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Zipfel J, Bantle SJ, Magunia H, Schlensak C, Neunhoeffer F, Schuhmann MU, Lescan M. Non-Invasive Cerebral Autoregulation Monitoring During Awake Carotid Endarterectomy Identifies Clinically Significant Brain Ischaemia. Eur J Vasc Endovasc Surg 2020; 60:647-654. [DOI: 10.1016/j.ejvs.2020.07.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 07/03/2020] [Accepted: 07/23/2020] [Indexed: 11/16/2022]
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Montgomery D, Brown C, Hogue CW, Brady K, Nakano M, Nomura Y, Antunes A, Addison PS. Real-Time Intraoperative Determination and Reporting of Cerebral Autoregulation State Using Near-Infrared Spectroscopy. Anesth Analg 2020; 131:1520-1528. [PMID: 33079875 PMCID: PMC7319873 DOI: 10.1213/ane.0000000000004614] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cerebral blood flow (CBF) is maintained over a range of blood pressures through cerebral autoregulation (CA). Blood pressure outside the range of CA, or impaired autoregulation, is associated with adverse patient outcomes. Regional oxygen saturation (rSO2) derived from near-infrared spectroscopy (NIRS) can be used as a surrogate CBF for determining CA, but existing methods require a long period of time to calculate CA metrics. We have developed a novel method to determine CA using cotrending of mean arterial pressure (MAP) with rSO2that aims to provide an indication of CA state within 1 minute. We sought to determine the performance of the cotrending method by comparing its CA metrics to data derived from transcranial Doppler (TCD) methods. METHODS Retrospective data collected from 69 patients undergoing cardiac surgery with cardiopulmonary bypass were used to develop a reference lower limit of CA. TCD-MAP data were plotted to determine the reference lower limit of CA. The investigated method to evaluate CA state is based on the assessment of the instantaneous cotrending relationship between MAP and rSO2 signals. The lower limit of autoregulation (LLA) from the cotrending method was compared to the manual reference derived from TCD. Reliability of the cotrending method was assessed as uptime (defined as the percentage of time that the state of autoregulation could be measured) and time to first post. RESULTS The proposed method demonstrated minimal mean bias (0.22 mmHg) when compared to the TCD reference. The corresponding limits of agreement were found to be 10.79 mmHg (95% confidence interval [CI], 10.09-11.49) and -10.35 mmHg (95% CI, -9.65 to -11.05). Mean uptime was 99.40% (95% CI, 99.34-99.46) and the mean time to first post was 63 seconds (95% CI, 58-71). CONCLUSIONS The reported cotrending method rapidly provides metrics associated with CA state for patients undergoing cardiac surgery. A major strength of the proposed method is its near real-time feedback on patient CA state, thus allowing for prompt corrective action to be taken by the clinician.
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Affiliation(s)
- Dean Montgomery
- From the Medtronic Respiratory & Monitoring Solutions, Edinburgh, United Kingdom
| | - Charles Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles W. Hogue
- Department of Anesthesiology, Northwestern University Feinberg, School of Medicine, Chicago, Illinois
| | - Ken Brady
- Department of Anesthesiology, Northwestern University Feinberg, School of Medicine, Chicago, Illinois
- Cardiac Anesthesia, Ann & Robert Lurie Children’s Hospital, Chicago, Illinois
| | - Mitsunori Nakano
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yohei Nomura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Andre Antunes
- From the Medtronic Respiratory & Monitoring Solutions, Edinburgh, United Kingdom
| | - Paul S. Addison
- From the Medtronic Respiratory & Monitoring Solutions, Edinburgh, United Kingdom
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Perioperative neurocognitive dysfunction: thinking from the gut? Aging (Albany NY) 2020; 12:15797-15817. [PMID: 32805716 PMCID: PMC7467368 DOI: 10.18632/aging.103738] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
Abstract
With the aging of the world population, and improvements in medical and health technologies, there are increasing numbers of elderly patients undergoing anaesthesia and surgery. Perioperative neurocognitive dysfunction has gradually attracted increasing attention from academics. Very recently, 6 well-known journals jointly recommended that the term perioperative neurocognitive dysfunction (defined according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition) should be adopted to improve the quality and consistency of academic communications. Perioperative neurocognitive dysfunction currently includes preoperatively diagnosed cognitive decline, postoperative delirium, delayed neurocognitive recovery, and postoperative cognitive dysfunction. Increasing evidence shows that the gut microbiota plays a pivotal role in neuropsychiatric diseases, and in central nervous system functions via the microbiota-gut-brain axis. We recently reported that abnormalities in the composition of the gut microbiota might underlie the mechanisms of postoperative cognitive dysfunction and postoperative delirium, suggesting a critical role for the gut microbiota in perioperative neurocognitive dysfunction. This article therefore reviewed recent findings on the linkage between the gut microbiota and the underlying mechanisms of perioperative neurocognitive dysfunction.
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Ferlini L, Su F, Creteur J, Taccone FS, Gaspard N. Cerebral autoregulation and neurovascular coupling are progressively impaired during septic shock: an experimental study. Intensive Care Med Exp 2020; 8:44. [PMID: 32797301 PMCID: PMC7426896 DOI: 10.1186/s40635-020-00332-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
Background Alteration of the mechanisms of cerebral blood flow (CBF) regulation might contribute to the pathophysiology of sepsis-associated encephalopathy (SAE). However, previous clinical studies on dynamic cerebral autoregulation (dCA) in sepsis had several cofounders. Furthermore, little is known on the potential impairment of neurovascular coupling (NVC) in sepsis. The aim of our study was to determine the presence and time course of dCA and NVC alterations in a clinically relevant animal model and their potential impact on the development of SAE. Methods Thirty-six anesthetized, mechanically ventilated female sheep were randomized to sham procedures (sham, n = 15), sepsis (n = 14), or septic shock (n = 7). Blood pressure, CBF, and electrocorticography were continuously recorded. Pearson’s correlation coefficient Lxa and transfer function analysis were used to estimate dCA. NVC was assessed by the analysis of CBF variations induced by cortical gamma activity (Eγ) peaks and by the magnitude-squared coherence (MSC) between the spontaneous fluctuations of CBF and Eγ. Cortical function was estimated by the alpha-delta ratio. Wilcoxon signed rank and rank sum tests, Friedman tests, and RMANOVA test were used as appropriate. Results Sepsis and sham animals did not differ neither in dCA nor in NVC parameters. A significant impairment of dCA occurred only after septic shock (Lxa, p = 0.03, TFA gain p = 0.03, phase p = 0.01). Similarly, NVC was altered during septic shock, as indicated by a lower MSC in the frequency band 0.03–0.06 Hz (p < 0.001). dCA and NVC impairments were associated with cortical dysfunction (reduction in the alpha-delta ratio (p = 0.03)). Conclusions A progressive loss of dCA and NVC occurs during septic shock and is associated with cortical dysfunction. These findings indicate that the alteration of mechanisms controlling cortical perfusion plays a late role in the pathophysiology of SAE and suggest that alterations of CBF regulation mechanisms in less severe phases of sepsis reported in clinical studies might be due to patients’ comorbidities or other confounders. Furthermore, a mean arterial pressure targeting therapy aiming to optimize dCA might not be sufficient to prevent neuronal dysfunction in sepsis since it would not improve NVC.
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Affiliation(s)
- Lorenzo Ferlini
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Bruxelles, Belgium.
| | - Fuhong Su
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Bruxelles, Belgium
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Thiele RH, Shaw AD, Bartels K, Brown CH, Grocott H, Heringlake M, Gan TJ, Miller TE, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Cerebral Near-Infrared Spectroscopy. Anesth Analg 2020; 131:1444-1455. [DOI: 10.1213/ane.0000000000005081] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Roberts ML, Lin HM, Tinuoye E, Cohen E, Flores RM, Fischer GW, Weiner MM. The Association of Cerebral Desaturation During One-Lung Ventilation and Postoperative Recovery: A Prospective Observational Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:542-550. [PMID: 32861541 DOI: 10.1053/j.jvca.2020.07.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study was designed to investigate whether cerebral oxygen desaturations during thoracic surgery are predictive of patients' quality of recovery. As a secondary aim, the authors investigated the relationship among cerebral desaturations and postoperative delirium and hospital length of stay. DESIGN This study was a prospective observational cohort study. SETTING A single tertiary-care medical center from September 2012 through March 2014. PATIENTS Adult patients scheduled for elective pulmonary surgery requiring one-lung ventilation. INTERVENTIONS All patients were monitored with the ForeSight cerebral oximeter. MEASUREMENTS AND MAIN RESULTS The primary assessment tool was the Postoperative Quality of Recovery Scale. Delirium was assessed using the Confusion Assessment Method. Of the 117 patients analyzed in the study, 60 of the patients desaturated below a cerebral oximetry level of 65% for a minimum of 3 minutes (51.3%). Patients who desaturated were significantly less likely to have cognitive recovery in the immediate postoperative period (p = 0.012), which did not persist in the postoperative period beyond day 0. Patients who desaturated also were more likely to have delirium (p = 0.048, odds ratio 2.81 [95% CI 1.01-7.79]) and longer length of stay (relative duration 1.35, 95% CI 1.05-1.73; p = 0.020). CONCLUSIONS Intraoperative cerebral oxygen desaturations, frequent during one-lung ventilation, are associated significantly with worse early cognitive recovery, high risk of postoperative delirium, and prolonged length of stay. Large interventional studies on cerebral oximetry in the thoracic operating room are warranted.
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Affiliation(s)
- Monique L Roberts
- Department of Anesthesia and Critical Care, Hospital of University of Pennsylvania, Philadelphia, PA.
