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Beqiri E, García-Orellana M, Politi A, Zeiler FA, Placek MM, Fàbregas N, Tas J, De Sloovere V, Czosnyka M, Aries M, Valero R, de Riva N, Smielewski P. Cerebral autoregulation derived blood pressure targets in elective neurosurgery. J Clin Monit Comput 2024; 38:649-662. [PMID: 38238636 PMCID: PMC11164832 DOI: 10.1007/s10877-023-01115-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/23/2023] [Indexed: 06/11/2024]
Abstract
Poor postoperative outcomes may be associated with cerebral ischaemia or hyperaemia, caused by episodes of arterial blood pressure (ABP) being outside the range of cerebral autoregulation (CA). Monitoring CA using COx (correlation between slow changes in mean ABP and regional cerebral O2 saturation-rSO2) could allow to individualise the management of ABP to preserve CA. We aimed to explore a continuous automated assessment of ABPOPT (ABP where CA is best preserved) and ABP at the lower limit of autoregulation (LLA) in elective neurosurgery patients. Retrospective analysis of prospectively collected data of 85 patients [median age 60 (IQR 51-68)] undergoing elective neurosurgery. ABPBASELINE was the mean of 3 pre-operative non-invasive measurements. ABP and rSO2 waveforms were processed to estimate COx-derived ABPOPT and LLA trend-lines. We assessed: availability (number of patients where ABPOPT/LLA were available); time required to achieve first values; differences between ABPOPT/LLA and ABP. ABPOPT and LLA availability was 86 and 89%. Median (IQR) time to achieve the first value was 97 (80-155) and 93 (78-122) min for ABPOPT and LLA respectively. Median ABPOPT [75 (69-84)] was lower than ABPBASELINE [90 (84-95)] (p < 0.001, Mann-U test). Patients spent 72 (56-86) % of recorded time with ABP above or below ABPOPT ± 5 mmHg. ABPOPT and ABP time trends and variability were not related to each other within patients. 37.6% of patients had at least 1 hypotensive insult (ABP < LLA) during the monitoring time. It seems possible to assess individualised automated ABP targets during elective neurosurgery.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Marta García-Orellana
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria
| | - Anna Politi
- Department of Anesthesiology, Intensive Care and Pain Medicine, Milano Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Univesity of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Neus Fàbregas
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Jeanette Tas
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht UMC, Maastricht, The Netherlands
| | - Veerle De Sloovere
- Department of Anesthesiology, University Hospitals Leuven, Louvain, Belgium
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht UMC, Maastricht, The Netherlands
| | - Ricard Valero
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Mohr NL, Krannich A, Jung H, Hulde N, von Dossow V. Intraoperative Blood Pressure Management and Its Effects on Postoperative Delirium After Cardiac Surgery: A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:1127-1134. [PMID: 38369449 DOI: 10.1053/j.jvca.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES There is accumulating evidence that blood pressure management might be associated with end-organ dysfunction after cardiac surgery. This study aimed to investigate the impact of intraoperative hypotension (IOH) on adverse neurologic outcomes and mortality. DESIGN A single-center retrospective cohort study. SETTING The Heart and Diabetes Centre Bad Oeynhausen NRW, Ruhr-University Bochum. PARTICIPANTS This retrospective cohort study included 31,315 adult patients who underwent elective cardiac surgery at the authors' institution between January 2009 and December 2018. INTERVENTIONS All cardiac surgery procedures except assist device implantation, organ transplantation, and emergency surgery. MEASUREMENTS AND MAIN RESULTS Adverse neurologic outcomes were defined as postoperative delirium and stroke. IOH was defined as mean arterial pressure below 60 mmHg for >2 minutes. The frequency of IOH episodes and the cumulative IOH duration were recorded. The association between IOH and adverse neurologic outcomes was examined with unadjusted statistical analysis and multiple logistic regression analysis. Eight hundred forty-nine (2.9%) patients developed postoperative stroke, and 2,401 (7.7%) patients developed postoperative delirium. The frequency of IOH episodes was independently associated with postoperative delirium in the multiple logistic regression analysis (odds ratio 1.02, 95% CI 1.003-1.03, p < 0.001), whereas there was no association between it and stroke. CONCLUSION This large retrospective monocentric cohort study revealed that increased episodes of IOH were associated with the risk of developing postoperative delirium after cardiac surgery. This might have important clinical implications with respect to careful and precise hemodynamic monitoring and proactive treatment, especially in patients with increased risk for postoperative delirium.
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Affiliation(s)
- Niklas L Mohr
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | | | - Hilke Jung
- Institute of Congenital heart diseases, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Nikolai Hulde
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany.
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Rössler J, Shah K, Medellin S, Turan A, Ruetzler K, Singh M, Sessler DI, Maheshwari K. Development and validation of delirium prediction models for noncardiac surgery patients. J Clin Anesth 2024; 93:111319. [PMID: 37984177 DOI: 10.1016/j.jclinane.2023.111319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023]
Abstract
STUDY OBJECTIVE Postoperative delirium is associated with morbidity and mortality, and its incidence varies widely. Using known predisposing and precipitating factors, we sought to develop postoperative delirium prediction models for noncardiac surgical patients. DESIGN Retrospective prediction model study. SETTING Major quaternary medical center. PATIENTS Our January 2016 to June 2020 training dataset included 51,677 patients of whom 2795 patients had delirium. Our July 2020 to January 2022 validation dataset included 14,438 patients of whom 912 patients had delirium. INTERVENTIONS None. MEASUREMENTS We trained and validated two static prediction models and one dynamic delirium prediction model. For the static models, we used random survival forests and traditional Cox proportional hazard models to predict postoperative delirium from preoperative variables, or from a combination of preoperative and intraoperative variables. We also used landmark modeling to dynamically predict postoperative delirium using preoperative, intraoperative, and postoperative variables before onset of delirium. MAIN RESULTS In the validation analyses, the static random forest model had a c-statistic of 0.81 (95% CI: 0.79, 0.82) and a Brier score of 0.04 with preoperative variables only, and a c-statistic of 0.86 (95% CI: 0.84, 0.87) and a Brier score of 0.04 when preoperative and intraoperative variables were combined. The corresponding Cox models had similar discrimination metrics with slightly better calibration. The dynamic model - using all available data, i.e., preoperative, intraoperative and postoperative data - had an overall c-index of 0.84 (95% CI: 0.83, 0.85). CONCLUSIONS Using preoperative and intraoperative variables, simple static models performed as well as a dynamic delirium prediction model that also included postoperative variables. Baseline predisposing factors thus appear to contribute far more to delirium after noncardiac surgery than intraoperative or postoperative variables. Improved postoperative data capture may help improve delirium prediction and should be evaluated in future studies.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Karan Shah
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, OH, USA
| | - Sara Medellin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Mriganka Singh
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Center on Innovation-Long Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Liu XY, Mu JJ, Han JG, Pang MJ, Zhang K, Zhai WQ, Su N, Ni GJ, Guo ZG, Ming D. Heart-brain axis: low blood pressure during off-pump CABG surgery is associated with postoperative heart failure. Mil Med Res 2024; 11:18. [PMID: 38509590 PMCID: PMC10956228 DOI: 10.1186/s40779-024-00522-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/12/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
- Xiu-Yun Liu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China.
- State Key Laboratory of Advanced Medical Materials and Devices, Tianjin, 300072, China.
