftentimes includes sedation to facilitate mechanical ventilation (MV) for airway protection. Dexmedetomidine has emerged as a potential candidate for improved patient outcomes when used for early sedation after TBI due to its potential modulation of autonomic dysfunction. We examined early sedation patterns, as well as the association of dexmedetomidine exposure with clinical and functional outcomes among mechanically ventilated patients with moderate-severe TBI (msTBI) in the United States. METHODS We conducted a retrospective cohort study using data from the Premier dataset and identified a cohort of critically ill adult patients with msTBI who required MV from January 2016 to June 2020. msTBI was defined by head-neck abbreviated injury scale (AIS) values of 3 (serious), 4 (severe), and 5 (critical). We described early continuous sedative utilization patterns. Using propensity-matched models, we examined the association of early dexmedetomidine exposure (within 2 days of intensive care unit [ICU] admission) with the primary outcome of hospital mortality and the following secondary outcomes: hospital length of stay (LOS), days on MV, vasopressor use after the first 2 days of admission, hemodialysis (HD) after the first 2 days of admission, hospital costs, and discharge disposition. All medications, treatments, and procedures were identified using date-stamped hospital charge codes. RESULTS The study population included 19,751 subjects who required MV within 2 days of ICU admission. The patients were majority male and white. From 2016 to 2020, the annual percent utilization of dexmedetomidine increased from 4.05% to 8.60%. After propensity score matching, early dexmedetomidine exposure was associated with reduced odds of hospital mortality (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.47-0.74; P < .0001), increased risk for liberation from MV (hazard ratio [HR], 1.20; 95% CI, 1.09-1.33; P = .0003), and reduced LOS (HR, 1.11; 95% CI, 1.01-1.22; P = .033). Exposure to early dexmedetomidine was not associated with odds of HD (OR, 1.14; 95% CI, 0.73-1.78; P = .56), vasopressor utilization (OR, 1.10; 95% CI, 0.78-1.55; P = .60), or increased hospital costs (relative cost ratio, 1.98; 95% CI, 0.93-1.03; P = .66). CONCLUSIONS Dexmedetomidine is being utilized increasingly as a sedative for mechanically ventilated patients with msTBI. Early dexmedetomidine exposure may lead to improved patient outcomes in this population.
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Affiliation(s)
- Sunny Yang Liu
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
- Department of Neurosurgery
- Department of Anesthesiology
- Department of Population Health Sciences, and
- Department of Neurology, Duke University, Durham, North Carolina
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
- Department of Medicine, Duke University, Durham, North Carolina; and
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Margot Kelly-Hedrick
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Jordan Komisarow
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Neurosurgery
| | - Jordan Hatfield
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Tetsu Ohnuma
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology
| | - Miriam M Treggiari
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology
- Department of Population Health Sciences, and
| | - Katharine Colton
- Department of Neurology, Duke University, Durham, North Carolina
| | - Evangeline Arulraja
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | | | - Adrian Hernandez
- Department of Medicine, Duke University, Durham, North Carolina; and
| | | | - Karthik Raghunathan
- From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology
- Department of Population Health Sciences, and
| | - Vijay Krishnamoorthy
- Department of Anesthesiology
- Department of Population Health Sciences, and
- Department of Medicine, Duke University, Durham, North Carolina; and
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Suarez-Roca H, Mamoun N, Watkins LL, Bortsov AV, Mathew JP. Higher Cardiovagal Baroreflex Sensitivity Predicts Increased Pain Outcomes After Cardiothoracic Surgery. J Pain 2024; 25:187-201. [PMID: 37567546 PMCID: PMC10841280 DOI: 10.1016/j.jpain.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/05/2023] [Accepted: 08/06/2023] [Indexed: 08/13/2023]
Abstract
Excessive postoperative pain can lead to extended hospitalization and increased expenses, but factors that predict its severity are still unclear. Baroreceptor function could influence postoperative pain by modulating nociceptive processing and vagal-mediated anti-inflammatory reflexes. To investigate this relationship, we conducted a study with 55 patients undergoing minimally invasive cardiothoracic surgery to evaluate whether cardiovagal baroreflex sensitivity (BRS) can predict postoperative pain. We assessed the spontaneous cardiovagal BRS under resting pain-free conditions before surgery. We estimated postoperative pain outcomes with the Pain, Enjoyment, and General Activity scale and pressure pain thresholds on the first (POD1) and second (POD2) postoperative days and persistent pain 3 and 6 months after hospital discharge. We also measured circulating levels of relevant inflammatory biomarkers (C-reactive protein, albumin, cytokines) at baseline, POD1, and POD2 to assess the contribution of inflammation to the relationship between BRS and postoperative pain. Our mixed-effects model analysis showed a significant main effect of preoperative BRS on postoperative pain (P = .013). Linear regression analysis revealed a significant positive association between preoperative BRS and postoperative pain on POD2, even after adjusting for demographic, surgical, analgesic treatment, and psychological factors. Moreover, preoperative BRS was linked to pain interfering with general activity and enjoyment but not with other pain parameters (pain intensity and pressure pain thresholds). Preoperative BRS had modest associations with postoperative C-reactive protein and IL-10 levels, but they did not mediate its relationship with postoperative pain. These findings indicate that preoperative BRS can independently predict postoperative pain, which could serve as a modifiable criterion for optimizing postoperative pain management. PERSPECTIVE: This article shows that preoperative BRS predicts postoperative pain outcomes independently of the inflammatory response and pain sensitivity to noxious pressure stimulation. These results provide valuable insights into the role of baroreceptors in pain and suggest a helpful tool for improving postoperative pain management.
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Affiliation(s)
- Heberto Suarez-Roca
- Center for Translational Pain Medicine, Duke University Medical Center, Durham, North Carolina
| | - Negmeldeen Mamoun
- Division of Cardiothoracic Anesthesia and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Lana L Watkins
- Psychiatry and Behavioral Sciences Department, Duke University Medical Center, Durham, North Carolina
| | - Andrey V Bortsov
- Center for Translational Pain Medicine, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Division of Cardiothoracic Anesthesia and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Devinney MJ, Wong MK, Wright MC, Marcantonio ER, Terrando N, Browndyke JN, Whitson HE, Cohen HJ, Nackley AG, Klein ME, Ely EW, Mathew JP, Berger M. Role of Blood-Brain Barrier Dysfunction in Delirium following Non-cardiac Surgery in Older Adults. Ann Neurol 2023; 94:1024-1035. [PMID: 37615660 PMCID: PMC10841407 DOI: 10.1002/ana.26771] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/21/2023] [Accepted: 08/12/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients. METHODS Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR). RESULTS Of 207 patients (median age = 68 years, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24 hours after surgery (median change = 0.28, interquartile range [IQR] = -0.48 to 1.24, Wilcoxon p = 0.001). Preoperative to 24 hours postoperative change in CPAR was greater among patients who developed delirium versus those who did not (median [IQR] = 1.31 [0.004 to 2.34] vs 0.19 [-0.55 to 1.08], p = 0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24 hours postoperative change in CPAR was independently associated with delirium occurrence (per CPAR increase of 1, odds ratio = 1.30, 95% confidence interval [CI] = 1.03-1.63, p = 0.026) and increased hospital length of stay (incidence rate ratio = 1.15, 95% CI = 1.09-1.22, p < 0.001). INTERPRETATION Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay. ANN NEUROL 2023;94:1024-1035.
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Affiliation(s)
- Michael J. Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
| | | | - Mary Cooter Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Edward R. Marcantonio
- Division of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Department of Cell Biology, Duke University School of Medicine, Durham NC
- Department of Immunology, Duke University School of Medicine, Durham NC
| | - Jeffrey N. Browndyke
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham NC
| | - Heather E. Whitson
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Harvey J. Cohen
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Andrea G. Nackley
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | | | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN
| | - Joseph P. Mathew
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
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Kelly-Hedrick M, Liu SY, Temkin N, Barber J, Komisarow J, Manley G, Ohnuma T, Colton K, Treggiari MM, Monson EE, Vavilala MS, Grandhi R, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Goldstein B, Markowitz AJ, Krishnamoorthy V. Association of Early Beta-Blocker Exposure and Functional Outcomes in Critically Ill Patients With Moderate to Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study. Crit Care Explor 2023; 5:e0958. [PMID: 37693305 PMCID: PMC10484371 DOI: 10.1097/cce.0000000000000958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVES We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury. DESIGN Retrospective cohort study. SETTING ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. PATIENTS Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI. INTERVENTIONS None. MEASUREMENTS Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction. MAIN RESULTS Of the 450 eligible participants, 57 (13%) received early beta blockers (BB+ group). The BB+ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB+ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB+ group and BB- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes. CONCLUSIONS About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.
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Affiliation(s)
- Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Duke University, Durham, NC
| | - Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Duke University, Durham, NC
| | - Nancy Temkin
- Departments of Biostatistics, University of Washington, Seattle, WA
- Departments of Neurosurgery, University of Washington, Seattle, WA
| | - Jason Barber
- Departments of Neurosurgery, University of Washington, Seattle, WA
| | | | - Geoffrey Manley
- Departments of Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
| | | | - Miriam M Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
- Departments of Population Health Sciences, Duke University, Durham, NC
| | - Eric E Monson
- Libraries Center for Data and Visualization Sciences, Duke University, Durham, NC
| | - Monica S Vavilala
- Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Daniel T Laskowitz
- Departments of Neurosurgery, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Neurology, Duke University, Durham, NC
| | | | | | - Michael L James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Neurology, Duke University, Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Population Health Sciences, Duke University, Durham, NC
| | - Ben Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Amy J Markowitz
- Departments of Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Departments of Anesthesiology, Duke University, Durham, NC
- Departments of Population Health Sciences, Duke University, Durham, NC
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Toro C, Jain S, Sun S, Temkin N, Barber J, Manley G, Komisarow JM, Ohnuma T, Foreman B, Korley F, James ML, Laskowitz D, Vavilala MS, Hernandez A, Mathew JP, Markowitz AJ, Krishnamoorthy V. Association of Brain Injury Biomarkers and Circulatory Shock Following Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study. J Neurosurg Anesthesiol 2023; 35:284-291. [PMID: 34967764 PMCID: PMC9243189 DOI: 10.1097/ana.0000000000000828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Early circulatory shock following traumatic brain injury (TBI) is a multifactorial process; however, the impact of brain injury biomarkers on the risk of shock has not been evaluated. We examined the association between neuronal injury biomarker levels and the development of circulatory shock following moderate-severe TBI. METHODS In this retrospective cohort study, we examined adults with moderate-severe TBI (Glasgow Coma Scale score <13) enrolled in the TRACK-TBI study, an 18-center prospective TBI cohort study. The exposures were day-1 levels of neuronal injury biomarkers (glial fibrillary acidic protein, ubiquitin C-terminal hydrolase-L1 [UCH-L1], S100 calcium-binding protein B [S100B], neuron-specific enolase), and of an inflammatory biomarker (high-sensitivity C-reactive protein). The primary outcome was the development of circulatory shock, defined as cardiovascular Sequential Organ Failure Assessment Score ≥2 within 72 hours of admission. Association between day-1 biomarker levels and the development of circulatory shock was assessed with regression analysis. RESULTS The study included 392 subjects, with a mean age of 40 years; 314 (80%) were male and 165 (42%) developed circulatory shock. Median (interquartile range) day-1 levels of UCH-L1 (994.8 [518.7 to 1988.2] pg/mL vs. 548.1 [280.2 to 1151.9] pg/mL; P <0.0001) and S100B (0.47 μg/mL [0.25 to 0.88] vs. 0.27 [0.16 to 0.46] μg/mL; P <0.0001) were elevated in those who developed early circulatory shock compared with those who did not. In multivariable regression, there were associations between levels of both UCH-L1 (odds ratio, 1.63 [95% confidence interval, 1.25-2.12]; P <0.0005) and S100B (odds ratio, 1.73 [95% confidence interval 1.27-2.36]; P <0.0005) with the development of circulatory shock. CONCLUSION Neuronal injury biomarkers may provide the improved mechanistic understanding and possibly early identification of patients at risk for early circulatory shock following moderate-severe TBI.