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Edmond Cohen
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Raja M Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Brown CH, Neufeld KJ, Tian J, Probert J, LaFlam A, Max L, Hori D, Nomura Y, Mandal K, Brady K, Hogue CW, Shah A, Zehr K, Cameron D, Conte J, Bienvenu OJ, Gottesman R, Yamaguchi A, Kraut M. Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients: A Nested Randomized Clinical Trial. JAMA Surg 2020; 154:819-826. [PMID: 31116358 DOI: 10.1001/jamasurg.2019.1163] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04). Conclusions and Relevance The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. Trial Registration ClinicalTrials.gov identifier: NCT00981474.
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karin J Neufeld
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Andrew LaFlam
- Medical Student, School of Medicine, Tufts University, Medford Massachusetts
| | - Laura Max
- Department of Radiology, Massachusetts General Hospital, Boston
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yohei Nomura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - Ken Brady
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles W Hogue
- Bluhm Cardiovascular Institute, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ashish Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenton Zehr
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Duke Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - John Conte
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - O Joseph Bienvenu
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Michael Kraut
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Peng A, Chua MJ, Chan B, Jaeger M, Aneman A, Chuan A. Tissue oxygenation indices of cerebrovascular autoregulation in healthy volunteers: a comparison of two NIRS devices. Neurol Res 2020; 42:897-903. [PMID: 32643591 DOI: 10.1080/01616412.2020.1790869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Correlation coefficients between blood pressure and cerebral oxygen saturation measured using near-infrared spectrometry may be used to derive the tissue oximetry index of cerebral autoregulation. Cerebral oxygen saturations demonstrate poor agreement between near-infrared spectrometers however it is unclear if measurements of autoregulation are similarly specific to the equipment used. METHODS Cerebral oxygen saturation was monitored bilaterally in 74 healthy volunteers using both the FORE-SIGHT and EQUANOX monitors in random order. The tissue oximetry index was calculated during changes in blood pressure induced by isometric handgrip manoeuvres and the mean bias and limits of agreement were calculated. RESULTS Tissue oximetry index measured by FORE-SIGHT was higher than EQUANOX (0.21 ± 0.16 versus 0.15 ± 0.17, P < 0.001) and limits of agreement were -0.24 to 0.36. Baseline cerebral oxygen saturation by FORE-SIGHT was lower than EQUANOX by 1.48% (CI95% 0.63-2.33) and limits of agreement ranged from -11.8% to 8.8%. CONCLUSIONS The substantial bias and wide limits of agreement for the tissue oximetry index as a measure of cerebral autoregulation indicate that values must be treated as specific to models of near-infrared spectrometers.
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Affiliation(s)
- Alexander Peng
- Department of Intensive Care, Blacktown Hospital , Sydney, Australia
| | - Matthew J Chua
- Department of Intensive Care, Nepean Hospital , Sydney, Australia
| | - Bernard Chan
- Junior Medical Staff Unit, Royal North Shore Hospital , Sydney, Australia
| | - Matthias Jaeger
- South Western Sydney Clinical School, University of New South Wales , Sydney, Australia.,Department of Neurosurgery, Wollongong Hospital , Wollongong, Australia
| | - Anders Aneman
- South Western Sydney Clinical School, University of New South Wales , Sydney, Australia.,Department of Intensive Care Medicine, Liverpool Hospital , Sydney, Australia
| | - Alwin Chuan
- South Western Sydney Clinical School, University of New South Wales , Sydney, Australia.,Department of Anaesthesia, Liverpool Hospital , Sydney, Australia
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Guo X, Hu J, Xiao H, Liu T, Niu Z, Wang M, Qi D. Effect of continuous intraoperative infusion of methoxamine on renal function in elderly patients undergoing gastrointestinal tumor surgery: a randomized controlled trial. BMC Anesthesiol 2020; 20:148. [PMID: 32534584 PMCID: PMC7293117 DOI: 10.1186/s12871-020-01064-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/02/2020] [Indexed: 12/29/2022] Open
Abstract
Background Acute renal injury (AKI) caused by hypotension often occurs in elderly patients after gastrointestinal tumor surgery. Although vasoactive drugs can increase effective filtration pressure, they may increase renal vascular resistance and reduce renal blood flow. The effect of methoxamine on renal function is not clear. Methods After obtaining written informed consent, 180 elderly patients undergoing elective gastrointestinal tumor surgery were randomly allocated into two groups: M group (continuous infusion of methoxamine at 2 μg/kg/min) and N group (continuous infusion of normal saline). The patients’ mean arterial pressure was maintained within 20% of baseline by a continuous infusion of methoxamine or normal saline. Maintenance fluid was kept at 5 mL/kg/h. According to Kidney disease improve global outcome (KDIGO) guidelines, creatinine was measured at 1, 2 and 7 days after operation, and urine volume at 6, 12 and 24 h after operation was measured to evaluate the occurrence of AKI. 162 patients were included in the final data analysis. Results Significant differences in the incidence of postoperative Acute kidney injury (M group: 7.5%; N group: 18.3%; P < 0.05), the frequency of hypotension (M group: 1 [1–3]; N group: 3 [1–5]; P < 0.05), and the duration of intraoperative hypotension (M group: 2[0–10]; N group: 10 [5–16]; P < 0.05) were identified between the groups. Multivariate logistic regression analyses demonstrated that preoperative creatinine and the frequency of intraoperative hypotension were the common factors leading to the occurrence of postoperative AKI. The results of Cox multivariate analysis showed that age and AKI were independent risk factors for 30-day death. Conclusion Compared with the intraoperative continuous infusion of placebo and methoxamine, continuous infusion of 2 μg/kg/min methoxamine reduced the incidence of postoperative AKI and other clinical complications in elderly patients undergoing gastrointestinal surgery by raising blood pressure and improved the prognosis of patients. Trial registration Trial registration: Chinese Clinical Trial Registry, ChiCTR1900020536, registered 7 January, 2019,
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Affiliation(s)
- Xiaowei Guo
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Jie Hu
- Xuzhou Medical University and Department of Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Hanbing Xiao
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Tianyu Liu
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Zheng Niu
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Min Wang
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Dunyi Qi
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China.
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Turner L, Hardikar A, Jose MD, Bhattarai K, Fenton C, Sharma R, Kirkland G, Jeffs L, Breslin M, Silva Ragaini B, Newland RF. Acute kidney injury, stroke and death after cardiopulmonary bypass surgery: the role of perfusion flow and pressure. Perfusion 2020; 36:78-86. [PMID: 32515271 DOI: 10.1177/0267659120924919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Acute kidney injury after cardiopulmonary bypass surgery is associated with morbidity and mortality. This study aims to evaluate the role of low perfusion flow and pressure in the development of cardiopulmonary bypass-associated acute kidney injury, stroke and death, using multicentre registry data. METHODS We identified patients from the Australian and New Zealand Collaborative Perfusion Registry who underwent coronary artery bypass grafting and/or valvular surgery between 2008 and 2018. Primary predictor variables were the length of time the perfusion flow was <1.6 L/min/m2 and the length of time perfusion pressure was < 50mmHg. The primary outcome was new postoperative acute kidney injury defined by the risk-injury-failure-loss-end stage criteria. Secondary outcomes were stroke and in-hospital death. The influence of perfusion flow and pressure during cardiopulmonary bypass on the primary and secondary outcomes was estimated using separate multivariate models. RESULTS A total of 16,356 patients were included. The mean age was 66 years and 75% were male. Acute kidney injury was observed in 1,844 patients (11%), stroke in 204 (1.3%) and in-hospital death in 286 (1.8%). Neither the duration of the time spent for perfusion flow (<1.6 L/minute/m2) nor the duration of the time spent for perfusion pressure (<50 mmHg) was associated with postoperative acute kidney injury, stroke or death in adjusted models. CONCLUSIONS Neither low perfusion pressure nor low perfusion flow during cardiopulmonary bypass were predictive of postoperative acute kidney injury, stroke or death.