- Haihe Laboratory of Brain -Computer Interaction and Human-Machine Integration, Tianjin, 300380, China.
| | - Jing-Jing Mu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China
| | - Jian-Ge Han
- Department of Anesthesiology, Tianjin University Chest Hospital, Tianjin Key Laboratory of Cardiovascular Emergency and Critical Care, Tianjin Municipal Science and Technology Bureau, Tianjin, 300222, China
| | - Mei-Jun Pang
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China
| | - Kuo Zhang
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China
| | - Wen-Qian Zhai
- Department of Anesthesiology, Tianjin University Chest Hospital, Tianjin Key Laboratory of Cardiovascular Emergency and Critical Care, Tianjin Municipal Science and Technology Bureau, Tianjin, 300222, China
| | - Nan Su
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China
| | - Guang-Jian Ni
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China
| | - Zhi-Gang Guo
- Department of Cardiac Surgery, Tianjin University Chest Hospital, Tianjin Key Laboratory of Cardiovascular Emergency and Critical Care, Tianjin Municipal Science and Technology Bureau, Tianjin, 300222, China.
| | - Dong Ming
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China.
- State Key Laboratory of Advanced Medical Materials and Devices, Tianjin, 300072, China.
- Haihe Laboratory of Brain -Computer Interaction and Human-Machine Integration, Tianjin, 300380, China.
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Udzik J, Pacholewicz J, Biskupski A, Safranow K, Wojciechowska-Koszko I, Kwiatkowski P, Roszkowska P, Rogulska K, Dziedziejko V, Marcinowska Z, Kwiatkowski S, Kwiatkowska E. Higher perfusion pressure and pump flow during cardiopulmonary bypass are beneficial for kidney function-a single-centre prospective study. Front Physiol 2024; 15:1257631. [PMID: 38420620 PMCID: PMC10899324 DOI: 10.3389/fphys.2024.1257631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Background: Kidneys play an essential role in the circulatory system, regulating blood pressure and intravascular volume. They are also set on maintaining an adequate filtration pressure in the glomerulus. During the CPB, a decrease in systemic blood pressure and hemoglobin concentration may lead to renal ischemia and subsequent acute kidney injury. Methods: One hundred nine adult patients were prospectively enrolled in this study. The intervention in this study was increasing the flow of the CPB pump to reach the target MAP of > 90 mmHg during the procedure. The control group had a standard pump flow of 2.4 L/min/m2. Results: Standard pump flow of 2.4 L/min/m2 resulted in mean MAP < 90 mmHg during the CPB in most patients in the control group. Maintaining a higher MAP during CPB in this study population did not affect CSA-AKI incidence. However, it increased the intraoperative and postoperative diuresis and decreased renin release associated with CPB. Higher MAP during the CPB did not increase the incidence of cerebrovascular complications after the operation; patients in the highest MAP group had the lowest incidence of postoperative delirium, but the result did not obtain statistical significance. Conclusion: Maintaining MAP > 90 mmHg during the CPB positively impacts intraoperative and postoperative kidney function. It significantly reduces renal hypoperfusion during the procedure compared to MAP < 70 mmHg. MAP > 90 mmHg is safe for the central nervous system, and preliminary results suggest that it may have a beneficial impact on the incidence of postoperative delirium.
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Affiliation(s)
- Jakub Udzik
- Cardiac Surgery Department, Pomeranian Medical University, Szczecin, Poland
| | - Jerzy Pacholewicz
- Cardiac Surgery Department, Pomeranian Medical University, Szczecin, Poland
| | - Andrzej Biskupski
- Cardiac Surgery Department, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | | | - Paweł Kwiatkowski
- Department of Diagnostic Immunology, Pomeranian Medical University, Szczecin, Poland
| | - Paulina Roszkowska
- Department of Diagnostic Immunology, Pomeranian Medical University, Szczecin, Poland
| | - Karolina Rogulska
- Department of Diagnostic Immunology, Pomeranian Medical University, Szczecin, Poland
| | - Violetta Dziedziejko
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Zuzanna Marcinowska
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Sebastian Kwiatkowski
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Szczecin, Poland
| | - Ewa Kwiatkowska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
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Krefting J, Gorki H, Hoenicka M, Albrecht G, Kraft R, Liebold A. Target flow deviations on the cardiopulmonary bypass cause postoperative delirium in cardiothoracic surgery-a retrospective study evaluating temporal fluctuations of perfusion data. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae016. [PMID: 38291898 PMCID: PMC10853608 DOI: 10.1093/icvts/ivae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 01/09/2024] [Accepted: 01/28/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES Postoperative delirium (POD) is common, costly and associated with long-term morbidity and increased mortality. We conducted a cohort study to assess the contribution of cardiopulmonary bypass (CPB) to the development of POD by means of algorithm-based data processing. METHODS A database was compiled from 3 datasets of patients who underwent cardiac surgery between 2014 and 2019: intensive care unit discharge files, CPB protocols and medical quality management records. Following data extraction and structuring using novel algorithms, missing data were imputed. Ten independent imputations were analysed by multiple logistic regression with stepwise deletion of factors to arrive at a minimal adequate model. RESULTS POD was diagnosed in 456/3163 patients (14.4%). In addition to known demographic risk factors and comorbidities like male sex, age, carotid disease, acute kidney failure and diabetes mellitus, cardiopulmonary parameters like total blood volume at the CPB [adjusted odds ratio (AOR) 1.001; confidence interval (CI) 1.1001-1.002] were independent predictors of POD. Higher values of the minimal blood flow were associated with a lower risk of POD (AOR 0.993; CI 0.988-0.997). Flow rates at least 30% above target did emerge in the minimal adequate model as a potential risk factor, but the confidence interval suggested a lack of statistical significance (AOR 1.819; 95% CI: 0.955-3.463). CONCLUSIONS CPB data processing proved to be a useful tool for obtaining compact information to better identify the roles of individual operational states. Strict adherence to perfusion limits along with tighter control of blood flow and acid-base balance during CPB may help to further decrease the risk of POD.
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Affiliation(s)
- Johannes Krefting
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Hagen Gorki
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Günter Albrecht
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Robert Kraft
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
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Zulauf FN, Sikora N. CON: There Should be an Individualized Optimal Perfusion Pressure on CPB. J Cardiothorac Vasc Anesth 2024; 38:566-568. [PMID: 37648612 DOI: 10.1053/j.jvca.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Fabio Nicolas Zulauf
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Normunds Sikora
- Children's Clinical University Hospital, Department of Paediatric Cardiology and Cardiac Surgery, Riga Stradins University, Department of Surgery, Riga, Latvia
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8
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Ramachandran RV, Subramaniam B. Pro: Individualized Optimal Perfusion Pressure-Maximizing Patient Care During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2024; 38:563-565. [PMID: 38065696 DOI: 10.1053/j.jvca.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/03/2023] [Accepted: 10/21/2023] [Indexed: 01/27/2024]
Abstract
Cardiopulmonary bypass (CPB) has revolutionized cardiac surgery but poses challenges such as hemodynamic instability and adverse clinical outcomes. Achieving optimal perfusion during CPB ensures adequate oxygen delivery to vital organs. Although mean arterial pressure is a key determinant of perfusion pressure, clear guidelines for optimal perfusion have yet to be established. Autoregulation, the organ's ability to maintain consistent blood flow, plays a vital role in perfusion. Individual variability in autoregulation responses and intraoperative factors necessitate an individualized approach to determining the autoregulation range. Continuous assessment of autoregulation during surgery allows for personalized perfusion targets, optimizing organ perfusion. Exploring techniques like multimodal intravenous anesthesia guided by electroencephalogram can enhance perfusion maintenance within the auto-regulatory range. By adopting an individualized approach to perfusion targets on CPB, we can improve outcomes and enhance patient care.
