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McEwen CC, Amir T, Qiu Y, Young J, Kennedy K, Grocott HP, Kessani H, Mazer D, Brudney S, Kavosh M, Jacobsohn E, Vedel A, Wang E, Whitlock RP, Belley-Coté EP, Spence J. Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:374-386. [PMID: 35014001 DOI: 10.1007/s12630-021-02171-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 07/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION PROSPERO (CRD42020177376); registered: 5 July 2020.
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Affiliation(s)
- Charlotte C McEwen
- Department of Surgery (Cardiac Surgery), McMaster University, Hamilton, ON, Canada
| | - Takhliq Amir
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Kevin Kennedy
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hilary P Grocott
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hesham Kessani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Scott Brudney
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Eric Jacobsohn
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Vedel
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eugene Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.,Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Coté
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada.,Departments of Medicine (Cardiology and Critical Care) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. .,Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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Abstract
Dexmedetomidine is currently used in the US in the treatment of alcohol withdrawal syndrome (AWS) in the intensive care unit (ICU) setting, although data to support this practice are limited. Dexmedetomidine targets the noradrenergic system, an important but frequently overlooked secondary mechanism in the development of AWS, and, in doing so, may reduce the need for excessive benzodiazepine use which can increase the risk of γ-aminobutyric acid (GABA)-mediated deliriogenesis and respiratory depression. The purpose of this narrative review is to evaluate available literature reporting on the safety and efficacy of dexmedetomidine for AWS in the ICU setting. An English-language MEDLINE search (1966 to July 2013) was performed to identify articles evaluating the efficacy and safety of dexmedetomidine for AWS. Case series, case reports and controlled trials were evaluated for topic relevance and clinical applicability. Reference lists of articles retrieved through this search were reviewed to identify any relevant publications. Studies focusing on the safety and efficacy of dexmedetomidine for AWS in humans were selected. Studies were included if they were published as full articles; abstracts alone were not included in this review. Eight published case studies and case series were identified. Based on a limited body of evidence, dexmedetomidine shows promise as a potentially safe and possibly effective adjuvant treatment for AWS in the ICU. Prospective, well-controlled studies are needed to confirm the safety and efficacy of the use of dexmedetomidine in AWS.
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Affiliation(s)
- Andrew J Muzyk
- Department of Pharmacy Practice, Campbell University School of Pharmacy and Health Sciences, P.O. Box 3089, Buies Creek, NC, 27710, USA,
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Gosling P, Brudney S, McGrath L, Riseboro S, Manji M. Mortality prediction at admission to intensive care: a comparison of microalbuminuria with acute physiology scores after 24 hours. Crit Care Med 2003; 31:98-103. [PMID: 12545001 DOI: 10.1097/00003246-200301000-00016] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare low level albumin excretion (microalbuminuria), a marker of systemic capillary permeability, with mortality, Acute Physiologic And Chronic Health Evaluation (APACHE II) score, the Simplified Acute Physiologic (SAP II) score, and their derived mortality probabilities in patients admitted to a general intensive care unit. DESIGN Prospective observational study. SETTING A 14-bed intensive care unit in a university teaching hospital. PATIENTS A total of 140 consecutive patients (59 surgical, 48 medical, 22 trauma, and 11 burns). INTERVENTIONS Urine collection within 15 mins of intensive care unit admission for assessment of microalbuminuria. MEASUREMENTS AND MAIN RESULTS Microalbuminuria, expressed as the albumin-creatinine ratio (ACR: normal, <2.3 mg/mmol), was compared with mortality, APACHE II and SAP II scores and their derived mortality probabilities after 24 hrs, intensive care unit stay, and markers of organ function and inflammation. Median (95% confidence interval) ACR at admission for survivors (n = 115) and nonsurvivors (n = 25) were 4.2 (3.6-6.5) and 17.8 (8.0-40.8) mg/mmol, respectively (p =.0002 Mann Whitney). For 92 surgical, trauma, and burn patients, of whom 81 survived, ACR of >5.9 mg/mmol gave a sensitivity for death of 100%, specificity of 59%, positive predictive value of 25%, and negative predictive value of 100%. Mortality probability receiver operator characteristic curve areas for ACR, APACHE II, and SAP II were 0.843 (p <.0001), 0.793 (p =.0004), and 0.770 (p =.0017), respectively. ACR was associated with intensive care unit stay (p =.0021) and highest serum C-reactive protein (p =.0002), serum creatinine (p <.0001), and bilirubin (p =.0009). For 48 medical patients, of whom 34 survived, admission ACRs for survivors and nonsurvivors were 8.3 (5.7-10.8) and 10.7 (4.1-48.2) mg/mmol, respectively (p =.32). SAP II, but not APACHE II, score was significantly higher for nonsurvivors. CONCLUSIONS For surgical, trauma, and burn patients, but not medical patients, microalbuminuria within 15 mins of intensive care unit admission predicted death as well as APACHE II and SAP II scores calculated after 24 hrs, and it shows promise as a predictor of outcome.
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Affiliation(s)
- Peter Gosling
- Department of Clinical Biochemistry, University Hospital Birmingham NHS Trust, UK.
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