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Affiliation(s)
- Laura Turner
- Department of Nephrology, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Ashutosh Hardikar
- Department of Cardiothoracic Surgery, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Matthew D Jose
- Department of Nephrology, Royal Hobart Hospital, Hobart, TAS, Australia.,School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Keshav Bhattarai
- Department of Cardiothoracic Surgery, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Carmel Fenton
- Department of Cardiothoracic Surgery, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Rajiv Sharma
- Department of Cardiothoracic Surgery, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Geoff Kirkland
- Department of Nephrology, Royal Hobart Hospital, Hobart, TAS, Australia.,School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Lisa Jeffs
- Department of Nephrology, Royal Hobart Hospital, Hobart, TAS, Australia.,School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Bruna Silva Ragaini
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Richard F Newland
- Department of Cardiothoracic Surgery, Flinders Medical Centre and Flinders University, Adelaide, SA, Australia
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Kotani Y, Kataoka Y, Izawa J, Fujioka S, Yoshida T, Kumasawa J, Kwong JSW. High versus low blood pressure targets for cardiac surgery with cardiopulmonary bypass. Hippokratia 2019. [DOI: 10.1002/14651858.cd013494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Yuki Kotani
- Kameda Medical Center; Department of Intensive Care Medicine; Kamogawa Japan
| | - Yuki Kataoka
- Hyogo Prefectural Amagasaki General Medical Center; Department of Respiratory Medicine; 2-17-77, Higashi-Naniwa-Cho Amagasaki Hyogo Japan 660-8550
| | - Junichi Izawa
- Jikei University School of Medicine; Department of Anesthesiology; Tokyo Japan
| | - Shoko Fujioka
- Jikei University School of Medicine; Department of Anesthesiology; Tokyo Japan
| | - Takuo Yoshida
- Jikei University School of Medicine; Department of Anesthesiology; Tokyo Japan
| | - Junji Kumasawa
- Sakai City Medical Center; Department of Critical Care Medicine, Department of Clinical Research and Epidemiology; Sakai City Japan
| | - Joey SW Kwong
- National Center for Child Health and Development; Department of Health Policy; 10-1 Okura 2-chome Setagaya-ku Tokyo Japan 157-8535
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Caldas JR, Panerai RB, Bor-Seng-Shu E, Ferreira GSR, Camara L, Passos RH, Salinet AM, Azevedo DS, de-Lima-Oliveira M, Galas FRBG, Fukushima JT, Nogueira R, Taccone FS, Landoni G, Almeida JP, Robinson TG, Hajjar LA. Intra-aortic balloon pump does not influence cerebral hemodynamics and neurological outcomes in high-risk cardiac patients undergoing cardiac surgery: an analysis of the IABCS trial. Ann Intensive Care 2019; 9:130. [PMID: 31773324 PMCID: PMC6879692 DOI: 10.1186/s13613-019-0602-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/07/2019] [Indexed: 12/24/2022] Open
Abstract
Background The intra-aortic balloon pump (IABP) is often used in high-risk patients undergoing cardiac surgery to improve coronary perfusion and decrease afterload. The effects of the IABP on cerebral hemodynamics are unknown. We therefore assessed the effect of the IABP on cerebral hemodynamics and on neurological complications in patients undergoing cardiac surgery who were randomized to receive or not receive preoperative IABP in the ‘Intra-aortic Balloon Counterpulsation in Patients Undergoing Cardiac Surgery’ (IABCS) trial. Methods This is a prospectively planned analysis of the previously published IABCS trial. Patients undergoing elective coronary artery bypass surgery with ventricular ejection fraction ≤ 40% or EuroSCORE ≥ 6 received preoperative IABP (n = 90) or no IABP (n = 91). Cerebral blood flow velocity (CBFV) of the middle cerebral artery through transcranial Doppler and blood pressure through Finometer or intra-arterial line were recorded preoperatively (T1) and 24 h (T2) and 7 days after surgery (T3) in patients with preoperative IABP (n = 34) and without IABP (n = 33). Cerebral autoregulation was assessed by the autoregulation index that was estimated from the CBFV response to a step change in blood pressure derived by transfer function analysis. Delirium, stroke and cognitive decline 6 months after surgery were recorded. Results There were no differences between the IABP and control patients in the autoregulation index (T1: 5.5 ± 1.9 vs. 5.7 ± 1.7; T2: 4.0 ± 1.9 vs. 4.1 ± 1.6; T3: 5.7 ± 2.0 vs. 5.7 ± 1.6, p = 0.97) or CBFV (T1: 57.3 ± 19.4 vs. 59.3 ± 11.8; T2: 74.0 ± 21.6 vs. 74.7 ± 17.5; T3: 71.1 ± 21.3 vs. 68.1 ± 15.1 cm/s; p = 0.952) at all time points. Groups were not different regarding postoperative rates of delirium (26.5% vs. 24.2%, p = 0.83), stroke (3.0% vs. 2.9%, p = 1.00) or cognitive decline through analysis of the Mini-Mental State Examination (16.7% vs. 40.7%; p = 0.07) and Montreal Cognitive Assessment (79.16% vs. 81.5%; p = 1.00). Conclusions The preoperative use of the IABP in high-risk patients undergoing cardiac surgery did not affect cerebral hemodynamics and was not associated with a higher incidence of neurological complications. Trial registrationhttp://www.clinicaltrials.gov (NCT02143544).
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Affiliation(s)
- Juliana R Caldas
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil.,Universidade de Salvador, UNIFACS, Salvador, Bahia, Brazil.,Critical Care Unit Hospital São Rafael Salvador, Salvador, Brazil.,Escola Bahiana de Medicina e Saude Púbica, Salvador, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Edson Bor-Seng-Shu
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | | | - Ligia Camara
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Rogério H Passos
- Critical Care Unit Hospital São Rafael Salvador, Salvador, Brazil
| | - Angela M Salinet
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Daniel S Azevedo
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | | | | | - Julia T Fukushima
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Ricardo Nogueira
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Fabio S Taccone
- Department of Intensive Care, Hopital Erasme, Brussels, Belgium
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University of Milan, Milan, Italy
| | - Juliano P Almeida
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Universidade de São Paulo, São Paulo, Brazil. .,Surgical Intensive Care, Heart Institute, University of São Paulo, Av. Dr. Ene´as de Carvalho Aguiar 44, 05403-000, São Paulo, Brazil.
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Monitoring tissue perfusion: a pilot clinical feasibility and safety study of a urethral photoplethysmography-derived perfusion device in high-risk patients. J Clin Monit Comput 2019; 34:961-969. [DOI: 10.1007/s10877-019-00414-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
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Khalid F, Yang GL, McGuire JL, Robson MJ, Foreman B, Ngwenya LB, Lorenz JN. Autonomic dysfunction following traumatic brain injury: translational insights. Neurosurg Focus 2019; 47:E8. [DOI: 10.3171/2019.8.focus19517] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/12/2019] [Indexed: 11/06/2022]
Abstract
Although there is a substantial amount of research on the neurological consequences of traumatic brain injury (TBI), there is a knowledge gap regarding the relationship between TBI and the pathophysiology of organ system dysfunction and autonomic dysregulation. In particular, the mechanisms or incidences of renal or cardiac complications after TBI are mostly unknown. Autonomic dysfunction following TBI exacerbates secondary injury and may contribute to nonneurologial complications that prolong hospital length of stay. Gaining insights into the mechanisms of autonomic dysfunction can guide advancements in monitoring and treatment paradigms to improve acute survival and long-term prognosis of TBI patients. In this paper, the authors will review the literature on autonomic dysfunction after TBI and possible mechanisms of paroxysmal sympathetic hyperactivity. Specifically, they will discuss the link among the brain, heart, and kidneys and review data to direct future research on and interventions for TBI-induced autonomic dysfunction.
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Affiliation(s)
- Fatima Khalid
- Departments of 1Pharmacology and Systems Physiology and
| | | | - Jennifer L. McGuire
- 2Neurosurgery, College of Medicine
- 3Collaborative for Research on Acute Neurological Injuries
| | - Matthew J. Robson
- 3Collaborative for Research on Acute Neurological Injuries
- 4Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy; and
| | - Brandon Foreman
- 2Neurosurgery, College of Medicine
- 3Collaborative for Research on Acute Neurological Injuries
- 5Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Ohio
| | - Laura B. Ngwenya
- 2Neurosurgery, College of Medicine
- 3Collaborative for Research on Acute Neurological Injuries
- 5Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Ohio
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Determining the Upper and Lower Limits of Cerebral Autoregulation With Cerebral Oximetry Autoregulation Curves: A Case Series. Crit Care Med 2019; 46:e473-e477. [PMID: 29419556 DOI: 10.1097/ccm.0000000000003012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Critical care guidelines recommend a single target value for mean arterial blood pressure in critically ill patients. However, growing evidence regarding cerebral autoregulation challenges this concept and supports individualizing mean arterial blood pressure targets to prevent brain and kidney hypo- or hyperperfusion. Regional cerebral oxygen saturation derived from near-infrared spectroscopy is an acceptable surrogate for cerebral blood flow and has been validated to measure cerebral autoregulation. This study suggests a novel mechanism to construct autoregulation curves based on near-infrared spectroscopy-measured cerebral oximetry. DESIGN Case-series study. SETTING Neurocritical care unit in a tertiary medical center. PATIENTS Patients with acute neurologic injury and Glasgow coma scale score less than or equal to 8. MEASUREMENTS AND MAIN RESULTS Autoregulation curves were plotted using the fractional-polynomial model in Stata after multimodal continuous monitoring of regional cerebral oxygen saturation and mean arterial blood pressure. Individualized autoregulation curves of seven patients exhibited varying upper and lower limits of autoregulation and provided useful clinical information on the autoregulation trend (curves moving to the right or left during the acute coma period). The median lower and upper limits of autoregulation were 86.5 mm Hg (interquartile range, 74-93.5) and 93.5 mm Hg (interquartile range, 83-99), respectively. CONCLUSIONS This case-series study showed feasibility of delineating real trends of the cerebral autoregulation plateau and direct visualization of the cerebral autoregulation curve after at least 24 hours of recording without manipulation of mean arterial blood pressure by external stimuli. The integration of multimodal monitoring at the bedside with cerebral oximetry provides a noninvasive method to delineate daily individual cerebral autoregulation curves.
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Nomura Y, Faegle R, Hori D, Al-Qamari A, Nemeth AJ, Gottesman R, Yenokyan G, Brown C, Hogue CW. Cerebral Small Vessel, But Not Large Vessel Disease, Is Associated With Impaired Cerebral Autoregulation During Cardiopulmonary Bypass: A Retrospective Cohort Study. Anesth Analg 2019; 127:1314-1322. [PMID: 29677060 PMCID: PMC6533899 DOI: 10.1213/ane.0000000000003384] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Impaired cerebral blood flow (CBF) autoregulation during cardiopulmonary bypass (CPB) is associated with stroke and other adverse outcomes. Large and small arterial stenosis is prevalent in patients undergoing cardiac surgery. We hypothesize that large and/or small vessel cerebral arterial disease is associated with impaired cerebral autoregulation during CPB. METHODS A retrospective cohort analysis of data from 346 patients undergoing cardiac surgery with CPB enrolled in an ongoing prospectively randomized clinical trial of autoregulation monitoring were evaluated. The study protocol included preoperative transcranial Doppler (TCD) evaluation of major cerebral artery flow velocity by a trained vascular technician and brain magnetic resonance imaging (MRI) between postoperative days 3 and 5. Brain MRI images were evaluated for chronic white matter hyperintensities (WMHI) by a vascular neurologist blinded to autoregulation data. "Large vessel" cerebral vascular disease was defined by the presence of characteristic TCD changes associated with stenosis of the major cerebral arteries. "Small vessel" cerebral vascular disease was defined based on accepted scoring methods of WMHI. All patients had continuous TCD-based autoregulation monitoring during surgery. RESULTS Impaired autoregulation occurred in 32.4% (112/346) of patients. Preoperative TCD demonstrated moderate-severe large vessel stenosis in 67 (25.2%) of 266 patients with complete data. In adjusted analysis, female sex (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25-0.86; P = .014) and higher average temperature during CPB (OR, 1.23; 95% CI, 1.02-1.475; P = .029), but not moderate-severe large cerebral arterial stenosis (P = .406), were associated with impaired autoregulation during CPB. Of the 119 patients with available brain MRI data, 42 (35.3%) demonstrated WMHI. The presence of small vessel cerebral vascular disease was associated with impaired CBF autoregulation (OR, 3.25; 95% CI, 1.21-8.71; P = .019) after adjustment for age, history of peripheral vascular disease, preoperative hemoglobin level, and preoperative treatment with calcium channel blocking drugs. CONCLUSIONS These data confirm that impaired CBF autoregulation is prevalent during CPB predisposing affected patients to brain hypoperfusion or hyperperfusion with low or high blood pressure, respectively. Small vessel, but not large vessel, cerebral vascular disease, male sex, and higher average body temperature during CPB appear to be associated with impaired autoregulation.