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Kamath V, Yanek LR, Neufeld KJ, Lewis A, Aziz H, Le LM, Tian J, Moghekar A, Hogue CW, Brown CH. Poor olfaction prior to cardiac surgery: Association with cognition, plasma neurofilament light, and post-operative delirium. Int J Geriatr Psychiatry 2024; 39:e6066. [PMID: 38314872 PMCID: PMC10958662 DOI: 10.1002/gps.6066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 01/27/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVES Post-operative delirium (POD) affects up to 50% of cardiac surgery patients, with higher incidence in older adults. There is increasing need for screening tools that identify individuals most vulnerable to POD. Here, we examined the relationship between pre-operative olfaction and both incident POD and POD severity in patients undergoing cardiac surgery. We also examined cross-sectional relationships between baseline olfaction, cognition, and plasma neurofilament light (NfL). METHODS Individuals undergoing cardiac surgery (n = 189; mean age = 70 years; 75% men) were enrolled in a clinical trial of cerebral autoregulation monitoring. At baseline, odor identification performance (Brief Smell Identification Test), cognitive performance, and plasma concentrations of NfL levels (Simoa™ NF-Light Assay) were measured. Delirium was assessed with the Confusion Assessment Method (CAM) or CAM-ICU, and delirium severity was assessed using the Delirium Rating Scale-Revised-98. The association of baseline olfaction, delirium incidence, and delirium severity was examined in regression models adjusting for age, duration of cardiopulmonary bypass, logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), and baseline cognition. RESULTS Olfactory dysfunction was present in 30% of patients, and POD incidence was 44%. Pre-operative olfactory dysfunction was associated with both incident POD (OR = 3.17, p = 0.001) and greater severity of POD after cardiac surgery (OR = 3.94 p < 0.001) in models adjusted for age, duration of bypass, and a surgical risk score. The addition of baseline cognition attenuated the strength of the association, but it remained significant for incident POD (OR = 2.25, p = 0.04) and POD severity (OR 2.10, p = 0.04). Poor baseline olfaction was associated with greater baseline cognitive dysfunction (p < 0.001) and increased baseline plasma NfL concentrations (p = 0.04). Neither age, cognition, nor baseline NFL concentration modified the association of impaired olfaction and delirium outcomes. CONCLUSIONS Olfactory assessment may be a useful pre-surgical screening tool for the identification of patients undergoing cardiac surgery at increased risk of POD. Identifying those at highest risk for severe delirium and poor cognitive outcomes following surgery would allow for earlier intervention and pre-operative rehabilitation strategies, which could ultimately impact the functional disability and morbidity associated with POD.
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Affiliation(s)
- Vidyulata Kamath
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa R Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Alexandria Lewis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hamza Aziz
- Department of Surgery Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lan M Le
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Emergent Biosolutions Company, Gaithersburg, Maryland, USA
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles W Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Charles H Brown
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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10
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Brown CH, Kim AS, Yanek L, Lewis A, Mandal K, Le L, Tian J, Neufeld KJ, Hogue C, Moghekar A. Association of perioperative plasma concentration of neurofilament light with delirium after cardiac surgery: a nested observational study. Br J Anaesth 2024; 132:312-319. [PMID: 38114355 PMCID: PMC10808824 DOI: 10.1016/j.bja.2023.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 10/12/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Neurofilament light is a blood-based biomarker of neuroaxonal injury that can provide insight into perioperative brain vulnerability and injury. Prior studies have suggested that increased baseline and postoperative concentrations of neurofilament light are associated with delirium after noncardiac surgery, but results are inconsistent. Results have not been reported in cardiac surgery patients, who are among those at highest risk for delirium. We hypothesised that perioperative blood concentrations of neurofilament light (both baseline and change from baseline to postoperative day 1) are associated with delirium after cardiac surgery. METHODS This study was nested in a trial of arterial blood pressure targeting during cardiopulmonary bypass using cerebral autoregulation metrics. Blood concentrations of neurofilament light were measured at baseline and on postoperative day 1. The primary outcome was postoperative delirium. Regression models were used to examine the associations between neurofilament light concentration and delirium and delirium severity, adjusting for age, sex, race, logistic European System for Cardiac Operative Risk Evaluation, bypass duration, and cognition. RESULTS Delirium occurred in 44.6% of 175 patients. Baseline neurofilament light concentration was higher in delirious than in non-delirious patients (median 20.7 pg ml-1 [IQR 16.1-33.2] vs median 15.5 pg ml-1 [IQR 12.1-24.2], P<0.001). In adjusted models, greater baseline neurofilament light concentration was associated with delirium (odds ratio, 1.027; 95% confidence interval, 1.003-1.053; P=0.029) and delirium severity. From baseline to postoperative day 1, neurofilament light concentration increased by 42%, but there was no association with delirium. CONCLUSIONS Baseline neurofilament light concentration, but not change from baseline to postoperative day 1, was associated with delirium after cardiac surgery.
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Affiliation(s)
- Charles H Brown
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Alexander S Kim
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Highland Hospital-Alameda Health System, Oakland, CA, USA
| | - Lisa Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandria Lewis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kaushik Mandal
- Department of Surgery, Detroit Medical Center, Detroit, MI, USA
| | - Lan Le
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Emergent Biosolutions Company, Gaithersburg, MD, USA
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, ON, Canada
| | - Charles Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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Khan JM, Shore A, Lee KFH, Wood MD, Maslove DM, Hunt M, Georgescu I, Muscedere J, Boyd JG. Cerebral autoregulation-based mean arterial pressure targets and delirium in critically ill adults without brain injury: a retrospective cohort study. Can J Anaesth 2024; 71:107-117. [PMID: 37932650 DOI: 10.1007/s12630-023-02609-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE Cerebral autoregulation (CA) is a mechanism that acts to maintain consistent cerebral perfusion across a range of blood pressures, and impaired CA is associated with delirium. Individualized CA-derived blood pressure targets are poorly characterized in critically ill patients and the association with intensive care unit (ICU) delirium is unknown. Our objectives were to characterize optimal mean arterial pressure (MAPopt) ranges in critically ill adults without brain injury and determine whether deviations from these targets contribute to ICU delirium. METHODS We performed a retrospective cohort analysis of patients with shock of any etiology and/or respiratory failure requiring invasive mechanical ventilation, without a neurologic admitting diagnosis. Patients were screened daily for delirium. Cerebral oximetry and mean arterial pressure data were captured for the first 24 hr from enrolment. RESULTS Forty-two patients with invasive blood pressure monitoring data were analyzed. Optimal mean arterial pressure targets ranged from 55 to 100 mm Hg. Optimal mean arterial pressure values were not significantly different based on history of hypertension or delirium status, and delirium was not associated with deviations from MAPopt. Nevertheless, the majority (69%) of blood pressure targets exceeded the current 65 mm Hg Surviving Sepsis guidelines. CONCLUSION We observed that MAPopt targets across patients were highly variable, but did not observe an association with the incidence of delirium. Studies designed to evaluate the impact on neurologic outcomes are needed to understand the association with individualized mean arterial pressure targets in the ICU. STUDY REGISTRATION ClinicalTrials.gov (NCT02344043); first submitted 22 January 2015.
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Affiliation(s)
- Jasmine M Khan
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Abigail Shore
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Kevin F H Lee
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michael D Wood
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - David M Maslove
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Miranda Hunt
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Ilinca Georgescu
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - J Gordon Boyd
- Department of Medicine, Queen's University, Kingston, ON, Canada.