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Affiliation(s)
- Camilo Toro
- Duke University School of Medicine. Durham, NC
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego. San Diego, CA
| | - Shelly Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego. San Diego, CA
| | - Nancy Temkin
- Department of Biostatistics, Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
- Department of Neurosurgery, Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco. San Francisco, CA
| | | | - Tetsu Ohnuma
- Department of Anesthesiology, Duke University. Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati. Cincinnati, OH
| | - Frederick Korley
- Department of Emergency Medicine, University of Michigan. Ann Arbor, MI
| | - Michael L. James
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University. Durham, NC
| | - Daniel Laskowitz
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University. Durham, NC
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, and Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | | | | | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco. San Francisco, CA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
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10
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Villalobos D, Reese M, Wright MC, Wong M, Syed A, Park J, Hall A, Browndyke JN, Martucci KT, Devinney MJ, Acker L, Moretti EW, Talbot L, Colin B, Ohlendorf B, Waligorska T, Shaw LM, Whitson HE, Cohen HJ, Mathew JP, Berger M. Perioperative changes in neurocognitive and Alzheimer's disease-related cerebrospinal fluid biomarker in older patients randomised to isoflurane or propofol for anaesthetic maintenance. Br J Anaesth 2023:S0007-0912(23)00194-0. [PMID: 37271721 PMCID: PMC10375507 DOI: 10.1016/j.bja.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Animal studies have shown that isoflurane and propofol have differential effects on Alzheimer's disease (AD) pathology and memory, although it is unclear whether this occurs in humans. METHODS This was a nested randomised controlled trial within a prospective cohort study; patients age ≥60 yr undergoing noncardiac/non-neurological surgery were randomised to isoflurane or propofol for anaesthetic maintenance. Cerebrospinal fluid (CSF) was collected via lumbar puncture before, 24 h, and 6 weeks after surgery. Cognitive testing was performed before and 6 weeks after surgery. Nonparametric methods and linear regression were used to evaluate CSF biomarkers and cognitive function, respectively. RESULTS There were 107 subjects (54 randomised to isoflurane and 53 to propofol) who completed the 6-week follow-up and were included in the analysis. There was no significant effect of anaesthetic treatment group, time, or group-by-time interaction for CSF amyloid-beta (Aβ), tau, or phospho-tau181p levels, or on the tau/Aβ or p-tau181p/Aβ ratios (all P>0.05 after Bonferroni correction). In multivariable-adjusted intention-to-treat analyses, there were no significant differences between the isoflurane and propofol groups in 6-week postoperative change in overall cognition (mean difference [95% confidence interval]: 0.01 [-0.12 to 0.13]; P=0.89) or individual cognitive domains (P>0.05 for each). Results remained consistent across as-treated and per-protocol analyses. CONCLUSIONS Intraoperative anaesthetic maintenance with isoflurane vs propofol had no significant effect on postoperative cognition or CSF Alzheimer's disease-related biomarkers within 6 weeks after noncardiac, non-neurological surgery in older adults. CLINICAL TRIAL REGISTRATION NCT01993836.
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Affiliation(s)
| | - Melody Reese
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA; Center for the Study of Aging and Human Development, Duke University Medical Centre, Durham, NC, USA
| | - Mary Cooter Wright
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Megan Wong
- Duke University School of Medicine, Durham, NC, USA
| | - Ayesha Syed
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA; Trinity College, Duke University, Durham, NC, USA
| | - John Park
- Duke University School of Medicine, Durham, NC, USA; Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Ashley Hall
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioural Medicine, Division of Behavioral Medicine & Neurosciences, Duke University Medical Center, Durham, NC, USA; Center for Cognitive Neuroscience, Duke University, Durham, NC, USA; Duke Brain Imaging and Analysis Center, Durham, NC, USA; Duke Institute for Brain Sciences, Durham, NC, USA
| | - Katherine T Martucci
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA; Center for Cognitive Neuroscience, Duke University, Durham, NC, USA; Duke Brain Imaging and Analysis Center, Durham, NC, USA; Duke Institute for Brain Sciences, Durham, NC, USA
| | - Michael J Devinney
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Leah Acker
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Eugene W Moretti
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Leonard Talbot
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Brian Colin
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Brian Ohlendorf
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Teresa Waligorska
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Leslie M Shaw
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather E Whitson
- Center for the Study of Aging and Human Development, Duke University Medical Centre, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Harvey J Cohen
- Center for the Study of Aging and Human Development, Duke University Medical Centre, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Miles Berger
- Duke University School of Medicine, Durham, NC, USA; Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA; Center for the Study of Aging and Human Development, Duke University Medical Centre, Durham, NC, USA; Center for Cognitive Neuroscience, Duke University, Durham, NC, USA; Duke Institute for Brain Sciences, Durham, NC, USA.
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Lascola CD, Cotter SF, Klinger RY, Bisanar T, Cooter Wright M, Berger M, Martin G, Podgoreanu MV, Newman MF, Terrando N, Mathew JP. Blood-brain barrier permeability and cognitive dysfunction after surgery - A pilot study. J Clin Anesth 2023; 86:111059. [PMID: 36739699 PMCID: PMC10072905 DOI: 10.1016/j.jclinane.2023.111059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/28/2022] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Christopher D Lascola
- Department of Radiology, Duke University Medical Center Box 3808, 2301 Erwin Road, Durham, NC 27710, United States of America.
| | - Sarah F Cotter
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Rebecca Y Klinger
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Tiffany Bisanar
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Mary Cooter Wright
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Miles Berger
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Gavin Martin
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Mihai V Podgoreanu
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Mark F Newman
- University of Kentucky, 900 S. Limestone St., Suite 317, Lexington, KY 40536, United States of America
| | - Niccolò Terrando
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Joseph P Mathew
- Department of Anesthesiology, 5692 HAFS Bldg, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, United States of America
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Devinney MJ, Wong MK, Wright MC, Marcantonio ER, Terrando N, Browndyke JN, Whitson HE, Cohen HJ, Nackley AG, Klein ME, Ely EW, Mathew JP, Berger M. A Role for Blood-brain Barrier Dysfunction in Delirium following Non-Cardiac Surgery in Older adults. medRxiv 2023:2023.04.07.23288303. [PMID: 37214925 PMCID: PMC10197714 DOI: 10.1101/2023.04.07.23288303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Objective Although animal models suggest a role for blood-brain barrier dysfunction in postoperative delirium-like behavior, its role in postoperative delirium and postoperative recovery in humans is unclear. Thus, we evaluated the role of blood-brain barrier dysfunction in postoperative delirium and hospital length of stay among older surgery patients. Methods Cognitive testing, delirium assessment, and cerebrospinal fluid and blood sampling were prospectively performed before and after non-cardiac, non-neurologic surgery. Blood-brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio (CPAR). Results Of 207 patients (median age 68, 45% female) with complete CPAR and delirium data, 26 (12.6%) developed postoperative delirium. Overall, CPAR increased from before to 24-hours after surgery (median postoperative change 0.28, [IQR] [-0.48-1.24]; Wilcoxon p=0.001). Preoperative to 24-hour postoperative change in CPAR was greater among patients who developed delirium vs those who did not (median [IQR] 1.31 [0.004, 2.34] vs 0.19 [-0.55, 1.08]; p=0.003). In a multivariable model adjusting for age, baseline cognition, and surgery type, preoperative to 24-hour postoperative change in CPAR was independently associated with delirium incidence (per CPAR increase of 1, OR = 1.30, [95% CI 1.03-1.63]; p=0.026) and increased hospital length of stay (IRR = 1.15 [95% CI 1.09-1.22]; p<0.001). Interpretation Postoperative increases in blood-brain barrier permeability are independently associated with increased delirium rates and postoperative hospital length of stay. Although these findings do not establish causality, studies are warranted to determine whether interventions to reduce postoperative blood-brain barrier dysfunction would reduce postoperative delirium rates and hospital length of stay.
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Affiliation(s)
- Michael J. Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
| | | | - Mary Cooter Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Edward R. Marcantonio
- Division of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Department of Cell Biology, Duke University School of Medicine, Durham NC
- Department of Immunology, Duke University School of Medicine, Durham NC
| | - Jeffrey N. Browndyke
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham NC
| | - Heather E. Whitson
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Harvey J. Cohen
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham NC
| | - Andrea G. Nackley
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | | | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN
| | - Joseph P. Mathew
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham NC
- Duke Center for the Study of Aging and Human Development, Duke University Medical Center, Durham NC
- Duke/UNC Alzheimer’s Disease Research Center, Duke University and University of North Carolina at Chapel Hill, Durham/Chapel Hill NC
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13
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Suarez-Roca H, Mamoun N, Watkins LL, Bortsov AV, Mathew JP. Higher Cardiovagal Baroreflex Sensitivity Predicts Increased Pain Severity After Cardiothoracic Surgery. The Journal of Pain 2023. [DOI: 10.1016/j.jpain.2023.02.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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Yuan MZ, Zhao J, McGinnis A, Mathew JP, Wang F, Ji RR. Mouse Brain Regions Activated By Isoflurane Anesthesia Marked By C-Fos Labeling. The Journal of Pain 2023. [DOI: 10.1016/j.jpain.2023.02.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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15
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Browndyke JN, Wright MC, Yang R, Syed A, Park J, Hall A, Martucci K, Devinney MJ, Shaw L, Waligorska T, Moretti EW, Whitson HE, Cohen HJ, Mathew JP, Berger M. Corrigendum to 'Perioperative neurocognitive and functional neuroimaging trajectories in older APOE4 carriers compared with non-carriers: secondary analysis of a prospective cohort study' (Br J Anaesth 2021; 127: 917-928). Br J Anaesth 2023; 130:646. [PMID: 36878808 PMCID: PMC10170390 DOI: 10.1016/j.bja.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Affiliation(s)
- Jeffrey N Browndyke
- Department of Psychiatry and Behavioural Medicine, Division of Behavioural Medicine & Neurosciences, Duke University Medical Centre, Durham, NC, USA; Centre for Cognitive Neuroscience, Duke University, Durham, NC, USA; Duke Brain Imaging and Analysis Centre, Durham, NC, USA; Duke Institute for Brain Sciences, Durham, NC, USA.
| | - Mary C Wright
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Rosa Yang
- Duke University School of Medicine, Durham, NC, USA
| | - Ayesha Syed
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA; Trinity College, Duke University, Durham, NC, USA
| | - John Park
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Ashley Hall
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Katherine Martucci
- Duke Institute for Brain Sciences, Durham, NC, USA; Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Michael J Devinney
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Leslie Shaw
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Teresa Waligorska
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Eugene W Moretti
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Heather E Whitson
- Centre for the Study of Aging and Human Development, Duke University Medical Centre, Durham, NC, USA; Department of Medicine, Duke University Medical Centre, Durham, NC, USA
| | - Harvey J Cohen
- Centre for the Study of Aging and Human Development, Duke University Medical Centre, Durham, NC, USA; Department of Medicine, Duke University Medical Centre, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA
| | - Miles Berger
- Centre for Cognitive Neuroscience, Duke University, Durham, NC, USA; Duke Institute for Brain Sciences, Durham, NC, USA; Department of Anaesthesiology, Duke University Medical Centre, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA; Centre for the Study of Aging and Human Development, Duke University Medical Centre, Durham, NC, USA.