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Affiliation(s)
- Yohei Nomura
- From the Division of Cardiac Surgery, Department of Surgery and
| | - Roland Faegle
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daijiro Hori
- From the Division of Cardiac Surgery, Department of Surgery and
| | | | - Alexander J Nemeth
- Radiology, Division of Neuroradiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rebecca Gottesman
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gayane Yenokyan
- The Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | - Charles Brown
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Brown CH, Neufeld KJ, Tian J, Probert J, LaFlam A, Max L, Hori D, Nomura Y, Mandal K, Brady K, Hogue CW, Shah A, Zehr K, Cameron D, Conte J, Bienvenu OJ, Gottesman R, Yamaguchi A, Kraut M. Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients: A Nested Randomized Clinical Trial. JAMA Surg 2019. [PMID: 31116358 DOI: 10.1001/jamasurg.2019.1163.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04). Conclusions and Relevance The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. Trial Registration ClinicalTrials.gov identifier: NCT00981474.
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karin J Neufeld
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Andrew LaFlam
- Medical Student, School of Medicine, Tufts University, Medford Massachusetts
| | - Laura Max
- Department of Radiology, Massachusetts General Hospital, Boston
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yohei Nomura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - Ken Brady
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles W Hogue
- Bluhm Cardiovascular Institute, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ashish Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenton Zehr
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Duke Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - John Conte
- Division of Cardiac Surgery, Department of Surgery, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - O Joseph Bienvenu
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Michael Kraut
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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MacKay EJ, Werner RM, Groeneveld PW, Desai ND, Reese PP, Gutsche JT, Augoustides JG, Neuman MD. Transesophageal Echocardiography, Acute Kidney Injury, and Length of Hospitalization Among Adults Undergoing Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2019; 34:687-695. [PMID: 31558399 DOI: 10.1053/j.jvca.2019.08.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/18/2019] [Accepted: 08/21/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To test the association between transesophageal echocardiography (TEE) and incidence of acute kidney injury and length of hospitalization among United States adults undergoing isolated coronary artery bypass graft (CABG) surgery. DESIGN This was an observational, retrospective cohort analysis. SETTING This study used a multicenter claims dataset from a commercially insured population undergoing CABG surgery in the United States between 2004 and 2016. PARTICIPANTS Adults aged 18 years or older with continuous insurance enrollment and an absence of renal-related diagnoses before the index CABG surgery. INTERVENTIONS Receipt of TEE within 1 calendar day of the index CABG surgery date. MEASUREMENTS AND MAIN RESULTS Of 51,487 CABG surgeries, 5,361 (10.4%; [95% confidence interval [CI]: 10.1-10.7%]) developed acute kidney injury and the mean length of hospitalization was 8.8 days (95% CI: 8.7-8.8). The TEE group demonstrated a greater absolute risk difference (RD) for acute kidney injury by multiple linear regression, overall, (RD=+1.0; [95% CI: 0.4-1.5%]; p < 0.001) and among a low-risk subgroup (RD=+1.0; [95% CI: 0.4-1.6; p = 0.002), but not by instrumental variable analysis (RD=+0.9 [95% CI: -1.1 to 2.9%]; p = 0.362). The TEE group demonstrated a longer length of hospitalization by multiple linear regression, overall (+2.0%; [95% CI: 1.1-2.9%]; p < 0.001), among a low-risk subgroup (+2.2%; [95% CI: 1.2-3.2%]; p < 0.001), and by instrumental variable analysis (+10.3%; [95% CI: 7.0-13.7%]; p < 0.001). CONCLUSIONS TEE monitoring in CABG surgery was not associated with a lower incidence of acute kidney injury or decreased length of hospitalization. These findings highlight the importance of additional work to study the clinical effectiveness of TEE in CABG surgery.
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Affiliation(s)
- Emily J MacKay
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA; Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA.
| | - Rachel M Werner
- Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA
| | - Peter W Groeneveld
- Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn's Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA
| | - Peter P Reese
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark D Neuman
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA
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Assessment of cerebral and renal autoregulation using near-infrared spectroscopy under normal, hypovolaemic and postfluid resuscitation conditions in a swine model. Eur J Anaesthesiol 2019; 36:531-540. [DOI: 10.1097/eja.0000000000001021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Vaini E, Bari V, Fantinato A, Pistuddi V, Cairo B, De Maria B, Ranucci M, Porta A. Causality analysis reveals the link between cerebrovascular control and acute kidney dysfunction after coronary artery bypass grafting. Physiol Meas 2019; 40:064006. [PMID: 31091519 DOI: 10.1088/1361-6579/ab21b1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients undergoing coronary artery bypass graft (CABG) surgery might experience postoperative complications and some of them, such as acute kidney dysfunction (AKD), are the likely consequence of hypoperfusion. We hypothesized that an impaired cerebrovascular control is a hallmark of a vascular damage that might favor AKD after CABG. OBJECTIVE Our aim is to characterize cerebrovascular control in CABG patients through the assessment of the relationship between mean arterial pressure (MAP) and mean cerebral blood flow velocity (MCBFV) and to check whether markers describing MCBFV-MAP dynamical interactions could identify subjects at risk to develop postoperative AKD. APPROACH MAP and MCBFV beat-to-beat series were extracted from invasive arterial pressure and transcranial Doppler recordings acquired simultaneously in 23 patients just before CABG after the induction of propofol general anesthesia. Subjects were divided into AKD group (n = 9, age: 68 ± 9, 8 males) and noAKD group (n = 14, age: 65 ± 8, 12 males) according to whether they developed postoperative AKD or not after CABG. We computed MAP and MCBFV time-domain and spectral markers as well as MCBFV-MAP cross-spectral indexes in very-low-frequency (VLF, 0.02-0.07 Hz), low-frequency (LF, 0.07-0.15 Hz) and high-frequency (HF, 0.15-0.30 Hz) bands. We also calculated model-based transfer entropy (TE) to quantify the degree of MCBFV dependence on MAP and vice versa. The null hypothesis of MCBFV-MAP uncoupling was tested via a surrogate approach associating MAP and MCBFV in different patients. MAIN RESULTS Time, spectral and cross-spectral markers had a limited power in separating AKD from noAKD individuals. Conversely, TE from MAP to MCBFV was significantly above the level set by surrogates only in AKD groups and significantly larger than that computed in noAKD. SIGNIFICANCE The reduced cerebrovascular autoregulation in AKD patients suggest a vascular impairment likely making them more at risk of hypoperfusion during CABG and AKD after CABG.
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Affiliation(s)
- Emanuele Vaini
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Untreated Relative Hypotension Measured as Perfusion Pressure Deficit During Management of Shock and New-Onset Acute Kidney Injury-A Literature Review. Shock 2019; 49:497-507. [PMID: 29040214 DOI: 10.1097/shk.0000000000001033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Maintaining an optimal blood pressure (BP) during shock is a fundamental tenet of critical care. Optimal BP targets may be different for different patients. In current practice, too often, uniform BP targets are pursued which may result in inadvertently accepting a degree of untreated relative hypotension, i.e., the deficit between patients' usual premorbid basal BP and the achieved BP, during vasopressor support. Relative hypotension is a common but an under-recognized and an under-treated sign among patients with potential shock state. From a physiological perspective, any relative reduction in the net perfusion pressure across an organ (e.g., renal) vasculature has a potential to overwhelm autoregulatory mechanisms, which are already under stress during shock. Such perfusion pressure deficit may consequently impact organs' ability to function or recover from an injured state. This review discusses such pathophysiologic mechanisms in detail with a particular focus on the risk of new-onset acute kidney injury (AKI). To review current literature, databases of Medline, Embase, and Google scholar were searched to retrieve articles that either adjusted BP targets based on patients' premorbid BP levels or considered relative hypotension as an exposure endpoint and assessed its association with clinical outcomes among acutely ill patients. There were no randomized controlled trials. Only seven studies could be identified and these were reviewed in detail. These studies indicated a significant association between the degree of relative hypotension that was inadvertently accepted in real-world practice and new-onset organ dysfunction or subsequent AKI. However, this is not a high-quality evidence. Therefore, well-designed randomized controlled trials are needed to evaluate whether adoption of individualized BP targets, which are initially guided by patient's premorbid basal BP and then tailored according to clinical response, is superior to conventional BP targets for vasopressor therapy, particularly among patients with vasodilatory shock states.