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
- Kingston General Hospital, Davies 2, 76 Stuart St., Kingston, ON, K7L 2V7, Canada.
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12
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Andersen L, Appelblad M, Wiklund U, Sundström N, Svenmarker S. Our initial experience of monitoring the autoregulation of cerebral blood flow during cardiopulmonary bypass. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:209-217. [PMID: 38099638 PMCID: PMC10723576 DOI: 10.1051/ject/2023032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/05/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Cerebral blood flow (CBF) is believed to be relatively constant within an upper and lower blood pressure limit. Different methods are available to monitor CBF autoregulation during surgery. This study aims to critically analyze the application of the cerebral oxygenation index (COx), one of the commonly used techniques, using a reference to data from a series of clinical registrations. METHOD CBF was monitored using near-infrared spectroscopy, while cerebral blood pressure was estimated by recordings obtained from either the radial or femoral artery in 10 patients undergoing cardiopulmonary bypass. The association between CBF and blood pressure was calculated as a moving continuous correlation coefficient. A COx index > 0.4 was regarded as a sign of abnormal cerebral autoregulation (CA). Recordings were examined to discuss reliability measures and clinical feasibility of the measurements, followed by interpretation of individual results, identification of possible pitfalls, and suggestions of alternative methods. RESULTS AND CONCLUSION Monitoring of CA during cardiopulmonary bypass is intriguing and complex. A series of challenges and limitations should be considered before introducing this method into clinical practice.
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Affiliation(s)
- Leon Andersen
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
| | - Micael Appelblad
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University 901 87 Umeå Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University 901 87 Umeå Sweden
| | - Staffan Svenmarker
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
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13
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Li K, Hu Z, Li W, Shah K, Sessler D. Tight perioperative blood pressure management to reduce complications: a randomised feasibility trial. BMJ Open 2023; 13:e071328. [PMID: 37977865 PMCID: PMC10660199 DOI: 10.1136/bmjopen-2022-071328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 10/29/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE Evaluate the feasibility of a trial of perioperative hypotension and serious complications. DESIGN A patient and assessor-blinded randomised feasibility trial. SETTING We included patients in a tertiary university hospital. PARTICIPANTS We enrolled 80 adults scheduled for major non-cardiac surgery. INTERVENTIONS In patients randomised to tight blood pressure control, intraoperative mean arterial pressure (MAP) was targeted to ≥85 mm Hg maintained with norepinephrine infusion, and restarting chronic antihypertensive medications was delayed until the third postoperative day. In the reference group, intraoperative blood pressure was managed per routine and antihypertensive medications were restarted immediately after surgery. PRIMARY AND SECONDARY OUTCOME MEASURES Our first co-primary outcome was the fraction of time when intraoperative MAP was >85 mm Hg, intraoperative area (time integral) of MAP >85 mm Hg and MAP <65 mm Hg. The second co-primary outcome was time until antihypertensive medications were restarted after surgery. Secondary outcomes were time-weighted average intraoperative MAP, cumulative minimum MAP for 10 min, average postoperative systolic blood pressure (SBP) and mean of the lowest three postoperative SBPs. RESULTS Forty patients in each group were analysed. The median for intraoperative area of MAP >85 mm Hg was 1303 (772-2419) mm Hg*min in routine blood pressure (BP) cases and 2425 (1926-3545) mm Hg*min in tight BP control. The area for intraoperative MAP <65 mm Hg was 7 (0-40) mm Hg*min with routine BP management, and 0 (0-0) mm Hg*min with tight BP control. The fraction of time with MAP >85 mm Hg was 0.52 (0.25) and 0.87 (0.15). Antihypertensive medications were restarted 2 (1-3) days later in tight BP control cases. However, postoperative SBPs were similar. CONCLUSIONS Tight BP management markedly increased intraoperative MAP and reduced the amount of hypotension. In contrast, delaying chronic antihypertensive medications had little effect on postoperative SBP. The full trial appears feasible and remains necessary but should not include postoperative antihypertensive management. TRIAL REGISTRATION NCT04789733.
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Affiliation(s)
- Kai Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Zhouting Hu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Wangyu Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Karan Shah
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Sessler
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Gilbey T, Milne B, de Somer F, Kunst G. Neurologic complications after cardiopulmonary bypass - A narrative review. Perfusion 2023; 38:1545-1559. [PMID: 35986553 PMCID: PMC10612382 DOI: 10.1177/02676591221119312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.
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Affiliation(s)
- Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Filip de Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King’s College London British Heart Foundation Centre of Excellence, London, UK
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15
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Gavish B, Gottschalk A, Hogue CW, Steppan J. Additional predictors of the lower limit of cerebral autoregulation during cardiac surgery. J Hypertens 2023; 41:1844-1852. [PMID: 37702558 PMCID: PMC10552816 DOI: 10.1097/hjh.0000000000003556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/31/2023] [Accepted: 08/22/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVES The lower limit of autoregulation (LLA) of cerebral blood flow was previously shown to vary directly with the Ambulatory Arterial Stiffness Index (AASI) redefined as 1-regression slope of DBP-versus-SBP readings invasively measured from the radial artery before the bypass. We aimed expanding the predictive capacity of the LLA with AASI by combining it with additional predictors and provide new indications whether mean arterial pressure (MAP) is above/below the LLA. DESIGN AND METHOD In 181 patients undergoing cardiac surgery, mean (SD) age 71 (8) years), we identified from the demographic, preoperative and intraoperative characteristics independent and statistically significant 'single predictors' of the LLA (including AASI). This was achieved using multivariate linear regression with a backward-elimination technique. The single predictors combined with 1-AASI generated new multiplicative and additive composite predictors of the LLA. Indicators for the MAP-to-LLA difference (DIF) were determined using DIF-versus-predictor plots. The odds ratio (OR) for the DIF sign (Outcome = 1 for DIF≤0) and predictor-minus-median sign (Exposure = 1 for Predictor ≤ Median) were calculated using logistic regression. RESULTS BMI, 1-AASI and systolic coefficient of variation were identified single predictors that correlated similarly with the LLA ( r = -0.26 to -0.27, P < 0.001). The multiplicative and additive composite predictors displayed higher correlation with LLA ( r = -0.41 and r = -0.43, respectively, P < 0.001) and improved LLA estimation. The adjusted OR for the composite predictors was nearly twice that of the single predictors. CONCLUSION The novel composite predictors may enhance the LLA estimation and the ability to maintain MAP in the cerebral autoregulatory range during cardiac surgery.
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Affiliation(s)
| | - Allan Gottschalk
- Johns Hopkins University, Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Charles W Hogue
- Northwestern University Feinberg, Department of Anesthesiology, Chicago, Illinois, USA
| | - Jochen Steppan
- Johns Hopkins University, Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
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16
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Luo Y, Liu J, Hong Y, Peng S, Meng S. Sevoflurane-induced hypotension causes cognitive dysfunction and hippocampal inflammation in mice. Behav Brain Res 2023; 455:114672. [PMID: 37716552 DOI: 10.1016/j.bbr.2023.114672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/18/2023]
Abstract
Sevoflurane commonly adopted for anesthetic in clinical practice, however, its influences on cerebral blood flow and cognitive function remain controversial. Herein, the sevoflurane-induced hypotension on arterial blood pressure, cerebral blood flow, cognitive function, and hippocampal inflammation was investigated in mice. A significant decrease in arterial blood pressure and cerebral blood flow was indicated by the sevoflurane anesthesia treatment. Moreover, sevoflurane-induced hypotension was associated with the impaired cognitive function and the increased levels of NLRP3 inflammasome activation and oxidative stress in hippocampus. These findings suggest that sevoflurane-induced hypotension may lead to the cognitive dysfunction and hippocampal inflammation.