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16
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Karatela MF, Fudim M, Mathew JP, Piccini JP. Neuromodulation therapy for atrial fibrillation. Heart Rhythm 2023; 20:100-111. [PMID: 35988908 DOI: 10.1016/j.hrthm.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation has a multifactorial pathophysiology influenced by cardiac autonomic innervation. Both sympathetic and parasympathetic influences are profibrillatory. Innovative therapies targeting the neurocardiac axis include catheter ablation or pharmacologic suppression of ganglionated plexi, renal sympathetic denervation, low-level vagal stimulation, and stellate ganglion blockade. To date, these therapies have variable efficacy. As our understanding of atrial fibrillation and the cardiac nervous system expands, our approach to therapeutic neuromodulation will continue evolving for the benefit of those with AF.
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Affiliation(s)
- Maham F Karatela
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Marat Fudim
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jonathan P Piccini
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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17
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Chen G, Xu J, Luo H, Luo X, Singh SK, Ramirez JJ, James ML, Mathew JP, Berger M, Eroglu C, Ji RR. Hevin/Sparcl1 drives pathological pain through spinal cord astrocyte and NMDA receptor signaling. JCI Insight 2022; 7:161028. [PMID: 36256481 PMCID: PMC9746899 DOI: 10.1172/jci.insight.161028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/13/2022] [Indexed: 01/24/2023] Open
Abstract
High endothelial venule protein/SPARC-like 1 (hevin/Sparcl1) is an astrocyte-secreted protein that regulates synapse formation in the brain. Here we show that astrocytic hevin signaling plays a critical role in maintaining chronic pain. Compared with WT mice, hevin-null mice exhibited normal mechanical and heat sensitivity but reduced inflammatory pain. Interestingly, hevin-null mice have faster recovery than WT mice from neuropathic pain after nerve injury. Intrathecal injection of WT hevin was sufficient to induce persistent mechanical allodynia in naive mice. In hevin-null mice with nerve injury, adeno-associated-virus-mediated (AAV-mediated) re-expression of hevin in glial fibrillary acidic protein-expressing (GFAP-expressing) spinal cord astrocytes could reinstate neuropathic pain. Mechanistically, hevin is crucial for spinal cord NMDA receptor (NMDAR) signaling. Hevin-potentiated N-Methyl-D-aspartic acid (NMDA) currents are mediated by GluN2B-containing NMDARs. Furthermore, intrathecal injection of a neutralizing Ab against hevin alleviated acute and persistent inflammatory pain, postoperative pain, and neuropathic pain. Secreted hevin that was detected in mouse cerebrospinal fluid (CSF) and nerve injury significantly increased CSF hevin abundance. Finally, neurosurgery caused rapid and substantial increases in SPARCL1/HEVIN levels in human CSF. Collectively, our findings support a critical role of hevin and astrocytes in the maintenance of chronic pain. Neutralizing of secreted hevin with monoclonal Ab may provide a new therapeutic strategy for treating acute and chronic pain and NMDAR-medicated neurodegeneration.
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Affiliation(s)
- Gang Chen
- Center for Translational Pain Medicine, Department of Anesthesiology, and
| | - Jing Xu
- Center for Translational Pain Medicine, Department of Anesthesiology, and
| | - Hao Luo
- Center for Translational Pain Medicine, Department of Anesthesiology, and
| | - Xin Luo
- Center for Translational Pain Medicine, Department of Anesthesiology, and
| | - Sandeep K. Singh
- Department of Cell Biology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Juan J. Ramirez
- Department of Cell Biology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Neurobiology
| | | | | | | | - Cagla Eroglu
- Department of Cell Biology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Neurobiology,,Howard Hughes Medical Institute, Duke University Medical Center, Durham, North Carolina, USA.,Duke Institute for Brain Sciences (DIBS), Durham, North Carolina, USA
| | - Ru-Rong Ji
- Center for Translational Pain Medicine, Department of Anesthesiology, and,Department of Cell Biology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Neurobiology,,Duke Institute for Brain Sciences (DIBS), Durham, North Carolina, USA
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18
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Andrew BY, Pieper CF, Cherry AD, Pendergast JF, Privratsky JR, Mathew JP, Stafford-Smith M. Identification of Trajectory-Based Acute Kidney Injury Phenotypes Among Cardiac Surgery Patients. Ann Thorac Surg 2022; 114:2235-2243. [PMID: 34968444 PMCID: PMC9237188 DOI: 10.1016/j.athoracsur.2021.11.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/05/2021] [Accepted: 11/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication of cardiac surgical procedures for which unrecognized heterogeneity may underpin poor success in identifying effective therapies. We aimed to identify phenotypically similar groups of patients as defined by their postoperative creatinine trajectories. METHODS This was a retrospective, single-center cohort study in an academic tertiary care center including patients undergoing coronary artery bypass graft procedures. AKI phenotypes were evaluated through latent class mixed modeling of serum creatinine patterns (trajectories). To identify trajectory phenotypes, modeling was performed using postoperative creatinine values from 50% of patients (development cohort) and for comparison similarly conducted for the remaining sample (validation cohort). Subsequent assessments included comparisons of classes between development and validation cohorts for consistency and stability, and among classes for patient and procedural characteristics, complications, and long-term survival. RESULTS We identified 12 AKI trajectories in both the development (n = 2647) and validation cohorts (n = 2647). Discrimination among classes was good (mean posterior class membership probability, 66%-88%), with differences in rate, timing, and degree of serum creatinine rise/fall, and recovery. In matched class comparisons between cohorts, many other phenotypic similarities were present. Notably, 4 high-risk phenotypes had greater long-term risk for death relative to lower risk classes. CONCLUSIONS Latent class mixed modeling identified 12 reproducible AKI classes (serum creatinine trajectory phenotypes), including 4 with higher risk of poor outcome, in patients following coronary artery bypass graft procedures. Such hidden structure offers a novel approach to grouping patients for renoprotection investigations in addition to reanalysis of previously conducted trials.
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Affiliation(s)
- Benjamin Y Andrew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
| | - Carl F Pieper
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Anne D Cherry
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Jane F Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Jamie R Privratsky
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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19
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Toro C, Ohnuma T, Komisarow J, Vavilala MS, Laskowitz DT, James ML, Mathew JP, Hernandez AF, Goldstein BA, Sampson JH, Krishnamoorthy V. Early Vasopressor Utilization Strategies and Outcomes in Critically Ill Patients With Severe Traumatic Brain Injury. Anesth Analg 2022; 135:1245-1252. [PMID: 35203085 PMCID: PMC9381646 DOI: 10.1213/ane.0000000000005949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Early hypotension after severe traumatic brain injury (sTBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors, commonly norepinephrine and phenylephrine, to support blood pressure after TBI. However, guidelines do not specify vasopressor type, resulting in variation in clinical practice. We describe early vasopressor utilization patterns in critically ill patients with TBI and examine the association between utilization of norepinephrine, compared to phenylephrine, with hospital mortality after sTBI. METHODS We conducted a retrospective cohort study of US hospitals participating in the Premier Healthcare Database between 2009 and 2018. We examined adult patients (>17 years of age) with a primary diagnosis of sTBI who were treated in an intensive care unit (ICU) after injury. The primary exposure was vasopressor choice (phenylephrine versus norepinephrine) within the first 2 days of hospital admission. The primary outcome was in-hospital mortality. Secondary outcomes examined included hospital length of stay (LOS) and ICU LOS. We conducted a post hoc subgroup analysis in all patients with intracranial pressure (ICP) monitor placement. Regression analysis was used to assess differences in outcomes between patients exposed to phenylephrine versus norepinephrine, with propensity matching to address selection bias due to the nonrandom allocation of treatment groups. RESULTS From 2009 to 2018, 24,718 (37.1%) of 66,610 sTBI patients received vasopressors within the first 2 days of hospitalization. Among these patients, 60.6% (n = 14,991) received only phenylephrine, 10.8% (n = 2668) received only norepinephrine, 3.5% (n = 877) received other vasopressors, and 25.0% (n = 6182) received multiple vasopressors. In that time period, the use of all vasopressors after sTBI increased. A moderate degree of variation in vasopressor choice was explained at the individual hospital level (23.1%). In propensity-matched analysis, the use of norepinephrine compared to phenylephrine was associated with an increased risk of in-hospital mortality (OR, 1.65; CI, 1.46-1.86; P < .0001). CONCLUSIONS Early vasopressor utilization among critically ill patients with sTBI is common, increasing over the last decade, and varies across hospitals caring for TBI patients. Compared to phenylephrine, norepinephrine was associated with increased risk of in-hospital mortality in propensity-matched analysis. Given the wide variation in vasopressor utilization and possible differences in efficacy, our analysis suggests the need for randomized controlled trials to better inform vasopressor choice for patients with sTBI.
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Affiliation(s)
- Camilo Toro
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Duke University School of Medicine. Durham, NC
| | - Tetsu Ohnuma
- Department of Anesthesiology, Duke University. Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | - Jordan Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurosurgery, Duke University. Durham, NC
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University. Durham, NC
- Department of Neurosurgery, Duke University. Durham, NC
| | - Michael L. James
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University. Durham, NC
| | | | | | - Ben A. Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | | | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University. Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
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20
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Hatfield J, Ohnuma T, Soto AL, Komisarow JM, Vavilala MS, Laskowitz DT, James ML, Mathew JP, Hernandez AF, Goldstein BA, Treggiari M, Raghunathan K, Krishnamoorthy V. Utilization and Outcomes of Extracorporeal Membrane Oxygenation Following Traumatic Brain Injury in the United States. J Intensive Care Med 2022; 38:440-448. [PMID: 36445019 DOI: 10.1177/08850666221139223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives: Describe contemporary ECMO utilization patterns among patients with traumatic brain injury (TBI) and examine clinical outcomes among TBI patients requiring ECMO. Design: Retrospective cohort study. Setting: Premier Healthcare Database (PHD) between January 2016 to June 2020. Subjects: Adult patients with TBI who were mechanically ventilated and stratified by exposure to ECMO. Results: Among patients exposed to ECMO, we examined the following clinical outcomes: hospital LOS, ICU LOS, duration of mechanical ventilation, and hospital mortality. Of our initial cohort (n = 59,612), 118 patients (0.2%) were placed on ECMO during hospitalization. Most patients were placed on ECMO within the first 2 days of admission (54.3%). Factors associated with ECMO utilization included younger age (OR 0.96, 95% CI (0.95–0.97)), higher injury severity score (ISS) (OR 1.03, 95% CI (1.01–1.04)), vasopressor utilization (2.92, 95% CI (1.90–4.48)), tranexamic acid utilization (OR 1.84, 95% CI (1.12–3.04)), baseline comorbidities (OR 1.06, 95% CI (1.03–1.09)), and care in a teaching hospital (OR 3.04, 95% CI 1.31–7.05). A moderate degree (ICC = 19.5%) of variation in ECMO use was explained at the individual hospital level. Patients exposed to ECMO had longer median (IQR) hospital and ICU length of stay (LOS) [26 days (11–36) versus 9 days (4–8) and 19.5 days (8–32) versus 5 days (2–11), respectively] and a longer median (IQR) duration of mechanical ventilation [18 days (8–31) versus 3 days (2–8)]. Patients exposed to ECMO experienced a hospital mortality rate of 33.9%, compared to 21.2% of TBI patients unexposed to ECMO. Conclusions: ECMO utilization in mechanically ventilated patients with TBI is rare, with significant variation across hospitals. The impact of ECMO on healthcare utilization and hospital mortality following TBI is comparable to non-TBI conditions requiring ECMO. Further research is necessary to better understand the role of ECMO following TBI and identify patients who may benefit from this therapy.