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Why and how to assess cerebral autoregulation? Best Pract Res Clin Anaesthesiol 2019; 33:211-220. [DOI: 10.1016/j.bpa.2019.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 02/07/2023]
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Rosenblatt K, Walker KA, Goodson C, Olson E, Maher D, Brown CH, Nyquist P. Cerebral Autoregulation-Guided Optimal Blood Pressure in Sepsis-Associated Encephalopathy: A Case Series. J Intensive Care Med 2019; 35:1453-1464. [PMID: 30760173 PMCID: PMC6692246 DOI: 10.1177/0885066619828293] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Impaired cerebral autoregulation and cerebral hypoperfusion may play a critical role in the high morbidity and mortality in patients with sepsis-associated encephalopathy (SAE). Bedside assessment of cerebral autoregulation may help individualize hemodynamic targets that optimize brain perfusion. We hypothesize that near-infrared spectroscopy (NIRS)-derived cerebral oximetry can identify blood pressure ranges that enhance autoregulation in patients with SAE and that disturbances in autoregulation are associated with severity of encephalopathy. METHODS Adult patients with acute encephalopathy directly attributable to sepsis were followed using NIRS-based multimodal monitoring for 12 consecutive hours. We used the correlation in time between regional cerebral oxygen saturation and mean arterial pressure (MAP) to determine the cerebral oximetry index (COx) as a measure of cerebral autoregulation. Autoregulation curves were constructed for each patient with averaged COx values sorted by MAP in 3 sequential 4-hour periods; the optimal pressure (MAPOPT), defined as the MAP associated with most robust autoregulation (lowest COx), was identified in each period. Severity of encephalopathy was measured with Glasgow coma scale (GCS). RESULTS Six patients with extracranial sepsis met the stringent criteria specified, including no pharmacological sedation or neurologic premorbidity. Optimal MAP was identified in all patients and ranged from 55 to 115 mmHg. Additionally, MAPOPT varied within individual patients over time during monitoring. Disturbed autoregulation, based on COx, was associated with worse neurologic status (GCS < 13) both with and without controlling for age and severity of sepsis (adjusted odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.77-2.52; P < .001; OR: 2.97; 95% CI: 1.63-5.43; P < .001). CONCLUSIONS In this high-fidelity group of patients with SAE, continuous, NIRS-based monitoring can identify blood pressure ranges that improve autoregulation. This is important given the association between cerebral autoregulatory function and severity of encephalopathy. Individualizing blood pressure goals using bedside autoregulation monitoring may better preserve cerebral perfusion in SAE than current practice.
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Affiliation(s)
- Kathryn Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Keenan A Walker
- Department of Neurology, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carrie Goodson
- Department of Pulmonary and Critical Care, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elsa Olson
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dermot Maher
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Nyquist
- Department of Anesthesiology and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
PURPOSE OF REVIEW Central pulse pressure (PP), a marker of vascular stiffness, is a novel indicator of risk for perioperative morbidity including ischemic stroke. Appreciation for the mechanism by which vascular stiffness leads to organ dysfunction along with understanding its clinical detection may lead to improved patient management. RECENT FINDINGS Vascular stiffness is associated with increased mortality and neurologic, cardiac, and renal injury in nonsurgical and surgical patients. Left ventricular hypertrophy and diastolic dysfunction along with microcirculatory changes in the low vascular resistance, high blood flow, cerebral and renal vasculature are seen in patients with vascular stiffness. Pulse wave velocity and the augmentation index have higher sensitivity for detecting of vascular stiffness than peripheral PP as the hemodynamic consequences of vascular stiffness are secondary to alterations in the central vasculature. Vascular stiffness alters cerebral autoregulation, resulting in a high likelihood of having a lower limit of autoregulation more than 65 mmHg during surgery. Vascular stiffness may predispose to cerebral hypoperfusion, increasing vulnerability to ischemic stroke, postoperative delirium, and acute kidney injury. SUMMARY Vascular stiffness leads to alterations in cerebral, cardiac, and renal hemodynamics increasing the risk of perioperative ischemic stroke and neurologic, cardiac, and renal dysfunction.
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Affiliation(s)
- Abbas Al-Qamari
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Chuan A, Short TG, Peng AZY, Wen SYB, Sun AX, Ting TH, Wan AS, Pope L, Jaeger M, Aneman A. Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study. Acta Anaesthesiol Scand 2019; 63:8-17. [PMID: 30079514 DOI: 10.1111/aas.13223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/15/2018] [Accepted: 07/11/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Studies have identified multiple risk factors for development of cognitive decline after surgery. Impaired cerebrovascular autoregulation may be a contributor to postoperative cognitive decline. METHODS One hundred and forty patients admitted for major elective noncardiac surgery were recruited. Near-infrared spectroscopy was used to calculate the tissue oxygenation index of dynamic autoregulation (TOx). The primary endpoint was Day 3 cognitive recovery as assessed using the Postoperative Quality of Recovery Scale. The secondary endpoint was a combined major adverse event of death, acute myocardial infarction, cardiac arrest, stroke, pulmonary embolism, sepsis, and acute kidney injury at Day 30. RESULTS Higher optimal TOx values, signifying impaired autoregulation, were associated with worse outcomes. Patients who cognitively recovered at Day 3 (n = 47) had lower optimal TOx values (TOxopt ) than patients who did not recover (n = 22): 0.06 (0.24) vs 0.18 (0.16) (mean [SD]), P = 0.02. Patients who did not suffer a major adverse event (n = 102) had lower TOxopt than patients who did (n = 17): 0.09 (0.21) vs 0.20 (0.27), P = 0.04. When dichotomized as having impaired or intact autoregulation based on TOxopt levels, a value of TOxopt ≥0.1 correctly identified 72.7% of patients who did not cognitively recover, OR 3.3 (1.1-9.9) (Odds ratio, [95% CI]), P = 0.03. TOxopt ≥0.1 correctly identified 82.4% of patients who suffered a major adverse event, OR 4.7 (1.3-17.2), P = 0.02. CONCLUSIONS In older and higher risk patients having major noncardiac surgery, impaired cerebrovascular autoregulation was associated with failure of cognitive recovery in the early postoperative period and with 1-month mortality and morbidity.
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Affiliation(s)
- Alwin Chuan
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Anaesthesia; Liverpool Hospital; Sydney New South Wales Australia
| | - Timothy G. Short
- Department of Anaesthesia; Auckland City Hospital; Auckland New Zealand
| | - Alexander Z. Y. Peng
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Shelly Y. B. Wen
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Alice X. Sun
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Timothy H. Ting
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
| | - Anthony S. Wan
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Anaesthesia; Liverpool Hospital; Sydney New South Wales Australia
| | - Linda Pope
- Department of Anaesthesia; Liverpool Hospital; Sydney New South Wales Australia
| | - Matthias Jaeger
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Neurosurgery; Wollongong Hospital; Wollongong New South Wales Australia
| | - Anders Aneman
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
- Department of Intensive Care; Liverpool Hospital; Sydney New South Wales Australia
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Berger M, Schenning KJ, Brown CH, Deiner SG, Whittington RA, Eckenhoff RG, for the Perioperative Neurotoxicity Working Group. Best Practices for Postoperative Brain Health: Recommendations From the Fifth International Perioperative Neurotoxicity Working Group. Anesth Analg 2018; 127:1406-1413. [PMID: 30303868 PMCID: PMC6309612 DOI: 10.1213/ane.0000000000003841] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
As part of the American Society of Anesthesiology Brain Health Initiative goal of improving perioperative brain health for older patients, over 30 experts met at the fifth International Perioperative Neurotoxicity Workshop in San Francisco, CA, in May 2016, to discuss best practices for optimizing perioperative brain health in older adults (ie, >65 years of age). The objective of this workshop was to discuss and develop consensus solutions to improve patient management and outcomes and to discuss what older adults should be told (and by whom) about postoperative brain health risks. Thus, the workshop was provider and patient oriented as well as solution focused rather than etiology focused. For those areas in which we determined that there were limited evidence-based recommendations, we identified knowledge gaps and the types of scientific knowledge and investigations needed to direct future best practice. Because concerns about perioperative neurocognitive injury in pediatric patients are already being addressed by the SmartTots initiative, our workshop discussion (and thus this article) focuses specifically on perioperative cognition in older adults. The 2 main perioperative cognitive disorders that have been studied to date are postoperative delirium and cognitive dysfunction. Postoperative delirium is a syndrome of fluctuating changes in attention and level of consciousness that occurs in 20%-40% of patients >60 years of age after major surgery and inpatient hospitalization. Many older surgical patients also develop postoperative cognitive deficits that typically last for weeks to months, thus referred to as postoperative cognitive dysfunction. Because of the heterogeneity of different tools and thresholds used to assess and define these disorders at varying points in time after anesthesia and surgery, a recent article has proposed a new recommended nomenclature for these perioperative neurocognitive disorders. Our discussion about this topic was organized around 4 key issues: preprocedure consent, preoperative cognitive assessment, intraoperative management, and postoperative follow-up. These 4 issues also form the structure of this document. Multiple viewpoints were presented by participants and discussed at this in-person meeting, and the overall group consensus from these discussions was then drafted by a smaller writing group (the 6 primary authors of this article) into this manuscript. Of course, further studies have appeared since the workshop, which the writing group has incorporated where appropriate. All participants from this in-person meeting then had the opportunity to review, edit, and approve this final manuscript; 1 participant did not approve the final manuscript and asked for his/her name to be removed.
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Affiliation(s)
- Miles Berger
- Anesthesiology Department, Duke University Medical Center, Durham, North Carolina
| | - Katie J. Schenning
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Charles H. Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stacie G. Deiner
- Anesthesiology Department, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert A. Whittington
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
| | - Roderic G. Eckenhoff
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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81
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Jinadasa SP, Mueller A, Prasad V, Subramaniam K, Heldt T, Novack V, Subramaniam B. Blood Pressure Coefficient of Variation and Its Association With Cardiac Surgical Outcomes. Anesth Analg 2018; 127:832-839. [DOI: 10.1213/ane.0000000000003362] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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82
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Lewis C, Parulkar SD, Bebawy J, Sherwani S, Hogue CW. Cerebral Neuromonitoring During Cardiac Surgery: A Critical Appraisal With an Emphasis on Near-Infrared Spectroscopy. J Cardiothorac Vasc Anesth 2018; 32:2313-2322. [DOI: 10.1053/j.jvca.2018.03.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Indexed: 11/11/2022]
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83
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Meng L, Yu W, Wang T, Zhang L, Heerdt PM, Gelb AW. Blood Pressure Targets in Perioperative Care. Hypertension 2018; 72:806-817. [DOI: 10.1161/hypertensionaha.118.11688] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, China (W.Y.)