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Affiliation(s)
- Yuelian Luo
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Jiayi Liu
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Yu Hong
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Shuling Peng
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China.
| | - Shiyu Meng
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China.
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17
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Müller-Wirtz LM, Ruetzler K, Rössler J. Intraoperative hypotension and delirium. J Clin Anesth 2023; 89:111153. [PMID: 37245475 DOI: 10.1016/j.jclinane.2023.111153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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18
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Sarwal A, Robba C, Venegas C, Ziai W, Czosnyka M, Sharma D. Are We Ready for Clinical Therapy based on Cerebral Autoregulation? A Pro-con Debate. Neurocrit Care 2023; 39:269-283. [PMID: 37165296 DOI: 10.1007/s12028-023-01741-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
Cerebral autoregulation (CA) is a physiological mechanism that maintains constant cerebral blood flow regardless of changes in cerebral perfusion pressure and prevents brain damage caused by hypoperfusion or hyperperfusion. In recent decades, researchers have investigated the range of systemic blood pressures and clinical management strategies over which cerebral vasculature modifies intracranial hemodynamics to maintain cerebral perfusion. However, proposed clinical interventions to optimize autoregulation status have not demonstrated clear clinical benefit. As future trials are designed, it is crucial to comprehend the underlying cause of our inability to produce robust clinical evidence supporting the concept of CA-targeted management. This article examines the technological advances in monitoring techniques and the accuracy of continuous assessment of autoregulation techniques used in intraoperative and intensive care settings today. It also examines how increasing knowledge of CA from recent clinical trials contributes to a greater understanding of secondary brain injury in many disease processes, despite the fact that the lack of robust evidence influencing outcomes has prevented the translation of CA-guided algorithms into clinical practice.
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Affiliation(s)
- Aarti Sarwal
- Atrium Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | | | - Carla Venegas
- Mayo Clinic School of Medicine, Jacksonville, FL, USA
| | - Wendy Ziai
- Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Marek Czosnyka
- Division of Neurosurgery, Cambridge University Hospital, Cambridge, UK
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19
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Ren S, Zang C, Yuan F, Yan X, Zhang Y, Yuan S, Sun Z, Lang B. Correlation between burst suppression and postoperative delirium in elderly patients: a prospective study. Aging Clin Exp Res 2023; 35:1873-1879. [PMID: 37479909 DOI: 10.1007/s40520-023-02460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 05/29/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE To explore the correlation between intraoperative burst suppression (BS) and postoperative delirium (POD) in elderly patients, and provide more ideas for reducing POD in clinical. METHODS Ninety patients, aged over 60 years, who underwent lumbar internal fixation surgery in our hospital were selected. General information of patients was obtained and informed consent was signed during preoperative visits. Patients were divided into burst suppression (BS) group and non-burst suppression (NBS) group by intraoperative electroencephalogram monitoring. Intraoperative systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded, and the variation and minimum value were obtained by calculating. Hemoglobin (HGB), C-reactive protein (CRP), system immune inflammatory index (SII) at 24 and 72 h after surgery, the incidence of postoperative adverse reactions, postoperative hospital stay, and total cost were recorded after operation. POD assessment was performed using CAM within 7 days after surgery or until discharge. SPSS25.0 was used for statistical analysis. RESULTS Compared with the NBS group, the number of elderly patients with high frailty level in BS group was more (P = 0.048). There is correlation between BS and POD (OR: 4.954, 95%CI 1.034-23.736, P = 0.045), and most of the POD patients in BS group behave as hyperactive type. CONCLUSION The occurrence of intraoperative BS is associated with POD, and elderly patients with frailty are more likely to have intraoperative BS. BS can be used as a predictor of POD.
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Affiliation(s)
- Shengjie Ren
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
- Department of Anesthesiology, Weifang Second People's Hospital, Weifang, 261041, China
| | - Chuanbo Zang
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Fang Yuan
- Department of Anesthesiology, Zibo Central Hospital, Zibo, 255020, China
| | - Xuemei Yan
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261041, China
| | - Yanan Zhang
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Shu Yuan
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Zenggang Sun
- School of Anesthesiology, Weifang Medical University, Weifang, 261053, China
| | - Bao Lang
- Department of Anesthesiology, Weifang People's Hospital, Weifang, 261041, China.
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20
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Duan W, Zhou CM, Yang JJ, Zhang Y, Li ZP, Ma DQ, Yang JJ. A long duration of intraoperative hypotension is associated with postoperative delirium occurrence following thoracic and orthopedic surgery in elderly. J Clin Anesth 2023; 88:111125. [PMID: 37084642 DOI: 10.1016/j.jclinane.2023.111125] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Postoperative delirium (POD) is a common surgical complication associated with increased morbidity and mortality in elderly. Although the underlying mechanisms remain elusive, perioperative risk factors were reported to be closely related to its development. This study was designed to investigate the association between the duration of intraoperative hypotension and POD incidence following thoracic and orthopedic surgery in elderly. METHOD The perioperative data from 605 elderly undergoing thoracic and orthopedic surgery from January 2021 to July 2022 were analyzed. The primary exposure was a cumulative duration of mean arterial pressure (MAP) ≤ 65 mmHg. The primary end-point was the POD incidence assessed with confusion assessment method (CAM) or CAM-ICU for three days after surgery. Restricted cubic spline (RCS) was conducted to examine the continuous relationship between the duration of intraoperative hypotension and POD incidence adjusted with patients' demographics and surgery related factors. Then the duration of intraoperative hypotension was categorized into three groups: no hypotension, short (< 5 mins) or long duration (≥ 5 mins) of hypotension for further analysis. RESULT The incidence of POD was 14.7% (89 cases out of 605) within three days after surgery. The duration of hypotension presented a non-linear and "inverted L-shaped" effect on POD development. Compared to no hypotension, long duration (adjusted OR 3.93; 95% CI: 2.07-7.45; P < 0.001) rather than short duration of MAP ≤65 mmHg (adjusted OR 1.18; 95% CI: 0.56-2.50; P = 0.671) was closely related to the POD incidence. CONCLUSION Intraoperative hypotension (MAP ≤65 mmHg) for ≥5 mins was associated with an increased incidence of POD after thoracic and orthopedic surgery in elderly.
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Affiliation(s)
- Wen Duan
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Cheng-Mao Zhou
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jin-Jin Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yue Zhang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ze-Ping Li
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Da-Qing Ma
- Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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21
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Descamps R, Amour J, Besnier E, Bougle A, Charbonneau H, Charvin M, Cholley B, Desebbe O, Fellahi JL, Frasca D, Labaste F, Lena D, Mahjoub Y, Mertes PM, Molliex S, Moury PH, Moussa MD, Oilleau JF, Ouattara A, Provenchere S, Rozec B, Parienti JJ, Fischer MO. Perioperative individualized hemodynamic optimization according to baseline mean arterial pressure in cardiac surgery patients: Rationale and design of the OPTIPAM randomized trial. Am Heart J 2023; 261:10-20. [PMID: 36934980 DOI: 10.1016/j.ahj.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Postoperative morbidity and mortality after cardiac surgery with cardiopulmonary bypass (CPB) remain high despite recent advances in both anesthesia and perioperative management. Among modifiable risk factors for postoperative complications, optimal arterial pressure during and after surgery has been under debate for years. Recent data suggest that optimizing arterial pressure to the baseline of the patient may improve outcomes. We hypothesize that optimizing the mean arterial pressure (MAP) to the baseline MAP of the patient during cardiac surgery with CPB and during the first 24 hours postoperatively may improve outcomes. STUDY DESIGN The OPTIPAM trial (NCT05403697) will be a multicenter, randomized, open-label controlled trial testing the superiority of optimized MAP management as compared with a MAP of 65 mm Hg or more during both the intraoperative and postoperative periods in 1,100 patients scheduled for cardiac surgery with CPB. The primary composite end point is the occurrence of acute kidney injury, neurological complications including stroke or postoperative delirium, and death. The secondary end points are hospital and intensive care unit lengths of stay, Day 7 and Day 90 mortality, postoperative cognitive dysfunction on Day 7 and Day 90, and quality of life at Day 7 and Day 90. Two interim analyses will assess the safety of the intervention. CONCLUSION The OPTIPAM trial will assess the effectiveness of an individualized target of mean arterial pressure in cardiac surgery with CPB in reducing postoperative morbidity. CLINICAL TRIAL REGISTRATION NCT05403697.