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Affiliation(s)
- Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alexandria L. Soto
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan M. Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Michael L. James
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | | | | | | | - Miriam Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Population Health Sciences, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Population Health Sciences, Duke University, Durham, NC, USA
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21
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Devinney MJ, VanDusen KW, Kfouri JM, Avasarala P, Spector AR, Mathew JP, Berger M. The potential link between obstructive sleep apnea and postoperative neurocognitive disorders: current knowledge and possible mechanisms. Can J Anaesth 2022; 69:1272-1287. [PMID: 35982354 PMCID: PMC9924301 DOI: 10.1007/s12630-022-02302-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE This narrative review examines the current evidence on whether obstructive sleep apnea (OSA) is associated with postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The mechanisms that could predispose OSA patients to these disorders are also explored. SOURCE Relevant literature was identified by searching for pertinent terms in Medline®, Pubmed, ScopusTM, and Google scholar databases. Case reports, abstracts, review articles, original research articles, and meta-analyses were reviewed. The bibliographies of retrieved sources were also searched to identify relevant papers. PRINCIPAL FINDINGS Seven studies have investigated the association between OSA and POD, with mixed results. No studies have examined the potential link between OSA and POCD. If these relationships exist, they could be mediated by several mechanisms, including increased neuroinflammation, blood-brain barrier breakdown, cerebrovascular disease, Alzheimer's disease neuropathology, disrupted cerebral autoregulation, sleep disruption, sympathovagal imbalance, and/or disrupted brain bioenergetics. CONCLUSION There is very limited evidence that OSA plays a role in postoperative neurocognitive disorders because few studies have been conducted in the perioperative setting. Additional perioperative prospective observational cohort studies and randomized controlled trials of sleep apnea treatment are needed. These investigations should also assess potential underlying mechanisms that could predispose patients with OSA to postoperative neurocognitive disorders. This review highlights the need for more research to improve postoperative neurocognitive outcomes for patients with OSA.
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Affiliation(s)
- Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
- Duke Hospital South, 3094 MS 01, 40 Medicine Circle, Rm 4324, Orange Zone, Durham, NC, 27710, USA.
| | - Keith W VanDusen
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jad M Kfouri
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Pallavi Avasarala
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Andrew R Spector
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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22
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Toro C, Hatfield J, Temkin N, Barber J, Manley G, Ohnuma T, Komisarow J, Foreman B, Korley FK, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Raghunathan K, Goldstein BA, Markowitz AJ, Krishnamoorthy V. Risk Factors and Neurological Outcomes Associated With Circulatory Shock After Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study. Neurosurgery 2022; 91:427-436. [PMID: 35593705 PMCID: PMC10553078 DOI: 10.1227/neu.0000000000002042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/03/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Extracranial multisystem organ failure is a common sequela of severe traumatic brain injury (TBI). Risk factors for developing circulatory shock and long-term functional outcomes of this patient subset are poorly understood. OBJECTIVE To identify emergency department predictors of circulatory shock after moderate-severe TBI and examine long-term functional outcomes in patients with moderate-severe TBI who developed circulatory shock. METHODS We conducted a retrospective cohort study using the Transforming Clinical Research and Knowledge in TBI database for adult patients with moderate-severe TBI, defined as a Glasgow Coma Scale (GCS) score of <13 and stratified by the development of circulatory shock within 72 hours of hospital admission (Sequential Organ Failure Assessment score ≥2). Demographic and clinical data were assessed with descriptive statistics. A forward selection regression model examined risk factors for the development of circulatory shock. Functional outcomes were examined using multivariable regression models. RESULTS Of our moderate-severe TBI population (n = 407), 168 (41.2%) developed circulatory shock. Our predictive model suggested that race, computed tomography Rotterdam scores <3, GCS in the emergency department, and development of hypotension in the emergency department were associated with developing circulatory shock. Those who developed shock had less favorable 6-month functional outcomes measured by the 6-month GCS-Extended (odds ratio 0.36, P = .002) and 6-month Disability Rating Scale score (Diff. in means 3.86, P = .002) and a longer length of hospital stay (Diff. in means 11.0 days, P < .001). CONCLUSION We report potential risk factors for circulatory shock after moderate-severe TBI. Our study suggests that developing circulatory shock after moderate-severe TBI is associated with poor long-term functional outcomes.
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Affiliation(s)
- Camilo Toro
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Nancy Temkin
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Jordan Komisarow
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Frederick K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Joseph P. Mathew
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Adrian Hernandez
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - John Sampson
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Michael L. James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Benjamin A. Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
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23
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Kourouni I, Shachi T, Mathew JP. A Man in His 80s With Sudden Onset of Hypoxemia. Chest 2022; 162:e53-e55. [DOI: 10.1016/j.chest.2021.08.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/20/2021] [Accepted: 08/11/2021] [Indexed: 10/17/2022] Open
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24
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Komisarow JM, Toro C, Curley J, Mills B, Cho C, Simo GM, Vavilala MS, Laskowitz DT, James ML, Mathew JP, Hernandez A, Sampson J, Ohnuma T, Krishnamoorthy V. Utilization of Brain Tissue Oxygenation Monitoring and Association with Mortality Following Severe Traumatic Brain Injury. Neurocrit Care 2022; 36:350-356. [PMID: 34845596 PMCID: PMC9941980 DOI: 10.1007/s12028-021-01394-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to describe the utilization patterns of brain tissue oxygen (PbtO2) monitoring following severe traumatic brain injury (TBI) and determine associations with mortality, health care use, and pulmonary toxicity. METHODS We conducted a retrospective cohort study of patients from United States trauma centers participating in the American College of Surgeons National Trauma Databank between 2008 and 2016. We examined patients with severe TBI (defined by admission Glasgow Coma Scale score ≤ 8) over the age of 18 years who survived more than 24 h from admission and required intracranial pressure (ICP) monitoring. The primary exposure was PbtO2 monitor placement. The primary outcome was hospital mortality, defined as death during the hospitalization or discharge to hospice. Secondary outcomes were examined to determine the association of PbtO2 monitoring with health care use and pulmonary toxicity and included the following: (1) intensive care unit length of stay, (2) hospital length of stay, and (3) development of acute respiratory distress syndrome (ARDS). Regression analysis was used to assess differences in outcomes between patients exposed to PbtO2 monitor placement and those without exposure by using propensity weighting to address selection bias due to the nonrandom allocation of treatment groups and patient dropout. RESULTS A total of 35,501 patients underwent placement of an ICP monitor. There were 1,346 (3.8%) patients who also underwent PbtO2 monitor placement, with significant variation regarding calendar year and hospital. Patients who underwent placement of a PbtO2 monitor had a crude in-hospital mortality of 31.1%, compared with 33.5% in patients who only underwent placement of an ICP monitor (adjusted risk ratio 0.84, 95% confidence interval 0.76-0.93). The development of the ARDS was comparable between patients who underwent placement of a PbtO2 monitor and patients who only underwent placement of an ICP monitor (9.2% vs. 9.8%, adjusted risk ratio 0.89, 95% confidence interval 0.73-1.09). CONCLUSIONS PbtO2 monitor utilization varied widely throughout the study period by calendar year and hospital. PbtO2 monitoring in addition to ICP monitoring, compared with ICP monitoring alone, was associated with a decreased in-hospital mortality, a longer length of stay, and a similar risk of ARDS. These findings provide further guidance for clinicians caring for patients with severe TBI while awaiting completion of further randomized controlled trials.
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Affiliation(s)
- Jordan M. Komisarow
- Departments of Neurosurgery, Duke University. Durham, NC.,Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
| | - Camilo Toro
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC.,Duke University School of Medicine. Durham, NC
| | | | - Brianna Mills
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington
| | - Christopher Cho
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington
| | - Georges Motchoffo Simo
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington
| | - Monica S. Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Daniel T. Laskowitz
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC.,Anesthesiology, Duke University. Durham, NC.,Neurology, Duke University. Durham, NC
| | - Michael L. James
- Departments of Neurosurgery, Duke University. Durham, NC.,Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC.,Neurology, Duke University. Durham, NC
| | | | | | - John Sampson
- Departments of Neurosurgery, Duke University. Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC.,Anesthesiology, Duke University. Durham, NC
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC.,Anesthesiology, Duke University. Durham, NC.,Population Health Sciences, Duke University. Durham, NC
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25
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Berger M, Browndyke JN, Cooter Wright M, Nobuhara C, Reese M, Acker L, Bullock WM, Colin BJ, Devinney MJ, Moretti EW, Moul JW, Ohlendorf B, Laskowitz DT, Waligorska T, Shaw LM, Whitson HE, Cohen HJ, Mathew JP. Postoperative changes in cognition and cerebrospinal fluid neurodegenerative disease biomarkers. Ann Clin Transl Neurol 2022; 9:155-170. [PMID: 35104057 PMCID: PMC8862419 DOI: 10.1002/acn3.51499] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Numerous investigators have theorized that postoperative changes in Alzheimer's disease neuropathology may underlie postoperative neurocognitive disorders. Thus, we determined the relationship between postoperative changes in cognition and cerebrospinal (CSF) tau, p-tau-181p, or Aβ levels after non-cardiac, non-neurologic surgery in older adults. METHODS Participants underwent cognitive testing before and 6 weeks after surgery, and lumbar punctures before, 24 h after, and 6 weeks after surgery. Cognitive scores were combined via factor analysis into an overall cognitive index. In total, 110 patients returned for 6-week postoperative testing and were included in the analysis. RESULTS There was no significant change from before to 24 h or 6 weeks following surgery in CSF tau (median [median absolute deviation] change before to 24 h: 0.00 [4.36] pg/mL, p = 0.853; change before to 6 weeks: -1.21 [3.98] pg/mL, p = 0.827). There were also no significant changes in CSF p-tau-181p or Aβ over this period. There was no change in cognitive index (mean [95% CI] 0.040 [-0.018, 0.098], p = 0.175) from before to 6 weeks after surgery, although there were postoperative declines in verbal memory (-0.346 [-0.523, -0.170], p = 0.003) and improvements in executive function (0.394, [0.310, 0.479], p < 0.001). There were no significant correlations between preoperative to 6-week postoperative changes in cognition and CSF tau, p-tau-181p, or Aβ42 changes over this interval (p > 0.05 for each). INTERPRETATION Neurocognitive changes after non-cardiac, non-neurologic surgery in the majority of cognitively healthy, community-dwelling older adults are unlikely to be related to postoperative changes in AD neuropathology (as assessed by CSF Aβ, tau or p-tau-181p levels or the p-tau-181p/Aβ or tau/Aβ ratios). TRIAL REGISTRATION clinicaltrials.gov (NCT01993836).