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (T.W.)
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan Province, China (L.Z.)
| | - Paul M. Heerdt
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Adrian W. Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (A.W.G.)
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84
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Schubert SA, Mehaffey JH, Booth A, Yarboro LT, Kern JA, Kennedy JLW, Ailawadi G, Mazimba S. Pulmonary-Systemic Pressure Ratio Correlates with Morbidity in Cardiac Valve Surgery. J Cardiothorac Vasc Anesth 2018; 33:677-682. [PMID: 30243869 DOI: 10.1053/j.jvca.2018.08.190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Pulmonary hypertension portends worse outcomes in cardiac valve surgery; however, isolated pulmonary artery pressures may not reflect patients' global cardiac function accurately. To better account for the interventricular relationship, the authors hypothesized that patients with greater pulmonary-systemic ratios (mean pulmonary arterial pressure)/(mean systemic arterial pressure) would correlate with worse outcomes after valve surgery. DESIGN Retrospective cohort study. SETTING Single academic hospital. PARTICIPANTS The study comprised 314 patients undergoing valve surgery with or without coronary artery bypass grafting (2004-2016) with Society of Thoracic Surgeons predicted risk scores and preoperative right heart catheterization. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The pulmonary-systemic ratio was calculated as follows: mean pulmonary arterial pressure/mean systemic arterial pressure. Patients were stratified by pulmonary-systemic ratio quartile. Logistic regression was used to assess the risk-adjusted association between pulmonary-systemic ratio or mean pulmonary arterial pressure. Median pulmonary-systemic ratio was 0.33 (Q1-Q3: 0.23-0.65); median pulmonary arterial pressure was 29 (21-30) mmHg. Patients with the highest pulmonary-systemic ratio had the highest rates of morbidity and mortality (p < 0.0001). A high pulmonary-systemic ratio was associated with longer duration in the intensive care unit (p < 0.0001) and hospital (p < 0.0001). After risk-adjustment, pulmonary-systemic ratio and pulmonary arterial pressure were independently associated with morbidity and mortality, but the pulmonary-systemic ratio (odds ratio 23.88, p = 0.008, Wald 7.1) was more strongly associated than the pulmonary arterial pressure (odds ratio 1.035, p = 0.011, Wald 6.5). CONCLUSIONS The pulmonary-systemic ratio is more strongly associated with risk-adjusted morbidity and mortality in valve surgery than pulmonary arterial pressure. By integrating ventricular interactions, this metric may better characterize the risk of valve surgery.
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Affiliation(s)
- Sarah A Schubert
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA.
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Alexander Booth
- University of Virginia School of Medicine, Charlottesville, VA
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, VA
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85
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Denault AY, Brassard P, Jacquet-Lagrèze M, Halwagi AE. Targeting optimal blood pressure monitoring: what's next? J Thorac Dis 2018; 10:S3281-S3285. [PMID: 30370138 DOI: 10.21037/jtd.2018.08.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- André Y Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada.,Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Quebec, Canada.,Research Center, Institut universitaire de cardiologie et de pneumologie de Québec, Quebec, Canada
| | - Matthias Jacquet-Lagrèze
- Department of Intensive Care and Anesthesiology, Hôpital Louis Pradel, Hospices civils de Lyon, Lyon, France
| | - Antoine E Halwagi
- Department of Anesthesiology and Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
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86
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Hori D, Katz NM, Fine DM, Ono M, Barodka VM, Lester LC, Yenokyan G, Hogue CW. Defining oliguria during cardiopulmonary bypass and its relationship with cardiac surgery-associated acute kidney injury. Br J Anaesth 2018; 117:733-740. [PMID: 27956671 DOI: 10.1093/bja/aew340] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND While urine flow rate ≤0.5 ml kg-1 h-1 is believed to define oliguria during cardiopulmonary bypass (CPB), it is unclear whether this definition identifies risk for acute kidney injury (AKI) . The purpose of this retrospective study was to evaluate if urine flow rate during CPB is associated with AKI. METHODS Urine flow rate was calculated in 503 patients during CPB. AKI in the first 48 h after surgery was defined by the Kidney Disease: Improving Global Outcomes classification. Adjusted risk factors associated with AKI and urine flow rate were assessed. RESULTS Patients with AKI [n=149 (29.5%)] had lower urine flow rate than those without AKI (P<0.001). The relationship between urine flow and AKI risk was non-linear, with an inflection point at 1.5 ml kg-1 h-1 Among patients with urine flow <1.5 ml kg-1 h-1, every 0.5 ml kg-1 h-1 higher urine flow reduced the adjusted risk of AKI by 26% (95% CI 13-37; P<0.001). Urine flow rate during CPB was independently associated with the risk for AKI. Age up to 80 years and preoperative diuretic use were inversely associated with urine flow rate; mean arterial pressure on CPB (when <87 mmHg) and CPB flow were positively associated with urine flow rate. CONCLUSIONS Urine flow rate during CPB <1.5 ml kg-1 h-1 identifies patients at risk for cardiac surgery-associated AKI. Careful monitoring of urine flow rate and optimizing mean arterial pressure and CPB flow might be a means to ensure renal perfusion during CPB. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00769691 and NCT00981474.
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Affiliation(s)
- D Hori
- Division of Cardiac Surgery, Department of Surgery
| | - N M Katz
- Division of Cardiac Surgery, Department of Surgery
| | - D M Fine
- Division of Nephrology, Department of Medicine
| | - M Ono
- Texas Heart Institute, Houston, TX, USA
| | - V M Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L C Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Yenokyan
- Biostatistics Consulting Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - C W Hogue
- Division of Cardiac Surgery, Department of Surgery .,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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87
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Low perfusion pressure is associated with renal tubular injury in infants undergoing cardiac surgery with cardiopulmonary bypass. Eur J Anaesthesiol 2018; 35:581-587. [DOI: 10.1097/eja.0000000000000782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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88
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Abstract
There is significant evidence that many older surgical patients experience at least a transient decrease in cognitive function. Although there is still equipoise regarding the degree, duration, and mechanism of cognitive dysfunction, there is a concurrent need to provide best-practice clinical evidence. The two major cognitive disorders seen after surgery are postoperative delirium and postoperative cognitive dysfunction. Delirium is a public health problem; millions of dollars are spent annually on delirium-related medical resource use and prolonged hospital stays. Postoperative cognitive dysfunction is a research construct that historically signifies decline in performance on a neuropsychiatric test or group of tests and begins days to weeks after surgery. This review focuses on the current state of information gathered by several interdisciplinary stakeholder groups. Although there is still a need for high-level evidence to guide clinical practice, there is an emerging literature that can guide practitioners.
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Affiliation(s)
- C Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Sheikh Zayed Tower, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - S Deiner
- Departments of Anesthesiology .,Neurosurgery.,Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box #1010, New York, NY 10029-6574, USA
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89
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Miyazawa H, Ookawara S, Ito K, Ueda Y, Yanai K, Ishii H, Mutsuyoshi Y, Kitano T, Shindo M, Aomatsu A, Hirai K, Hoshino T, Morishita Y. Association of cerebral oxygenation with estimated glomerular filtration rate and cognitive function in chronic kidney disease patients without dialysis therapy. PLoS One 2018; 13:e0199366. [PMID: 29940017 PMCID: PMC6016918 DOI: 10.1371/journal.pone.0199366] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/06/2018] [Indexed: 01/08/2023] Open
Abstract
Background A decline in estimated glomerular filtration rate (eGFR) is reportedly associated with increased prevalence rates of cognitive impairment. However, data concerning the association between the cerebral saturation of oxygen (rSO2) and cognitive function of patients with chronic kidney disease (CKD) is limited. This study aimed to (i) elucidate the clinical factors associating with cerebral rSO2 and (ii) investigate the association between cerebral rSO2 and cognitive assessment in CKD patients. Methods A total of 40 CKD patients not requiring dialysis (26 men and 14 women; mean age, 61.0 ± 2.7 years) were recruited. The numbers of patients at each CKD stage were as follows: G1, 5; G2, 8; G3a, 6; G3b, 5; G4, 11; and G5, 5. Cerebral rSO2 was monitored at the forehead using the oxygen saturation monitor INVOS 5100C. The cognitive function of each patient was confirmed using the Mini-Mental State Examination (MMSE). Results Cerebral rSO2 levels were significantly higher in CKD patients than in hemodialysis patients (63.8 ± 1.5% vs. 44.9 ± 2.2%, p < 0.001). Multiple regression analysis showed that cerebral rSO2 was independently associated with eGFR (standardized coefficient: 0.530), serum albumin concentration (standardized coefficient: 0.365), and serum sodium concentration (standardized coefficient: 0.224). Furthermore, MMSE showed a significantly positive correlation with cerebral rSO2 (r = 0.624, p < 0.001). Conclusions Cerebral rSO2 was affected by eGFR and serum albumin and sodium concentrations in CKD patients. Furthermore, cerebral rSO2 monitoring, which reflected MMSE scores, might be a useful method for assessing cognitive function in CKD patients.