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Affiliation(s)
- Richard Descamps
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Caen, France.
| | - Julien Amour
- Institute of Perfusion, Critical Care Medicine and Anesthesiology in Cardiac Surgery (IPRA), Hôpital Privé Jacques Cartier, Massy, France
| | - Emmanuel Besnier
- Normandie Univ, UNIROUEN, INSERM U1096, CHU Rouen, Department of Anesthesiology and Critical Care, Rouen, France
| | - Adrien Bougle
- Sorbonne Université, GRC 29, Assistance Publique - Hôpitaux de Paris, DMU DREAM, Département d'Anesthésie et Réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Hélène Charbonneau
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, France
| | - Martin Charvin
- CHU Clermont-Ferrand, Médecine Péri-Opératoire (MC, FL, PJ, A-LC, EF); Université Clermont-Auvergne (EF), France
| | | | - Olivier Desebbe
- Department of Anesthesiology and Intensive Care, Ramsay Sante Sauvegarde Clinic, Lyon, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-Réanimation, Hôpital Louis Pradel, Boulevard Pinel, Bron Cedex, France
| | - Denis Frasca
- Department of Anaesthesia and Intensive Care, University Hospital of Poitiers, France
| | - François Labaste
- Anesthesiology and Intensive Care Department, University Hospital of Toulouse, Toulouse, France
| | - Diane Lena
- Institut Arnault Tzanck, Cardiologie Médico-chirurgicale, Saint Laurent du Var, France
| | - Yazine Mahjoub
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, Amiens, France
| | - Paul-Michel Mertes
- Service d'Anesthésie-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Serge Molliex
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Nord, Saint Etienne, France
| | | | | | - Jean-Ferreol Oilleau
- Department of Anaesthesia and Critical Care, Brest University Hospital, Brest, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medical Surgical Centre, Bordeaux, France
| | - Sophie Provenchere
- Anesthesiology and surgical critical care department, DMU PARABOL, AP-HP, Bichat Hospital, Paris, France
| | - Bertand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes France
| | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, Caen University Hospital, Caen, France
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22
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Sainbhi AS, Vakitbilir N, Gomez A, Stein KY, Froese L, Zeiler FA. Non-Invasive Mapping of Cerebral Autoregulation Using Near-Infrared Spectroscopy: A Study Protocol. Methods Protoc 2023; 6:58. [PMID: 37368002 DOI: 10.3390/mps6030058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
The ability of cerebral vessels to maintain a fairly constant cerebral blood flow is referred to as cerebral autoregulation (CA). Using near-infrared spectroscopy (NIRS) paired with arterial blood pressure (ABP) monitoring, continuous CA can be assessed non-invasively. Recent advances in NIRS technology can help improve the understanding of continuously assessed CA in humans with high spatial and temporal resolutions. We describe a study protocol for creating a new wearable and portable imaging system that derives CA maps of the entire brain with high sampling rates at each point. The first objective is to evaluate the CA mapping system's performance during various perturbations using a block-trial design in 50 healthy volunteers. The second objective is to explore the impact of age and sex on regional disparities in CA using static recording and perturbation testing in 200 healthy volunteers. Using entirely non-invasive NIRS and ABP systems, we hope to prove the feasibility of deriving CA maps of the entire brain with high spatial and temporal resolutions. The development of this imaging system could potentially revolutionize the way we monitor brain physiology in humans since it would allow for an entirely non-invasive continuous assessment of regional differences in CA and improve our understanding of the impact of the aging process on cerebral vessel function.
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Affiliation(s)
- Amanjyot Singh Sainbhi
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
| | - Nuray Vakitbilir
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
| | - Kevin Y Stein
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
| | - Logan Froese
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
| | - Frederick A Zeiler
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
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23
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Deininger MM, Schnitzler S, Benstoem C, Simon TP, Marx G, Panagiotidis D, Ziles D, Schnoering H, Karasimos E, Breuer T. Standardized pharmacological management of delirium after on-pump cardiac surgery reduces ICU stay and ventilation in a retrospective pre-post study. Sci Rep 2023; 13:3741. [PMID: 36878954 PMCID: PMC9988974 DOI: 10.1038/s41598-023-30781-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Cardiac surgery patients not only undergo a highly invasive procedure but are at risk for a diversity of postoperative complications. Up to 53% of these patients suffer from postoperative delirium (POD). This severe and common adverse event increases mortality and prolonged mechanical ventilation and extends the intensive care unit stay. The objective of this study was to test the hypothesis that standardized pharmacological management of delirium (SPMD) may reduce the length of stay in the intensive care unit (ICU), duration of postoperative mechanical ventilation, and the incidence of postoperative complications such as pneumonia or bloodstream infections in on-pump cardiac surgery ICU patients. In this retrospective, single-center observational cohort study, 247 patients were examined between May 2018 to June 2020, who underwent on-pump cardiac surgery, suffered from POD, and received pharmacological POD treatment. 125 were treated before and 122 after SPMD implementation in the ICU. The primary endpoint was a composite outcome, including the length of ICU stay, postoperative mechanical ventilation time, and ICU survival rate. The secondary endpoints were complications including postoperative pneumonia and bloodstream infections. Although the ICU survival rate was not significantly different between both groups, the length of ICU stay (control group: 23 ± 27 days; SPMD group: 16 ± 16 days; p = 0.024) and the duration of mechanical ventilation were significantly reduced in the SPMD-cohort (control group: 230 ± 395 h; SPMD group: 128 ± 268 h; p = 0.022). Concordantly, the pneumonic risk was reduced after SPMD introduction (control group: 44.0%; SPMD group: 27.9%; p = 0.012) as well as the incidence for bloodstream infections (control group: 19.2%; SPMD group: 6.6%; p = 0.004). Standardized pharmacological management of postoperative delirium in on-pump cardiac surgery ICU patients reduced the length of ICU stay and duration of mechanical ventilation significantly, leading to a decrease in pneumonic complications and bloodstream infections.