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Affiliation(s)
- Miles Berger
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for Cognitive NeuroscienceDuke UniversityDurhamNorth CarolinaUSA
| | - Jeffrey N. Browndyke
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for Cognitive NeuroscienceDuke UniversityDurhamNorth CarolinaUSA
- Division of Geriatric Behavioral Health, Department of Psychiatry and Behavioral MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke Brain Imaging and Analysis CenterDurhamNorth CarolinaUSA
| | - Mary Cooter Wright
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Chloe Nobuhara
- Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Melody Reese
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Leah Acker
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - W. Michael Bullock
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Brian J. Colin
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Michael J. Devinney
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Eugene W. Moretti
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Judd W. Moul
- Urology Division, Department of SurgeryDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Brian Ohlendorf
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Daniel T. Laskowitz
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of NeurologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Teresa Waligorska
- Department of Pathology and Lab Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Leslie M. Shaw
- Department of Pathology and Lab Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Heather E. Whitson
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
- Geriatrics Research Education and Clinical Center (GRECC)Durham VA Medical CenterDurhamNCUSA
| | - Harvey J. Cohen
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Joseph P. Mathew
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
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26
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Waldron NH, Sigurdsson MI, Mathew JP. Perioperative Management of Valvular Heart Disease. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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27
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Oyeyemi DM, Cooter M, Chung S, Whitson HE, Browndyke JN, Devinney MJ, Smith PJ, Garrigues GE, Moretti E, Moul JW, Cohen HJ, Mathew JP, Berger M. Relationship Between Depression/Anxiety and Cognitive Function Before and 6 Weeks After Major Non-Cardiac Surgery in Older Adults. J Geriatr Psychiatry Neurol 2022; 35:145-154. [PMID: 33380241 PMCID: PMC8243391 DOI: 10.1177/0891988720978791] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the relationship between affective measures and cognition before and after non-cardiac surgery in older adults. METHODS Observational prospective cohort study in 103 surgical patients age ≥ 60 years old. All participants underwent cognitive testing, Center for Epidemiologic Studies-Depression, and State Anxiety Inventory screening before and 6 weeks after surgery. Cognitive test scores were combined by factor analysis into 4 cognitive domains, whose mean was defined as the continuous cognitive index (CCI). Postoperative global cognitive change was defined by CCI change from before to after surgery, with negative CCI change indicating worsened postoperative global cognition and vice versa. RESULTS Lower global cognition before surgery was associated with greater baseline depression severity (Spearman's r = -0.30, p = 0.002) and baseline anxiety severity (Spearman's r = -0.25, p = 0.010), and these associations were similar following surgery (r = -0.36, p < 0.001; r = -0.26, p = 0.008, respectively). Neither baseline depression or anxiety severity, nor postoperative changes in depression or anxiety severity, were associated with pre- to postoperative global cognitive change. CONCLUSIONS Greater depression and anxiety severity were each associated with poorer cognitive performance both before and after surgery in older adults. Yet, neither baseline depression or anxiety symptoms, nor postoperative change in these symptoms, were associated with postoperative cognitive change.
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Affiliation(s)
- Deborah M Oyeyemi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Stacey Chung
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Heather E Whitson
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, NC, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Eugene Moretti
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Judd W Moul
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Harvey Jay Cohen
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, NC, USA
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28
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Newman MF, Berger M, Mathew JP. Postoperative Cognitive Dysfunction and Delirium. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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29
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Krishnamoorthy V, Temkin N, Barber J, Foreman B, Komisarow J, Korley FK, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Bartz R, Raghunathan K, Goldstein BA, Markowitz AJ, Vavilala MS. Association of Early Multiple Organ Dysfunction With Clinical and Functional Outcomes Over the Year Following Traumatic Brain Injury: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. Crit Care Med 2021; 49:1769-1778. [PMID: 33935162 PMCID: PMC8448900 DOI: 10.1097/ccm.0000000000005055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Traumatic brain injury is a leading cause of death and disability in the United States. While the impact of early multiple organ dysfunction syndrome has been studied in many critical care paradigms, the clinical impact of early multiple organ dysfunction syndrome in traumatic brain injury is poorly understood. We examined the incidence and impact of early multiple organ dysfunction syndrome on clinical, functional, and disability outcomes over the year following traumatic brain injury. DESIGN Retrospective cohort study. SETTING Patients enrolled in the Transforming Clinical Research and Knowledge in Traumatic Brain Injury study, an 18-center prospective cohort study of traumatic brain injury patients evaluated in participating level 1 trauma centers. SUBJECTS Adult (age > 17 yr) patients with moderate-severe traumatic brain injury (Glasgow Coma Scale < 13). We excluded patients with major extracranial injury (Abbreviated Injury Scale score ≥ 3). INTERVENTIONS Development of early multiple organ dysfunction syndrome, defined as a maximum modified Sequential Organ Failure Assessment score greater than 7 during the initial 72 hours following admission. MEASUREMENTS AND MAIN RESULTS The main outcomes were: hospital mortality, length of stay, 6-month functional and disability domains (Glasgow Outcome Scale-Extended and Disability Rating Scale), and 1-year mortality. Secondary outcomes included: ICU length of stay, 3-month Glasgow Outcome Scale-Extended, 3-month Disability Rating Scale, 1-year Glasgow Outcome Scale-Extended, and 1-year Disability Rating Scale. We examined 373 subjects with moderate-severe traumatic brain injury. The mean (sd) Glasgow Coma Scale in the emergency department was 5.8 (3.2), with 280 subjects (75%) classified as severe traumatic brain injury (Glasgow Coma Scale 3-8). Among subjects with moderate-severe traumatic brain injury, 252 (68%) developed early multiple organ dysfunction syndrome. Subjects that developed early multiple organ dysfunction syndrome had a 75% decreased odds of a favorable outcome (Glasgow Outcome Scale-Extended 5-8) at 6 months (adjusted odds ratio, 0.25; 95% CI, 0.12-0.51) and increased disability (higher Disability Rating Scale score) at 6 months (adjusted mean difference, 2.04; 95% CI, 0.92-3.17). Subjects that developed early multiple organ dysfunction syndrome experienced an increased hospital length of stay (adjusted mean difference, 11.4 d; 95% CI, 7.1-15.8), with a nonsignificantly decreased survival to hospital discharge (odds ratio, 0.47; 95% CI, 0.18-1.2). CONCLUSIONS Early multiple organ dysfunction following moderate-severe traumatic brain injury is common and independently impacts multiple domains (mortality, function, and disability) over the year following injury. Further research is necessary to understand underlying mechanisms, improve early recognition, and optimize management strategies.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Nancy Temkin
- Department of Neurosurgery, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Fred K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC
- Department of Neurosurgery, Duke University, Durham, NC
- Department of Neurology, Duke University, Durham, NC
| | | | | | - John Sampson
- Department of Neurosurgery, Duke University, Durham, NC
| | - Michael L. James
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University, Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Raquel Bartz
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | | | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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30
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VanDusen KW, Li YJ, Cai V, Hall A, Hiles S, Thompson JW, Moseley MA, Cooter M, Acker L, Levy JH, Ghadimi K, Quiñones QJ, Devinney MJ, Chung S, Terrando N, Moretti EW, Browndyke JN, Mathew JP, Berger M. Cerebrospinal Fluid Proteome Changes in Older Non-Cardiac Surgical Patients with Postoperative Cognitive Dysfunction. J Alzheimers Dis 2021; 80:1281-1297. [PMID: 33682719 PMCID: PMC8052629 DOI: 10.3233/jad-201544] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Postoperative cognitive dysfunction (POCD), a syndrome of cognitive deficits occurring 1–12 months after surgery primarily in older patients, is associated with poor postoperative outcomes. POCD is hypothesized to result from neuroinflammation; however, the pathways involved remain unclear. Unbiased proteomic analyses have been used to identify neuroinflammatory pathways in multiple neurologic diseases and syndromes but have not yet been applied to POCD. Objective: To utilize unbiased mass spectrometry-based proteomics to identify potential neuroinflammatory pathways underlying POCD. Methods: Unbiased LC-MS/MS proteomics was performed on immunodepleted cerebrospinal fluid (CSF) samples obtained before, 24 hours after, and 6 weeks after major non-cardiac surgery in older adults who did (n = 8) or did not develop POCD (n = 6). Linear mixed models were used to select peptides and proteins with intensity differences for pathway analysis. Results: Mass spectrometry quantified 8,258 peptides from 1,222 proteins in > 50%of patient samples at all three time points. Twelve peptides from 11 proteins showed differences in expression over time between patients with versus without POCD (q < 0.05), including proteins previously implicated in neurodegenerative disease pathophysiology. Additionally, 283 peptides from 182 proteins were identified with trend-level differences (q < 0.25) in expression over time between these groups. Among these, pathway analysis revealed that 50 were from 17 proteins mapping to complement and coagulation pathways (q = 2.44*10–13). Conclusion: These data demonstrate the feasibility of performing unbiased mass spectrometry on perioperative CSF samples to identify pathways associated with POCD. Additionally, they provide hypothesis-generating evidence for CSF complement and coagulation pathway changes in patients with POCD.