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Affiliation(s)
- Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
- * E-mail:
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuichiro Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Katsunori Yanai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroki Ishii
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuko Mutsuyoshi
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taisuke Kitano
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsutoshi Shindo
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Akinori Aomatsu
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Alnawaiseh M, Ertmer C, Seidel L, Arnemann PH, Lahme L, Kampmeier TG, Rehberg SW, Heiduschka P, Eter N, Hessler M. Feasibility of optical coherence tomography angiography to assess changes in retinal microcirculation in ovine haemorrhagic shock. Crit Care 2018; 22:138. [PMID: 29843760 PMCID: PMC5975442 DOI: 10.1186/s13054-018-2056-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/07/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND This study aimed to investigate the feasibility of optical coherence tomography angiography (OCT-A) for quantitative analysis of flow density to assess changes in retinal perfusion in an experimental model of haemorrhagic shock. METHODS Haemorrhagic shock was induced in five healthy, anaesthetized sheep by stepwise blood withdrawal of 3 × 10 ml∙kg- 1 body weight. OCT-A imaging of retinal perfusion was performed using an OCT device. Incident dark-field illumination microscopy videos were obtained for the evaluation of conjunctival microcirculation. Haemodynamic variables and flow density data in the OCT angiogram were analysed before and during progressive haemorrhage resulting in haemorrhagic shock as well as after fluid resuscitation with 10 ml∙kg- 1 body weight of balanced hydroxyethyl starch solution (6% HES 130/0.4). Videos of the conjunctival microcirculation were recorded at baseline, in haemorrhagic shock, and after resuscitation. Data are presented as median with interquartile range. Comparisons between time points were made using Friedman's test and the degree of correlation between two variables was expressed as Spearman's rank correlation coefficient. RESULTS Mean arterial pressure and cardiac index (CI) decreased and lactate concentration increased after induction of shock, and haemodynamics recovered after resuscitation. The flow density in the superficial retinal OCT angiogram decreased significantly after shock induction (baseline 44.7% (40.3; 50.5) vs haemorrhagic shock 34.5% (32.8; 40.4); P = 0.027) and recovered after fluid resuscitation (46.9% (41.7; 50.7) vs haemorrhagic shock; P = 0.027). The proportion of perfused vessels of the conjunctival microcirculation showed similar changes. The flow density measured using OCT-A correlated with the conjunctival microcirculation (perfused vessel density: Spearman's rank correlation coefficient ρ = 0.750, P = 0.001) and haemodynamic parameters (CI: ρ = 0.693, P < 0.001). CONCLUSIONS Retinal flow density, measured using OCT-A, significantly decreased in shock and recovered after fluid therapy in an experimental model of haemorrhagic shock. OCT-A is feasible to assess changes in retinal perfusion in haemorrhagic shock and fluid resuscitation.
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Affiliation(s)
- Maged Alnawaiseh
- Department of Ophthalmology, University of Muenster Medical Centre, Domagkstraße 15, 48149 Muenster, Germany
| | - Christian Ertmer
- Department of Anaesthesiology, Intensive Care, and Pain Therapy, University of Muenster Medical Centre, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Laura Seidel
- Department of Anaesthesiology, Intensive Care, and Pain Therapy, University of Muenster Medical Centre, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Philip Helge Arnemann
- Department of Anaesthesiology, Intensive Care, and Pain Therapy, University of Muenster Medical Centre, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Larissa Lahme
- Department of Ophthalmology, University of Muenster Medical Centre, Domagkstraße 15, 48149 Muenster, Germany
| | - Tim-Gerald Kampmeier
- Department of Anaesthesiology, Intensive Care, and Pain Therapy, University of Muenster Medical Centre, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Sebastian Willy Rehberg
- Department of Anaesthesiology, University of Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - Peter Heiduschka
- Department of Ophthalmology, University of Muenster Medical Centre, Domagkstraße 15, 48149 Muenster, Germany
| | - Nicole Eter
- Department of Ophthalmology, University of Muenster Medical Centre, Domagkstraße 15, 48149 Muenster, Germany
| | - Michael Hessler
- Department of Anaesthesiology, Intensive Care, and Pain Therapy, University of Muenster Medical Centre, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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91
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Kumpaitiene B, Svagzdiene M, Sirvinskas E, Adomaitiene V, Petkus V, Zakelis R, Krakauskaite S, Chomskis R, Ragauskas A, Benetis R. Cerebrovascular autoregulation impairments during cardiac surgery with cardiopulmonary bypass are related to postoperative cognitive deterioration: prospective observational study. Minerva Anestesiol 2018; 85:594-603. [PMID: 29756691 DOI: 10.23736/s0375-9393.18.12358-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) occurs in approximately 33-83% of patients after cardiac surgery with cardiopulmonary bypass (CPB). Recent clinical data suggest that real-time, intraoperative monitoring of patient-specific cerebrovascular autoregulation (CA) may help to prevent POCD by detecting individual critical limits for mean arterial pressure (MAP) outside which CA is impaired. Objectives of the study were to detect the episodes of impaired CA during cardiac surgery with CPB, and to investigate the association between CA impairment and POCD. METHODS The observational study of non-invasive ultrasonic volumetric CA monitoring included 59 patients undergoing elective coronary artery bypass graft surgery with CPB. All patients underwent series of neuropsychological tests the day before and ten days after the surgery in order to evaluate cognitive function. RESULTS Twenty-two patients (37%) experienced POCD, 37 patients (63%) showed no cognitive deterioration. The duration of the single longest CA impairment event was found reliably associated with occurrence of POCD (P<0.05). The critical duration of the single longest CA impairment event was 5.03 minutes (odds ratio 14.5; CI 3.9-51.8) for studied population. CONCLUSIONS Prospective clinical study showed that single longest CA impairment may result in post-operative deterioration of mental abilities. The duration of the single longest CA impairment event is the risk factor that is associated with POCD.
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Affiliation(s)
| | - Milda Svagzdiene
- Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Edmundas Sirvinskas
- Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Rolandas Zakelis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Solventa Krakauskaite
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Romanas Chomskis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Rimantas Benetis
- Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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92
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Chan B, Butler E, Frost SA, Chuan A, Aneman A. Cerebrovascular autoregulation monitoring and patient-centred outcomes after cardiac surgery: a systematic review. Acta Anaesthesiol Scand 2018; 62:588-599. [PMID: 29573399 DOI: 10.1111/aas.13115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/16/2018] [Accepted: 02/19/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Impaired cerebrovascular autoregulation (CVAR) is observed in up to 20% of cardiac surgical patients. This systematic review aims to evaluate the association between impaired CVAR, measured by current monitoring techniques, and patient-centred outcomes in adults following cardiac surgery. METHODS MEDLINE, EMBASE, PubMed, MEDLINE In-Process and Cochrane Library were systematically searched through 8 December 2017. Studies were included if they assessed associations between CVAR and patient-centred outcomes in the adult cardiac surgical population. The primary outcome of this systematic review was mortality. Secondary outcomes were stroke, delirium and acute kidney injury. Risk of bias was systematically assessed, and the GRADE methodology was used to evaluate the quality of evidence across outcomes. RESULTS Eleven observational studies and no randomised controlled trials met the inclusion criteria. Due to methodological heterogeneity, meta-analysis was not possible. There was a high risk of bias within individual studies and low quality of evidence across outcomes. Of the included studies, one assessed mortality, five assessed stroke, four assessed delirium, and three assessed acute kidney injury. No reliable conclusions can be drawn from the one study assessing mortality. Interpretation of studies investigating CVAR and stroke, delirium and acute kidney injury was complicated by the lack of standardisation of monitoring techniques as well as varying definitions of impaired CVAR. CONCLUSIONS There is a paucity of high quality evidence for CVAR monitoring and its associations with outcome measures in post-cardiac surgical patients, highlighting the need for future studies.
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Affiliation(s)
- B. Chan
- Faculty of Medicine; University of New South Wales; Sydney NSW Australia
| | - E. Butler
- Faculty of Medicine; University of New South Wales; Sydney NSW Australia
| | - S. A. Frost
- Intensive Care Unit; Liverpool Hospital; Liverpool NSW Australia
- Ingham Institute for Applied Medical Research; Sydney NSW Australia
- South Western Sydney Clinical School; University of New South Wales; Sydney NSW Australia
- Centre for Applied Nursing Research; Western Sydney University; Sydney NSW Australia
| | - A. Chuan
- Ingham Institute for Applied Medical Research; Sydney NSW Australia
- South Western Sydney Clinical School; University of New South Wales; Sydney NSW Australia
- Department of Anaesthesia; Liverpool Hospital; Liverpool NSW Australia
| | - A. Aneman
- Intensive Care Unit; Liverpool Hospital; Liverpool NSW Australia
- Ingham Institute for Applied Medical Research; Sydney NSW Australia
- South Western Sydney Clinical School; University of New South Wales; Sydney NSW Australia
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93
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Kwon HM, Moon YJ, Jung KW, Jeong HW, Park YS, Jun IG, Song JG, Hwang GS. Low Mean Arterial Blood Pressure is Independently Associated with Postoperative Acute Kidney Injury After Living Donor Liver Transplantation: A Propensity Score Weighing Analysis. Ann Transplant 2018. [PMID: 29632296 PMCID: PMC6248026 DOI: 10.12659/aot.908329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background As end-stage liver disease progresses, renal blood flow linearly correlates with mean arterial blood pressure (MBP) due to impaired autoregulation. We investigated whether the lower degree of postoperative MBP would predict the occurrence of postoperative acute kidney injury (AKI) after liver transplantation. Material/Methods This retrospective study enrolled 1,136 recipients with normal preoperative kidney function. Patients were categorized into two groups according to the averaged postoperative MBP: <90 mmHg (MBPbelow90) and ≥90 mmHg (MBPover90). The primary endpoint was occurrence of postoperative AKI, defined by the creatinine criteria of the Kidney Disease Improving Global Outcomes. The logistic regression model with inverse probability treatment weighting (IPTW) of propensity score was used to compare the risk of postoperative AKI between two groups. Results MBPbelow90 group (83.0±5.1 mmHg) showed higher prevalence and risk of postoperative AKI (74.2% versus 62.6%, p<0.001; IPTW-OR 1.34 [1.12–1.61], p=0.001) compared with MBPover90 group (97.3±5.2 mmHg). When stratified by quartiles of baseline cystatin C glomerular filtration ratio (GFR), the association between MBPbelow90 and postoperative AKI remained significant only with the lowest quartile (cystatin C GFR ≤85 mL/min/1.73 m2; IPTW-OR 2.24 [1.53–3.28], p<0.001), but not with 2nd–4th quartiles. Conclusions Our results suggest that maintaining supranormal MBP over 90 mmHg may be beneficial to reduce the risk of post-LT AKI, especially for liver transplant recipients with cystatin C GFR ≤85 mL/min/1.73 m2.