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Affiliation(s)
- Matthias Manfred Deininger
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Stefan Schnitzler
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Carina Benstoem
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Gernot Marx
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Despina Panagiotidis
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Dmitrij Ziles
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Heike Schnoering
- Department of Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Evangelos Karasimos
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Thomas Breuer
- Department of Intensive and Intermediate Care, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
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24
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Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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25
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Hypotension and Cardiac Surgical Outcomes: Comment. Anesthesiology 2023; 138:335-336. [PMID: 36652598 DOI: 10.1097/aln.0000000000004416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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26
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He L, Liang S, Liang Y, Fang M, Li J, Deng J, Fang H, Li Y, Jiang X, Chen C. Defining a postoperative mean arterial pressure threshold in association with acute kidney injury after cardiac surgery: a prospective observational study. Intern Emerg Med 2023; 18:439-448. [PMID: 36577909 DOI: 10.1007/s11739-022-03187-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
Acute kidney injury (AKI) is a common but fatal complication after cardiac surgery. In the absence of effective treatments, the identification and modification of risk factors has been a major component of disease management. However, the optimal blood pressure target for preventing cardiac surgery-associated acute kidney injury (CSA-AKI) remains unclear. We sought to determine the effect of postoperative mean arterial pressure (MAP) in CSA-AKI. It is hypothesized that longer periods of hypotension after cardiac surgery are associated with an increased risk of AKI. This prospective cohort study was conducted on adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between October 2018 and May 2020. The primary outcome is the occurrence of CSA-AKI. MAP and its duration in the ranges of less than 65, 65 to 74, and 75 to 84 mmHg within 24 h after surgery were recorded. The association between postoperative MAP and CSA-AKI was examined by using logistic regression. Among the 353 patients enrolled, 217 (61.5%) had a confirmed diagnosis of CSA-AKI. Each 1 h epoch of postoperative MAP less than 65 mmHg was associated with an adjusted odds ratio of 1.208 (95% CI, 1.007 to 1.449; P = 0.042), and each 1 h epoch of postoperative MAP between 65 and 74 mmHg was associated with an adjusted odds ratio of 1.144 (95% CI, 1.026 to 1.275; P = 0.016) for CSA-AKI. A potentially modifiable risk factor, postoperative MAP less than 75 mmHg for 1 h or more is associated with an increased risk of CSA-AKI.
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Affiliation(s)
- Linling He
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
- Shantou University Medical College, Shantou, 515000, China
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Silin Liang
- Department of Critical Care Medicine, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of South University of Science and Technology, Shenzhen, 518020, China
| | - Yu Liang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Miaoxian Fang
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
| | - Jiaxin Li
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
| | - Jia Deng
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Department of Critical Care Medicine, The Second Hospital of Dalian Medical University, Dalian, 116023, China
| | - Heng Fang
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Ying Li
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
| | - Xinyi Jiang
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Chunbo Chen
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China.
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China.
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
- Department of Emergency Medicine, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, China.
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27
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Satomoto M. Predicting Postoperative Emergence Delirium From the Heart Rate Variability of Patients Undergoing Elective Cardiac Surgery. Cureus 2023; 15:e34613. [PMID: 36891021 PMCID: PMC9986650 DOI: 10.7759/cureus.34613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
Background and objective The complication of postoperative delirium is directly linked to prognosis, leading to prolonged hospital stays and an increase in mortality. Since there is no magic medicine that cures delirium, the prevention of its onset is important, and the development of simple tools that enable the early assessment of the risk is valuable. In the previous study, we hypothesized that postoperative delirium could be predicted from heart rate variability (HRV) measured by using an electrocardiogram (ECG) on the day before elective esophageal cancer surgery. HRV is calculated based on the fluctuation of RR intervals on ECG. The preoperative high-frequency (HF) power in delirium patients was significantly lower than that in non-delirium patients. The HF component is considered a reflection of parasympathetic function. In the current study, we evaluated the hypothesis that parasympathetic nerve activity is low in the resting HRV on the night before surgery in patients who go on to develop postoperative delirium. To that end, we recorded resting HRV in patients scheduled for cardiac surgery on the night before surgery. We then compared the HRV between patients with and without delirium in the postoperative intensive care unit (ICU). The Confusion Assessment Method for the ICU (CAM-ICU) was used to diagnose delirium. Methods This was a prospective observational study involving patients undergoing elective cardiac surgery. After obtaining approval from the institutional review board, patients aged 65 years and older were enrolled in the study. The day before surgery, a Mini-Mental State Examination (MMSE) was performed. The ECG was used in patients for five minutes. All patients were transferred to the ICU after surgery, and CAM-ICU was measured every eight hours until discharge from the ICU, and positive patients were diagnosed with delirium. Results In this study, 14 patients who developed delirium and 22 patients who did not were included in the analysis. The average MMSE score was 27.4, with no patients diagnosed with preoperative dementia. In the analysis of HRV, the HF component was significantly lower in the group with delirium compared to the group without delirium (Mann-Whitney U test, p<0.05). Conclusion Based on our findings, in patients with postoperative delirium, the activity of parasympathetic nerves was lower than before surgery, and we concluded that it is possible to predict the onset of postoperative delirium based on preoperative ECG measurement.
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28
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Ranucci M, Cotza M, Di Dedda U. The Conundrum of Systemic Arterial Pressure Management on Cardiopulmonary Bypass. J Clin Med 2023; 12:jcm12030806. [PMID: 36769463 PMCID: PMC9918189 DOI: 10.3390/jcm12030806] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
The recently released EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass (CPB) in adult cardiac surgery [...].
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29
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Jiang JL, Zhang L, He LL, Yu H, Li XF, Dai SH, Yu H. Volatile Versus Total Intravenous Anesthesia on Postoperative Delirium in Adult Patients Undergoing Cardiac Valve Surgery: A Randomized Clinical Trial. Anesth Analg 2023; 136:60-69. [PMID: 36301724 DOI: 10.1213/ane.0000000000006257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The effect of anesthesia regimens on postoperative delirium after on-pump cardiac valve surgery is yet undetermined. This study aimed to evaluate the effect of volatile anesthesia compared with propofol-based total intravenous anesthesia (TIVA) on the occurrence of delirium after on-pump cardiac valve surgery. METHODS This randomized clinical trial was conducted at a university academic hospital in China, from February 2019 to January 2021. Patients scheduled for on-pump cardiac valve surgery or combined valve with coronary artery bypass grafting (CABG) surgeries were randomly assigned to receive anesthesia maintenance with either a volatile anesthetic (sevoflurane or desflurane) or propofol-based TIVA. The primary outcome was the incidence of delirium during the first 7 days after surgery, assessed using the confusion assessment method for the intensive care unit (ICU). The secondary outcomes included duration of delirium, subtypes of delirium, 30-day mortality, pain score, major morbidity (including cerebral infarction, respiratory failure, and pneumonia), duration of mechanical ventilation, and lengths of ICU and hospital stay. The statistical analysis of the primary outcome variable was by Pearson's χ 2 test. RESULTS Among the 684 patients analyzed (mean age, 53.8 years; 381 [55.7%] women), 676 were assessed for the primary outcome. Postoperative delirium occurred in 63 of 337 (18.7%) patients receiving volatile anesthesia versus 76 of 339 (22.4%) patients receiving propofol-based TIVA (relative risk, 0.80; 95% confidence interval [CI], 0.55-1.16; P = .231). There were no significant differences between the groups in any of the secondary outcomes. CONCLUSIONS Among patients undergoing on-pump cardiac valve surgery, anesthesia maintenance with a volatile agent did not result in significantly fewer occurrences of postoperative delirium than propofol-based TIVA.