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Affiliation(s)
- Keith W VanDusen
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.,Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Victor Cai
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Ashley Hall
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Sarah Hiles
- Duke Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
| | - J Will Thompson
- Duke Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
| | - M Arthur Moseley
- Duke Center for Genomic and Computational Biology, Duke University, Durham, NC, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Leah Acker
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Quintin J Quiñones
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Stacey Chung
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Eugene W Moretti
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Geriatric Behavioral Health, Duke University Medical Center, Durham, NC, USA.,Duke Institute for Brain Sciences, Duke University, Durham, NC, USA.,Center for Cognitive Neuroscience, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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31
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Kourouni I, Parekh K, Mathew JP. A Hydropneumothorax That Never Was! Chest 2021; 160:e305-e309. [PMID: 34488973 DOI: 10.1016/j.chest.2020.08.2142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/06/2020] [Accepted: 08/06/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ismini Kourouni
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Hospital Center, Case Western Reserve University, Cleveland, OH.
| | - Karishma Parekh
- Pulmonary Critical Care, Centennial Medical Group, Inc, Mercy Medical Center, Roseburg, OR
| | - Joseph P Mathew
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, NY
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32
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Toro C, Temkin N, Barber J, Manley G, Jain S, Ohnuma T, Komisarow J, Foreman B, Korley FK, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Goldstein BA, Markowitz AJ, Krishnamoorthy V. Association of Vasopressor Choice with Clinical and Functional Outcomes Following Moderate to Severe Traumatic Brain Injury: A TRACK-TBI Study. Neurocrit Care 2021; 36:180-191. [PMID: 34341913 DOI: 10.1007/s12028-021-01280-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early hypotension following moderate to severe traumatic brain injury (TBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors to support blood pressure following TBI; however, guidelines do not specify vasopressor type, resulting in variation in clinical practice. Minimal data are available to guide clinicians on optimal early vasopressor choice to support blood pressure following TBI. Therefore, we conducted a multicenter study to examine initial vasopressor choice for the support of blood pressure following TBI and its association with clinical and functional outcomes after injury. METHODS We conducted a retrospective cohort study of patients enrolled in the transforming research and clinical knowledge in traumatic brain injury (TRACK-TBI) study, an 18-center prospective cohort study of patients with TBI evaluated in participating level I trauma centers. We examined adults with moderate to severe TBI (defined as Glasgow Coma Scale score < 13) who were admitted to the intensive care unit and received an intravenous vasopressor within 48 h of admission. The primary exposure was initial vasopressor choice (phenylephrine versus norepinephrine), and the primary outcome was 6-month Glasgow Outcomes Scale Extended (GOSE), with the following secondary outcomes: length of hospital stay, length of intensive care unit stay, in-hospital mortality, new requirement for dialysis, and 6-month Disability Rating Scale. Regression analysis was used to assess differences in outcomes between patients exposed to norepinephrine versus phenylephrine, with propensity weighting to address selection bias due to the nonrandom allocation of the treatment groups and patient dropout. RESULTS The final study sample included 156 patients, of whom 79 (51%) received norepinephrine, 69 (44%) received phenylephrine, and 8 (5%) received an alternate drug as their initial vasopressor. 121 (77%) of patients were men, with a mean age of 43.1 years. Of patients receiving norepinephrine as their initial vasopressor, 32% had a favorable outcome (GOSE 5-8), whereas 40% of patients receiving phenylephrine as their initial vasopressor had a favorable outcome. Compared with phenylephrine, exposure to norepinephrine was not significantly associated with improved 6-month GOSE (weighted odds ratio 1.40, 95% confidence interval 0.66-2.96, p = 0.37) or any secondary outcome. CONCLUSIONS The majority of patients with moderate to severe TBI received either phenylephrine or norepinephrine as first-line agents for blood pressure support following brain injury. Initial choice of norepinephrine, compared with phenylephrine, was not associated with improved clinical or functional outcomes.
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Affiliation(s)
- Camilo Toro
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Nancy Temkin
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, CA, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Daniel T Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - John Sampson
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Michael L James
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA.
- Department of Anesthesiology, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
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Mathew JP, Skubas NJ, Shernan SK. Paul G. Barash, MD: In Memoriam. Anesth Analg 2021; 133:53-54. [PMID: 34127589 DOI: 10.1213/ane.0000000000005577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joseph P Mathew
- From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stanton K Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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34
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Ho KS, Narasimhan B, Kumar A, Flynn E, Salonia J, El-Hachem K, Mathew JP. Syndrome of inappropriate antidiuretic hormone as the initial presentation of COVID-19: A novel case report. Nefrologia 2021; 41:218-220. [PMID: 36165387 PMCID: PMC8215899 DOI: 10.1016/j.nefroe.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
- Kam Sing Ho
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Bharat Narasimhan
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aravinth Kumar
- Institute of Nephrology, Madras Medical College, Chennai, India
| | - Erin Flynn
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Salonia
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karim El-Hachem
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph P Mathew
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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35
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Terrando N, Park JJ, Devinney M, Chan C, Cooter M, Avasarala P, Mathew JP, Quinones QJ, Maddipati KR, Berger M. Immunomodulatory lipid mediator profiling of cerebrospinal fluid following surgery in older adults. Sci Rep 2021; 11:3047. [PMID: 33542362 PMCID: PMC7862598 DOI: 10.1038/s41598-021-82606-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
Arachidonic acid (AA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA) derived lipids play key roles in initiating and resolving inflammation. Neuro-inflammation is thought to play a causal role in perioperative neurocognitive disorders, yet the role of these lipids in the human central nervous system in such disorders is unclear. Here we used liquid chromatography–mass spectrometry to quantify AA, DHA, and EPA derived lipid levels in non-centrifuged cerebrospinal fluid (CSF), centrifuged CSF pellets, and centrifuged CSF supernatants of older adults obtained before, 24 h and 6 weeks after surgery. GAGE analysis was used to determine AA, DHA and EPA metabolite pathway changes over time. Lipid mediators derived from AA, DHA and EPA were detected in all sample types. Postoperative lipid mediator changes were not significant in non-centrifuged CSF (p > 0.05 for all three pathways). The AA metabolite pathway showed significant changes in centrifuged CSF pellets and supernatants from before to 24 h after surgery (p = 0.0000247, p = 0.0155 respectively), from before to 6 weeks after surgery (p = 0.0000497, p = 0.0155, respectively), and from 24 h to 6 weeks after surgery (p = 0.0000499, p = 0.00363, respectively). These findings indicate that AA, DHA, and EPA derived lipids are detectable in human CSF, and the AA metabolite pathway shows postoperative changes in centrifuged CSF pellets and supernatants.
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Affiliation(s)
| | - John J Park
- Duke University School of Medicine, Durham, NC, USA
| | | | | | - Mary Cooter
- Duke University Medical Center, Durham, NC, USA
| | | | | | | | | | - Miles Berger
- Duke University Medical Center, Durham, NC, USA.
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36
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Ganesh A, Qadri YJ, Boortz-Marx RL, Al-Khatib SM, Harpole DH, Katz JN, Koontz JI, Mathew JP, Ray ND, Sun AY, Tong BC, Ulloa L, Piccini JP, Fudim M. Stellate Ganglion Blockade: an Intervention for the Management of Ventricular Arrhythmias. Curr Hypertens Rep 2020; 22:100. [PMID: 33097982 DOI: 10.1007/s11906-020-01111-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To highlight the indications, procedural considerations, and data supporting the use of stellate ganglion blockade (SGB) for management of refractory ventricular arrhythmias. RECENT FINDINGS In patients with refractory ventricular arrhythmias, unilateral or bilateral SGB can reduce arrhythmia burden and defibrillation events for 24-72 h, allowing time for use of other therapies like catheter ablation, surgical sympathectomy, or heart transplantation. The efficacy of SGB appears to be consistent despite the type (monomorphic vs polymorphic) or etiology (ischemic vs non-ischemic cardiomyopathy) of the ventricular arrhythmia. Ultrasound-guided SGB is safe with low risk for complications, even when performed on anticoagulation. SGB is effective and safe and could be considered for patients with refractory ventricular arrhythmias.
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Affiliation(s)
- Arun Ganesh
- Duke Anesthesiology, Duke University, Durham, NC, USA
| | - Yawar J Qadri
- Emory Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - Sana M Al-Khatib
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - David H Harpole
- Cardiothoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jason N Katz
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Jason I Koontz
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.,Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke University, Durham, NC, USA
| | | | - Neil D Ray
- Duke Anesthesiology, Duke University, Durham, NC, USA
| | - Albert Y Sun
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Betty C Tong
- Cardiothoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Luis Ulloa
- Duke Anesthesiology, Duke University, Durham, NC, USA.,Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Jonathan P Piccini
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.,Duke Clinical Research Institute, Durham, NC, USA.,Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Marat Fudim
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
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Abstract
IMPORTANCE Synthetic cannabinoids (SCs), commonly known as K2, spice, or fake weed, are cheap, artificially manufactured recreational drugs that have emerged as a major public health threat in various regions of the US. OBJECTIVE To describe the clinical manifestations of SC intoxication. DESIGN, SETTING, AND PARTICIPANTS This case series assessed adults admitted to the intensive care unit from 2014 to 2016 with acute life-threatening complications of SC use. Data analysis was completed in October 2016. EXPOSURES Use of SCs such as K2, spice, or other synthetic versions of cannabinoids. MAIN OUTCOMES AND MEASURES Data collected included patient demographic data, medical history, presenting symptoms, physical findings, laboratory and imaging data, and intensive care unit and hospital course. RESULTS Thirty patients (mean age, 41 years [range, 21-59 years]; 24 men [80%]) with SC ingestion were admitted to the intensive care unit over a 2-year period. Thirteen patients were undomiciled. The majority had a history of polysubstance abuse, psychiatric illness, or personality disorder. The admission diagnoses were coma (10 patients [33%]), agitation (10 patients [33%]), and seizure (6 patients [20%]). Eighteen patients (60%) had acute respiratory failure, and tracheal intubation was required in 21 patients (70%) for either airway protection or acute respiratory failure. Rhabdomyolysis was noted in 8 patients (26%). A man developed transient cerebral edema with loss of gray-white differentiation but had complete recovery. A woman with history of asthma died of acute respiratory distress syndrome. All patients underwent routine toxicology testing, which was unrevealing in 16 cases and revealed coingestion in the remainder. Sixteen patients (53%) left the hospital against medical advice. CONCLUSIONS AND RELEVANCE Ingestion of SCs can lead to life-threatening complications, including severe toxic encephalopathy, acute respiratory failure, and death. Synthetic cannabinoids are undetectable in routine serum and urine toxicology testing but can be suspected on the basis of history and clinical presentation, which may include extreme agitation or coma. Frontline clinicians must be aware of the presentation and be vigilant in suspecting SC intoxication.
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Affiliation(s)
- Ismini Kourouni
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
- Now at Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Hospital Center, Case Western Reserve University, Cleveland, Ohio
| | - Bashar Mourad
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
- Now at Division of Pulmonary, Critical Care, and Sleep Medicine, New York University, New York, New York
| | - Hassan Khouli
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
- Now at Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Janet M. Shapiro
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
- Now at Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph P. Mathew
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
- Now at Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Morningside and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
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38
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Nobuhara CK, Bullock WM, Bunning T, Colin B, Cooter M, Devinney MJ, Ferrandino MN, Gadsden J, Garrigues G, Habib AS, Moretti E, Moul J, Ohlendorf B, Sandler A, Scheri R, Sharma B, Thomas JP, Young C, Mathew JP, Berger M. A protocol to reduce self-reported pain scores and adverse events following lumbar punctures in older adults. J Neurol 2020; 267:2002-2006. [PMID: 32198714 PMCID: PMC7336280 DOI: 10.1007/s00415-020-09797-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/10/2020] [Accepted: 03/15/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Lumbar punctures (LPs) are important for obtaining CSF in neurology studies but are associated with adverse events and feared by many patients. We determined adverse event rates and pain scores in patients prospectively enrolled in two cohort studies who underwent LPs using a standardized protocol and 25 g needle. METHODS Eight hundred and nine LPs performed in 262 patients age ≥ 60 years in the MADCO-PC and INTUIT studies were analyzed. Medical records were monitored for LP-related adverse events, and patients were queried about subjective complaints. We analyzed adverse event rates, including headaches and pain scores. RESULTS There were 22 adverse events among 809 LPs performed, a rate of 2.72% (95% CI 1.71-4.09%). Patient hospital stay did not increase due to adverse events. Four patients (0.49%) developed a post-lumbar puncture headache (PLPH). Twelve patients (1.48%) developed nausea, vasovagal responses, or headaches that did not meet PLPH criteria. Six patients (0.74%) reported lower back pain at the LP site not associated with muscular weakness or paresthesia. The median pain score was 1 [0, 3]; the mode was 0 out of 10. CONCLUSIONS The LP protocol described herein may reduce adverse event rates and improve patient comfort in future studies.