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Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyeo-Woon Jung
- Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hye-Won Jeong
- Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yong-Seok Park
- Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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94
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Obata Y, Barodka V, Berkowitz DE, Gottschalk A, Hogue CW, Steppan J. Relationship Between the Ambulatory Arterial Stiffness Index and the Lower Limit of Cerebral Autoregulation During Cardiac Surgery. J Am Heart Assoc 2018; 7:JAHA.117.007816. [PMID: 29437601 PMCID: PMC5850197 DOI: 10.1161/jaha.117.007816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Pulse pressure, the ambulatory arterial stiffness index (AASI), and the symmetric AASI are established predictors of adverse cardiovascular outcomes. However, little is known about their relationship to cerebral autoregulation. This study evaluated whether these markers of vascular properties relate to the lower limit of cerebral autoregulation (LLA). Methods and Results The LLA was determined during cardiac surgery with transcranial Doppler ultrasonography in 181 patients. All other variables were calculated from continuous intraoperative readings obtained before cardiopulmonary bypass. The LLA varied directly with the AASI (β=3.12 per 0.1 change in AASI, P<0.001) and to a lesser extent the symmetric AASI (β=2.02 per 0.1 change in symmetric AASI, P≤0.022), while peripheral pulse pressure was not significantly related (β=0.0, P>0.99). Logistic regression revealed that the likelihood of LLA being >65 mm Hg increased by 50% (95% confidence interval, 11%–102%, P=0.008) for every 0.1 increase in the AASI. The AASI was able to predict a LLA above certain thresholds (area under the curve receiver operating characteristic for AASI predicting an LLA >65 mm Hg: 0.60; 95% confidence interval, 0.51%–0.68%, P=0.043). Incorporating additional variables improved the model's predictive ability (area under the curve for AASI predicting a LLA >65 mm Hg: 0.75; 95% confidence interval, 0.68–0.82, P=0.036). Conclusions These data indicate that the LLA is related to the mechanical properties of the vasculature as represented by the AASI. The AASI can be used to predict LLA threshold levels during cardiac surgery. It is now possible to link elevations in the LLA with an increased AASI as determined from readily accessible intraoperative variables.
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Affiliation(s)
- Yurie Obata
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Viachaslau Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Dan E Berkowitz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.,Department of Biomedical Engineering, Johns Hopkins University Baltimore, MD
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Charles W Hogue
- Department of Anesthesiology, Northwestern University Feinberg, Chicago, IL
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
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95
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Hood R, Budd A, Sorond FA, Hogue CW. Peri-operative neurological complications. Anaesthesia 2018; 73 Suppl 1:67-75. [DOI: 10.1111/anae.14142] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 11/27/2022]
Affiliation(s)
- R. Hood
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - A. Budd
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - F. A. Sorond
- Department of Neurology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - C. W. Hogue
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
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96
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Chang AJ, Nomura Y, Barodka VM, Hori D, Magruder JT, Katz NM, Berkowitz DE, Hogue CW. Validation of a Real-Time Minute-to-Minute Urine Output Monitor and the Feasibility of Its Clinical Use for Patients Undergoing Cardiac Surgery. Anesth Analg 2017; 125:1883-1886. [PMID: 29190218 DOI: 10.1213/ane.0000000000002217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute kidney injury after cardiac surgery is associated with increased morbidity and mortality. Methods for measuring urine output in real time may better ensure renal perfusion perioperatively in contrast to the current standard of care where urine output is visually estimated after empiric epochs of time. In this study, we describe an accurate method for monitoring urine output continuously during cardiopulmonary bypass. This may provide a means for setting patient-specific targets for blood pressure and cardiopulmonary bypass flow as a potential strategy to reduce the risk for acute kidney injury.
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Affiliation(s)
- Aaron J Chang
- From the Center for Bioengineering Innovation and Design, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Yohei Nomura
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Viachaslau M Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan T Magruder
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nevin M Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dan E Berkowitz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charles W Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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97
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Zorrilla-Vaca A, Ziai W, Connolly ES, Geocadin R, Thompson R, Rivera-Lara L. Acute Kidney Injury Following Acute Ischemic Stroke and Intracerebral Hemorrhage: A Meta-Analysis of Prevalence Rate and Mortality Risk. Cerebrovasc Dis 2017; 45:1-9. [PMID: 29176313 DOI: 10.1159/000479338] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 07/06/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The epidemiology of acute renal dysfunction after stroke is routinely overlooked following stroke events. Our aim in this meta-analysis is to report the prevalence of acute kidney injury (AKI) following acute stroke and its impact on mortality. METHODS A systematic literature search was performed on PubMed, EMBASE and Google Scholar for observational studies examining the prevalence and mortality risk of stroke patients with AKI as a complication. The pooled prevalence rates and odds ratios for mortality risk were calculated using subgroup analyses between the stroke subtypes: acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). RESULTS A total of 12 studies (4,532,181 AIS and 615,636 ICH) were included. The pooled prevalence rate of AKI after all stroke types was 11.6% (95% CI 10.6-12.7). Subgroup analyses revealed that the pooled prevalence rate of AKI after AIS was greater but not statistically significantly different than ICH (19.0%; 95% CI 8.2-29.7 vs. 12.9%; 95% CI 10.3-15.5, p = 0.5). AKI was found to be a significant risk factor of mortality in AIS (adjusted OR [aOR] 2.23; 95% CI 1.28-3.89; I2 = 98.8%), whereas this relationship did not reach statistical significance in ICH (aOR 1.20; 95% CI 0.68-2.12; I2 = 74.2%). CONCLUSIONS This meta-analysis provides evidence that AKI is a common complication following both AIS and ICH and it is associated with increased mortality following AIS but not ICH. This highlights the need for early assessment of renal function in the acute phase of AIS, in particular, and avoidance of factors than may induce AKI in vulnerable patients.
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Affiliation(s)
- Andrés Zorrilla-Vaca
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Faculty of Health, Universidad del Valle, Cali, Colombia
| | - Wendy Ziai
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins Bayview Medical Institutions, Baltimore, Maryland, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Romer Geocadin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins Bayview Medical Institutions, Baltimore, Maryland, USA
| | - Richard Thompson
- Bloomberg Johns Hopkins Public Health School, Baltimore, Maryland, USA
| | - Lucia Rivera-Lara
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins Bayview Medical Institutions, Baltimore, Maryland, USA
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98
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Caldas JR, Haunton VJ, Panerai RB, Hajjar LA, Robinson TG. Cerebral autoregulation in cardiopulmonary bypass surgery: a systematic review. Interact Cardiovasc Thorac Surg 2017; 26:494-503. [DOI: 10.1093/icvts/ivx357] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/03/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Juliana R Caldas
- Department of Anesthesia, Heart Institute, University of São Paulo, São Paulo, Brazil
- Hospital Sao Rafael, Salvador, Bahia, Brazil
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ludhmila A Hajjar
- Department of Anesthesia, Heart Institute, University of São Paulo, São Paulo, Brazil
- Department of Cardiopneumology, Heart Institute, University of São Paulo, Brazil
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
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99
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Nenna A, Barbato R, Greco SM, Pugliese G, Lusini M, Covino E, Chello M. Near-infrared spectroscopy in adult cardiac surgery: between conflicting results and unexpected uses. J Geriatr Cardiol 2017; 14:659-661. [PMID: 29321795 PMCID: PMC5756738 DOI: 10.11909/j.issn.1671-5411.2017.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/13/2017] [Accepted: 10/17/2017] [Indexed: 12/04/2022] Open
Affiliation(s)
- Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Raffaele Barbato
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Giuseppe Pugliese
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Mario Lusini
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Elvio Covino
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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100
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Lannemyr L, Lundin E, Reinsfelt B, Bragadottir G, Redfors B, Oras J, Ricksten SE. Renal tubular injury during cardiopulmonary bypass as assessed by urinary release of N-acetyl-ß-D-glucosaminidase. Acta Anaesthesiol Scand 2017; 61:1075-1083. [PMID: 28748536 DOI: 10.1111/aas.12946] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 06/14/2017] [Accepted: 06/30/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication with a major impact on morbidity and mortality after cardiac surgery with cardiopulmonary bypass (CPB). The aim of the present study was to perform a detailed analysis on the release of the tubular injury biomarker N-acetyl-b-D-glucosaminidase (NAG) during and early after CPB and to describe independent predictors of maximal tubular injury. We hypothesized that renal tubular injury occurs early after the onset of CPB. METHODS In this prospective observational study, we included 61 patients undergoing open cardiac surgery with an expected CPB duration exceeding 60 min. The urinary NAG levels were measured at 30 min intervals during CPB, as well as early (30 min) after CPB and post-operatively. Independent predictors of tubular injury were identified using an Interquantile multivariate regression model. RESULTS Already 30 min after the onset of CPB, NAG excretion was significantly increased (P < 0.001), followed by a sixfold peak increase after discontinuation of CPB (P < 0.001). In the multivariable regression model, CPB duration (P < 0.05) and the degree of rewarming during CPB (P < 0.05), were independent predictors of peak NAG excretion. CONCLUSION In cardiac surgery, a renal tubular cell injury is seen early after onset of CPB with a peak biomarker increase early after end of CPB. The magnitude of this tubular injury is independently related to CPB duration and the degree of rewarming. Efforts made to decrease the CPB duration and to avoid hypothermia and the need for rewarming may decrease the risk for tubular injury.
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Affiliation(s)
- L. Lannemyr
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - E. Lundin
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - B. Reinsfelt
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - G. Bragadottir
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - B. Redfors
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - J. Oras
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
| | - S.-E. Ricksten
- Department of Anaesthesiology and Intensive Care Medicine; Sahlgrenska Academy; Sahlgrenska University Hospital; University of Gothenburg; Gothenburg Sweden
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