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Affiliation(s)
- Chloe K Nobuhara
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - W Michael Bullock
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Thomas Bunning
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Brian Colin
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Michael N Ferrandino
- Urology Division, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Gadsden
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Grant Garrigues
- Department of Orthopedics, Duke University Medical Center, Durham, NC, USA
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Eugene Moretti
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Judd Moul
- Urology Division, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian Ohlendorf
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Aaron Sandler
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Randall Scheri
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Bharat Sharma
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Jake P Thomas
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Christopher Young
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA.
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA.
- Center for Cognitive Neuroscience and the Duke Institute for Brain Sciences, Duke University, Durham, NC, USA.
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39
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Ho KS, Narasimhan B, Kumar A, Flynn E, Salonia J, El-Hachem K, Mathew JP. [Syndrome of inappropriate antidiuretic hormone as the initial presentation of COVID-19: A novel case report]. Nefrologia 2020; 41:219-220. [PMID: 32653253 PMCID: PMC7245262 DOI: 10.1016/j.nefro.2020.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 01/12/2023] Open
Affiliation(s)
- Kam Sing Ho
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Bharat Narasimhan
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aravinth Kumar
- Institute of Nephrology, Madras Medical College, Chennai, India
| | - Erin Flynn
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Salonia
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karim El-Hachem
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph P Mathew
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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40
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Berger M, Murdoch DM, Staats JS, Chan C, Thomas JP, Garrigues GE, Browndyke JN, Cooter M, Quinones QJ, Mathew JP, Weinhold KJ. Flow Cytometry Characterization of Cerebrospinal Fluid Monocytes in Patients With Postoperative Cognitive Dysfunction: A Pilot Study. Anesth Analg 2020; 129:e150-e154. [PMID: 31085945 DOI: 10.1213/ane.0000000000004179] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Animal models suggest postoperative cognitive dysfunction may be caused by brain monocyte influx. To study this in humans, we developed a flow cytometry panel to profile cerebrospinal fluid (CSF) samples collected before and after major noncardiac surgery in 5 patients ≥60 years of age who developed postoperative cognitive dysfunction and 5 matched controls who did not. We detected 12,654 ± 4895 cells/10 mL of CSF sample (mean ± SD). Patients who developed postoperative cognitive dysfunction showed an increased CSF monocyte/lymphocyte ratio and monocyte chemoattractant protein 1 receptor downregulation on CSF monocytes 24 hours after surgery. These pilot data demonstrate that CSF flow cytometry can be used to study mechanisms of postoperative neurocognitive dysfunction.
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Affiliation(s)
- Miles Berger
- From the Anesthesiology Department, Duke University Medical Center, Durham, North Carolina.,Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina.,Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, North Carolina
| | - David M Murdoch
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Janet S Staats
- Surgical Oncology Research Facility, Surgery Department, Duke University Medical Center, Durham, North Carolina
| | - Cliburn Chan
- Surgical Oncology Research Facility, Surgery Department, Duke University Medical Center, Durham, North Carolina
| | - Jake P Thomas
- From the Anesthesiology Department, Duke University Medical Center, Durham, North Carolina.,Trinity College, Duke University, Durham, North Carolina
| | - Grant E Garrigues
- Department of Orthopedics, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey N Browndyke
- Center for Cognitive Neuroscience, Duke Institute for Brain Sciences, Duke University, Durham, North Carolina.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter
- From the Anesthesiology Department, Duke University Medical Center, Durham, North Carolina
| | - Quintin J Quinones
- From the Anesthesiology Department, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- From the Anesthesiology Department, Duke University Medical Center, Durham, North Carolina
| | - Kent J Weinhold
- Surgical Oncology Research Facility, Surgery Department, Duke University Medical Center, Durham, North Carolina
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41
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Aronson S, Martin G, Gulur P, Lipkin ME, Lagoo-Deenadayalan SA, Mantyh CR, Attarian DE, Mathew JP, Kirk AD. Preoperative Optimization. Anesth Analg 2020; 130:808-810. [DOI: 10.1213/ane.0000000000004492] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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42
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Klinger RY, Cooter M, Bisanar T, Terrando N, Berger M, Podgoreanu MV, Stafford-Smith M, Newman MF, Mathew JP. Intravenous Lidocaine Does Not Improve Neurologic Outcomes after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology 2020; 130:958-970. [PMID: 30870159 DOI: 10.1097/aln.0000000000002668] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cognitive decline after cardiac surgery occurs frequently and persists in a significant proportion of patients. Preclinical studies and human trials suggest that intravenous lidocaine may confer protection in the setting of neurologic injury. It was hypothesized that lidocaine administration would reduce cognitive decline after cardiac surgery compared to placebo. METHODS After institutional review board approval, 478 patients undergoing cardiac surgery were enrolled into this multicenter, prospective, randomized, double-blinded, placebo-controlled, parallel group trial. Subjects were randomized to lidocaine 1 mg/kg bolus after the induction of anesthesia followed by a continuous infusion (48 μg · kg · min for the first hour, 24 μg · kg · min for the second hour, and 10 μg · kg · min for the next 46 h) or saline with identical volume and rate changes to preserve blinding. Cognitive function was assessed preoperatively and at 6 weeks and 1 yr postoperatively using a standard neurocognitive test battery. The primary outcome was change in cognitive function between baseline and 6 weeks postoperatively, adjusting for age, years of education, baseline cognition, race, and procedure type. RESULTS Among the 420 allocated subjects who returned for 6-week follow-up (lidocaine: N = 211; placebo: N = 209), there was no difference in the continuous cognitive score change (adjusted mean difference [95% CI], 0.02 (-0.05, 0.08); P = 0.626). Cognitive deficit (greater than 1 SD decline in at least one cognitive domain) at 6 weeks occurred in 41% (87 of 211) in the lidocaine group versus 40% (83 of 209) in the placebo group (adjusted odds ratio [95% CI], 0.94 [0.63, 1.41]; P = 0.766). There were no differences in any quality of life outcomes between treatment groups. At the 1-yr follow-up, there continued to be no difference in cognitive score change, cognitive deficit, or quality of life. CONCLUSIONS Intravenous lidocaine administered during and after cardiac surgery did not reduce postoperative cognitive decline at 6 weeks.
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Affiliation(s)
- Rebecca Y Klinger
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina (R.Y.K., M.C., T.B., N.T., M.B., M.V.P., M.S.-S., J.P.M.) the Department of Anesthesiology, University of Kentucky School of Medicine, Lexington, Kentucky (M.F.N.)
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Aronson S, Murray S, Martin G, Blitz J, Crittenden T, Lipkin ME, Mantyh CR, Lagoo-Deenadayalan SA, Flanagan EM, Attarian DE, Mathew JP, Kirk AD, Caldwell DM, Williams DGA, Ulrich K, Flintom C. Roadmap for Transforming Preoperative Assessment to Preoperative Optimization. Anesth Analg 2020; 130:811-819. [DOI: 10.1213/ane.0000000000004571] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Karhausen J, Choi HW, Maddipati KR, Mathew JP, Ma Q, Boulaftali Y, Lee RH, Bergmeier W, Abraham SN. Platelets trigger perivascular mast cell degranulation to cause inflammatory responses and tissue injury. Sci Adv 2020; 6:eaay6314. [PMID: 32206714 PMCID: PMC7080499 DOI: 10.1126/sciadv.aay6314] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 12/20/2019] [Indexed: 06/08/2023]
Abstract
Platelet responses have been associated with end-organ injury and mortality following complex insults such as cardiac surgery, but how platelets contribute to these pathologies remains unclear. Our studies originated from the observation of microvascular platelet retention in a rat cardiac surgery model. Ensuing work supported the proximity of platelet aggregates with perivascular mast cells (MCs) and demonstrated that platelet activation triggered systemic MC activation. We then identified platelet activating factor (PAF) as the platelet-derived mediator stimulating MCs and, using chimeric animals with platelets defective in PAF generation or MCs lacking PAF receptor, defined the role of this platelet-MC interaction for vascular leakage, shock, and tissue inflammation. In application of these findings, we demonstrated that inhibition of platelet activation in modeled cardiac surgery blunted MC-dependent inflammation and tissue injury. Together, our work identifies a previously undefined mechanism of inflammatory augmentation, in which platelets trigger local and systemic responses through activation of perivascular MCs.
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Affiliation(s)
- Jörn Karhausen
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Hae Woong Choi
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
- Department of Life Sciences, Korea University, Seoul 02841, South Korea
| | | | - Joseph P. Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Qing Ma
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Yacine Boulaftali
- Université Paris Diderot, Sorbonne Paris Cité, Laboratory of Vascular Translational Science, U1148 Institute National de la Santé et de la Recherche Medicale (INSERM), Paris, France
| | - Robert Hugh Lee
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC, USA
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Blood Research, University of North Carolina, Chapel Hill, NC, USA
| | - Soman N. Abraham
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
- Department of Immunology, Duke University Medical Center, Durham, NC, USA
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
- Program in Emerging Infectious Diseases, Duke-National University of Singapore, Singapore, Singapore
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Fudim M, Qadri YJ, Waldron NH, Boortz-Marx RL, Ganesh A, Patel CB, Podgoreanu MV, Sun AY, Milano CA, Tong BC, Harpole DH, Mathew JP, Piccini JP. Stellate Ganglion Blockade for the Treatment of Refractory Ventricular Arrhythmias. JACC Clin Electrophysiol 2020; 6:562-571. [PMID: 32439042 DOI: 10.1016/j.jacep.2019.12.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/13/2019] [Accepted: 12/27/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to describe our institutional experience with establishing a neurocardiology service in an attempt to provide autonomic modulation as a treatment for ventricular arrhythmias (VAs). BACKGROUND Treatment-refractory VAs are commonly driven and exacerbated by heightened sympathetic tone. METHODS Among patients referred to the neurocardiology service (August 2016 to December 2018), we performed ultrasound-based, bilateral, temporary stellate ganglion blockade (SGB) in 20 consecutive patients. We analyzed outcomes of interest including sustained VA or VA requiring defibrillation in the 24 and 48 h before and 24 and 48 h after SGB. RESULTS The majority of patients were men (n = 19, 95%), with a mean age of 58 ± 14 years. At the time of SGB, 10 (50%) were on inotropic support and 9 (45%) were on mechanical circulatory support. Besides 1 case of hoarseness, there were no apparent procedural complications. SGB was associated with a reduction in the number of VA episodes from the 24 h before (median 5.5 [interquartile range (IQR): 2.0 to 15.8]) to 24 h after SGB (median 0 [IQR: 0 to 3.8]) (p < 0.001). The number of defibrillation events decreased from 2.5 (IQR: 0 to 10.3) to 0 (IQR: 0 to 2.5) (p = 0.002). Similar findings were observed over the 48-h period before and after the SGB. Overall, 9 of 20 (45%) patients had a complete response with no recurrence of ventricular tachycardia (VT) or ventricular fibrillation (VF) for 48 h after SGB. Four (20%) patients had no recurrent VT or VF following SGB through discharge. Similar response rates were observed in those with ischemic (median 6 [IQR: 1.8 to 18.8] to 0.5 [IQR: 0 to 5.3] events; p = 0.031) and nonischemic (median 3.5 [IQR: 1.8 to 6.8] to 0 [IQR: 0 to 1.3] events; p = 0.012) cardiomyopathy. CONCLUSIONS Minimally invasive, ultrasound-guided bilateral SGB appears safe and provides substantial reduction in VA burden with approximately 1 in 2 patients exhibiting complete suppression of VT or VF for 48 h.
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Affiliation(s)
- Marat Fudim
- Duke Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Yawar J Qadri
- Duke Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan H Waldron
- Duke Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Richard L Boortz-Marx
- Duke Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Arun Ganesh
- Duke Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chetan B Patel
- Duke Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Mihai V Podgoreanu
- Duke Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Albert Y Sun
- Duke Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Betty C Tong
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - David H Harpole
- Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke University, Durham, North Carolina, USA
| | - Joseph P Mathew
- Duke Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Duke Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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Klinger RY, Mathew JP. Intravenous Lidocaine and Postoperative Cognition: Reply. Anesthesiology 2020; 132:398-399. [PMID: 31939860 DOI: 10.1097/aln.0000000000003040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cherry AD, Hauck JN, Andrew BY, Li YJ, Privratsky JR, Kartha LD, Nicoara A, Thompson A, Mathew JP, Stafford-Smith M. Intraoperative renal resistive index threshold as an acute kidney injury biomarker. J Clin Anesth 2019; 61:109626. [PMID: 31699495 DOI: 10.1016/j.jclinane.2019.109626] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/13/2019] [Accepted: 09/20/2019] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVE The lag in creatinine-mediated diagnosis of cardiac surgery-associated acute kidney injury (AKI) may be impeding the development of renoprotection therapies. Postoperative renal resistive index (RRI) measured by transabdominal Doppler ultrasound is a promising early AKI biomarker. RRI measured intraoperatively by transesophageal echocardiography (TEE) is available even earlier but is less evaluated. Therefore, we conducted an assessment of intraoperative RRI as an AKI biomarker using previously reported post-renal insult thresholds. DESIGN Retrospective convenience sample. SETTING Intraoperative. PATIENTS 180 adult cardiac surgical patients between July 2013 and July 2014. INTERVENTION None. MEASUREMENTS Pre- and post-cardiopulmonary bypass (CPB) RRI thresholds, measured using intraoperative TEE, exceeding 0.74 or 0.79 were used to evaluate for an association with KDIGO AKI risk using the Chi-square test. Other consensus AKI criteria (AKIN, RIFLE) were similarly evaluated. Additional t-test analyses examined the relationship of pre- and pre-to-post (delta) CPB RRI with AKI. MAIN RESULTS Post-CPB RRI for 99 patients included 36 and 23 with values exceeding 0.74 and 0.79, respectively. Analyses confirmed associations of both RRI thresholds with all consensus AKI definitions (0.74; KDIGO: p = 0.05, AKIN: p = 0.03, RIFLE: p = 0.03, 0.79; KDIGO: p = 0.002, AKIN: p = 0.001, RIFLE: p = 0.004). In contrast, pre-CPB and pre-to post-CPB RRI were not associated with AKI. CONCLUSIONS RRI obtained intraoperatively in cardiac surgery patients, assessed using previously reported thresholds, is highly associated with AKI and warrants further evaluation as a promising "earliest" AKI biomarker. These significant findings suggest that RRI assessment should be included in the standard intraoperative TEE exam.
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Affiliation(s)
- Anne D Cherry
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Jennifer N Hauck
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Benjamin Y Andrew
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Yi-Ju Li
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Jamie R Privratsky
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Lakshmi D Kartha
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA; MetroHealth Hospital, Dept. of Internal Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Alina Nicoara
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Annemarie Thompson
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Joseph P Mathew
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Mark Stafford-Smith
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
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Farkas A, Sassine J, Mathew JP, Stavropoulos C, Stern R, Mckinley G. Outcomes associated with the use of a revised risk assessment strategy to predict antibiotic resistance in community-onset pneumonia: a stewardship perspective. J Antimicrob Chemother 2019; 73:2555-2558. [PMID: 29897465 DOI: 10.1093/jac/dky202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/01/2018] [Indexed: 12/21/2022] Open
Abstract
Objectives There is growing evidence that patients with community-onset pneumonia and recent healthcare exposure are not at equally high risk of infection with MDR organisms. An individualized approach is necessary with regard to risk assessment and choice of antibiotics. Methods We reviewed the records of 102 patients admitted for community-onset pneumonia, before and after the implementation of a revised risk assessment programme for MDR organisms using the drug resistance in pneumonia (DRIP) score. The primary aim of the study was to identify the effects of this intervention on antibiotic days of therapy (DOT), and secondary outcomes included all-cause readmissions and time to clinical improvement. Statistical analysis was performed using generalized linear regression and Cox hazards models. Results Implementation of the programme resulted in a decrease in anti-MRSA (-1.44 DOT, P = 0.007) and anti-pseudomonal (-2.03 DOT, P < 0.001) antibiotic utilization, but was not associated with a significant difference in the odds of readmissions (OR 0.64, 95% CI 0.16-2.57) or in time to clinical improvement (HR 1.19, 95% CI 0.62-2.21). Conclusions An individualized MDR organism risk assessment strategy using a clinical prediction score for community-onset pneumonia can decrease the utilization of broad-spectrum antibiotics without an increase in adverse outcomes.
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Affiliation(s)
- Andras Farkas
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, USA
| | - Joseph Sassine
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
| | - Joseph P Mathew
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
| | - Christine Stavropoulos
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA.,Division of Infectious Diseases, Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
| | - Ron Stern
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, USA
| | - George Mckinley
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA.,Division of Infectious Diseases, Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
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Waldron NH, Fudim M, Mathew JP, Piccini JP. Neuromodulation for the Treatment of Heart Rhythm Disorders. JACC Basic Transl Sci 2019; 4:546-562. [PMID: 31468010 PMCID: PMC6712352 DOI: 10.1016/j.jacbts.2019.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 12/13/2022]
Abstract
Derangement of autonomic nervous signaling is an important contributor to cardiac arrhythmogenesis. Modulation of autonomic nervous signaling holds significant promise for the prevention and treatment of cardiac arrhythmias. Further clinical investigation is necessary to establish the efficacy and safety of autonomic modulatory therapies in reducing cardiac arrhythmias.
There is an increasing recognition of the importance of interactions between the heart and the autonomic nervous system in the pathophysiology of arrhythmias. These interactions play a role in both the initiation and maintenance of arrhythmias and are important in both atrial and ventricular arrhythmia. Given the importance of the autonomic nervous system in the pathophysiology of arrhythmias, there has been notable effort in the field to improve existing therapies and pioneer additional interventions directed at cardiac-autonomic targets. The interventions are targeted to multiple and different anatomic targets across the neurocardiac axis. The purpose of this review is to provide an overview of the rationale for neuromodulation in the treatment of arrhythmias and to review the specific treatments under evaluation and development for the treatment of both atrial fibrillation and ventricular arrhythmias.
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Key Words
- AERP, atrial effective refractory period
- AF, atrial fibrillation
- AGP, autonomic ganglionic plexus
- ANS, autonomic nervous system
- CABG, coronary artery bypass grafting
- HRV, heart rate variability
- ICD, implantable cardioverter-defibrillator
- LLVNS, low-level vagal nerve stimulation
- OSA, obstructive sleep apnea
- POAF, post-operative atrial fibrillation
- PVI, pulmonary vein isolation
- RDN, renal denervation
- SCS, spinal cord stimulation
- SGB, stellate ganglion blockade
- SNS, sympathetic nervous system
- VF, ventricular fibrillation
- VNS, vagal nerve stimulation
- VT, ventricular tachycardia
- arrhythmia
- atrial fibrillation
- autonomic nervous system
- ganglionated plexi
- neuromodulation
- ventricular arrhythmias
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Affiliation(s)
- Nathan H Waldron
- Department of Anesthesia, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina.,Electrophysiology Section, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesia, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina.,Electrophysiology Section, Duke University Medical Center, Durham, North Carolina
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50
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Iribarne A, Pan S, McCullough JN, Mathew JP, Hung J, Zeng X, Voisine P, O'Gara PT, Sledz NM, Gelijns AC, Taddei-Peters WC, Messé SR, Moskowitz AJ, Thourani VH, Argenziano M, Groh MA, Giustino G, Overbey JR, DiMaio JM, Smith PK. Impact of Aortic Atherosclerosis Burden on Outcomes of Surgical Aortic Valve Replacement. Ann Thorac Surg 2019; 109:465-471. [PMID: 31400333 DOI: 10.1016/j.athoracsur.2019.06.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 06/04/2019] [Accepted: 06/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Epiaortic ultrasound detects and localizes ascending aortic atherosclerosis. In this analysis we investigated the association between epiaortic ultrasound-based atheroma grade during surgical aortic valve replacement (SAVR) and perioperative adverse outcomes. METHODS SAVR patients in a randomized trial of 2 embolic protection devices underwent a protocol-defined 5-view epiaortic ultrasound read at a core laboratory. Aortic atherosclerosis was quantified with the Katz atheroma grade, and patients were categorized as mild (grade I-II) or moderate/severe (grade III-V). Multivariable logistic regression was used to estimate associations between atheroma grade and adverse outcomes, including death, clinically apparent stroke, cerebral infarction on diffusion-weighted magnetic resonance imaging, delirium, and acute kidney injury (AKI) by 7 and 30 days. RESULTS Precannulation epiaortic ultrasound data were available for 326 of 383 randomized patients (85.1%). Of these, 106 (32.5%) had moderate/severe Katz atheroma grade at any segment of the ascending aorta. Although differences in the composite of death, stroke, or cerebral infarction on diffusion-weighted magnetic resonance imaging by 7 days were not statistically significant, moderate/severe atheroma grade was associated with a greater risk of AKI by 7 days (adjusted odds ratio, 2.63; 95% confidence interval, 1.24-5.58; P = .01). At 30 days, patients with moderate/severe atheroma grade had a greater risk of death, stroke, or AKI (adjusted odds ratio, 1.97; 95% confidence interval, 1.04-3.71; P = .04). CONCLUSIONS Moderate/severe aortic atherosclerosis was associated with an increased risk of adverse events after SAVR. Epiaortic ultrasound may serve as a useful adjunct for identifying patients who may benefit from strategies to reduce atheroembolic complications during SAVR.
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Affiliation(s)
- Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Stephanie Pan
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jock N McCullough
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joseph P Mathew
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Xin Zeng
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Pierre Voisine
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec, Québec, Canada
| | - Patrick T O'Gara
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nancy M Sledz
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annetine C Gelijns
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Steven R Messé
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan J Moskowitz
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vinod H Thourani
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Washington, DC
| | - Michael Argenziano
- Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Mark A Groh
- Cardiovascular and Thoracic Surgery, Mission Health and Hospitals, Asheville, North Carolina
| | - Gennaro Giustino
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jessica R Overbey
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - J Michael DiMaio
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Baylor Scott & White Health, Plano, Texas
| | - Peter K Smith
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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