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Affiliation(s)
- Jia-Li Jiang
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Zhang
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei-Lei He
- Department of Anesthesiology, Sichuan Jinxin Women and Children's Hospital, Chengdu, Sichuan, China
| | - Hong Yu
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xue-Fei Li
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shun-Hui Dai
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hai Yu
- From the Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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30
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Santos DPDAD, Thirumala PD, Reddy G, Barros DFD, Faria VNR, Shandal V, Kurtz P. Risk of perioperative stroke and cerebral autoregulation monitoring: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1196-1203. [PMID: 36580956 PMCID: PMC9800166 DOI: 10.1055/s-0042-1758648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Perioperative stroke, delirium, and cognitive impairment could be related to management and to variations in blood pressure control, cerebral hypoperfusion and raised blood volume. Cerebral autoregulation (CAR) is a mechanism to maintain cerebral perfusion through the control of the vascular tone and hemodynamic reactions in the circulation. OBJECTIVE The present systematic review addresses the relationship between impaired CAR and perioperative stroke by evaluating the rate of neurological complications after surgery in studies in which perioperative CAR was tested or monitored. METHODS We included randomized clinical trials and prospective observational studies. All studies had adjusted the relative risk, hazard ratio or 95% confidence interval (95%CI) values. These estimation effects were tested using random-effects models. Heterogeneity among the selected studies was assessed using the Higgins and Thompson I2 statistics. RESULTS The Web of Science, PubMed and EMBASE electronic databases were searched to retrieve articles. A total of 4,476 studies published between 1983 and 2019 were analyzed, but only 5 qualified for the data extraction and were included in the final analysis. The combined study cohort comprised 941 patients who underwent CAR monitoring during surgical procedures. All studies provided information about perioperative stroke, which equated to 16% (158 of 941) of the overall patient population. CONCLUSION The present meta-analysis showed evidence of the impact of CAR impairment in the risk of perioperative stroke. On the pooled analysis, blood fluctuations or other brain insults large enough to compromise CAR were associated with the outcome of stroke (odds ratio [OR]: 2.26; 95%CI: 1.54-2.98; p < 0.0001).
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Affiliation(s)
- Daniel Paes de Almeida dos Santos
- Hospital Copa Star, Centro de Terapia Intensiva, Rio de Janeiro RJ, Brazil.,Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Address for correspondence Daniel P. A. Santos
| | | | - Gautama Reddy
- Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Intraneuro, Rio de Janeiro RJ, Brazil.
| | | | - Vinicius Naves Rezende Faria
- Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Universidade Federal de Uberlândia, Faculdade de Engenharia Elétrica, Uberlândia MG, Brazil.
| | - Varun Shandal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.
| | - Pedro Kurtz
- Instituto D'Or de Pesquisa e Ensino, Departamento de Cuidado Intensivo, São Paulo SP, Brazil.
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31
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Zhang Y, Zhang Y, Zhou Z, Sang X, Qin M, Dai G, Zhao Z, Yan F, Zhang X. Higher intraoperative mean arterial blood pressure does not reduce postoperative delirium in elderly patients following gastrointestinal surgery: A prospective randomized controlled trial. PLoS One 2022; 17:e0278827. [PMID: 36548296 PMCID: PMC9778934 DOI: 10.1371/journal.pone.0278827] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aimed to describe the relationship between the different levels of intraoperative mean arterial blood pressure (MAP) and postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. MATERIALS AND METHODS This prospective controlled clinical trial enrolled 116 patients aged 65 to 85 years who underwent gastrointestinal laparoscopic surgery. These patients were randomized 1:1 to a MAP goal of 65 to 85 mmHg (L group) or an 86 to 100 mmHg (H group). The primary endpoint was the incidence of postoperative delirium, assessed twice daily with the Confusion Assessment Method (CAM) and Richmond Agitation-Sedation Scale (RASS) during the first five postoperative days. Delirium severity was evaluated with the Delirium-O-Meter (D-O-M). RESULTS 108 patients (L group n = 55, H group n = 53) were eventually included in intention-to-treat analyses. Postoperative delirium occurred in 18 (32.7%) of 55 cases of L group and in 15 (28.3%) of 53 cases of H group. The incidence of delirium subtypes between the two groups: hypoactive delirium 14.5% (8/55) vs 11.3% (6/53); hyperactive delirium 7.3% (4/55) vs 3.8% (2/53); mixed delirium 10.9% (6/55) vs 13.2% (7/53). However, the L group showed higher D-O-M scores of the first episode of delirium: 14.5 (Q1 = 12, Q3 = 18.5) vs 12 (Q1 = 10, Q3 = 14), which means the delirium is more severe. CONCLUSIONS Compared with 65 to 85 mmHg, maintaining intraoperative MAP at 86-100 mmHg did not reduce the incidence of postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. However, the severity of delirium could be reduced and blood loss is a risk factor for postoperative delirium.
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Affiliation(s)
- Yanke Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Zhou Zhou
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Xiaoqiao Sang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Miaomiao Qin
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Guangrong Dai
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Zhibin Zhao
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Fang Yan
- Department of Basic Medical Science, Kangda College of Nanjing Medical University, Lianyungang, China
| | - Xiaobao Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
- Department of Anesthesiology, Kangda College of Nanjing Medical University, Lianyungang, China
- * E-mail:
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32
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Manquat E, Vallée F, Cartailler J. Risk of overestimating loss of cerebral autoregulation-author's reply. BJA OPEN 2022; 4:100094. [PMID: 37588790 PMCID: PMC10430805 DOI: 10.1016/j.bjao.2022.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 08/18/2023]
Affiliation(s)
- Elsa Manquat
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hopitaux de Paris, Paris, France
- AP-HP-Inria, Laboratoire Daniel Bernoulli, Paris, France
| | - Fabrice Vallée
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hopitaux de Paris, Paris, France
- Laboratoire de Mecanique des Solides (LMS), Ecole Polytechnique/CNRS/Institut Polytechnique de Paris, France
| | - Jerome Cartailler
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hopitaux de Paris, Paris, France
- INSERM, UMR-942, Paris, France
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Zipfel J, Wikidal B, Schwaneberg B, Schuhmann MU, Magunia H, Hofbeck M, Schlensak C, Schmid S, Neunhoeffer F. Identifying the optimal blood pressure for cerebral autoregulation in infants after cardiac surgery by monitoring cerebrovascular reactivity-A pilot study. Paediatr Anaesth 2022; 32:1320-1329. [PMID: 36083106 DOI: 10.1111/pan.14555] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/13/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Advances in the treatment of pediatric congenital heart disease have increased survival rates. Despite efforts to prevent neurological injury, many patients suffer from impaired neurodevelopmental outcomes. Compromised cerebral autoregulation can increase the risk of brain injury following pediatric cardiac surgery with cardiopulmonary bypass. Monitoring autoregulation and maintaining adequate cerebral blood flow can help prevent neurological injury. AIMS Our objective was to evaluate autoregulation parameters and to define the optimal blood pressure as well as the lower and upper blood pressure limits of autoregulation. METHODS Autoregulation was monitored prospectively in 36 infants after cardiopulmonary bypass surgery for congenital heart defects between January and December 2019. Autoregulation indices were calculated by correlating invasive arterial blood pressure, cortical oxygen saturation, and relative tissue hemoglobin levels with near-infrared spectroscopy parameters. RESULTS The mean patient age was 4.1 ± 2.8 months, and the mean patient weight was 5.2 ± 1.8 kg. Optimal mean arterial pressure could be identified in 88.9% of patients via the hemoglobin volume index and in 91.7% of patients via the cerebral oxygenation index, and a lower limit of autoregulation could be found in 66.7% and 63.9% of patients, respectively. No significant changes in autoregulation indices at the beginning or end of the monitoring period were observed. In 76.5% ± 11.1% and 83.8% ± 9.9% of the 8 and 16 h monitoring times, respectively, the mean blood pressure was inside the range of intact autoregulation (below in 21.5% ± 25.4% and 11.3% ± 16.5% and above in 8.7% ± 10.4% and 6.0% ± 11.0%, respectively). The mean optimal blood pressure was 57.4 ± 8.7 mmHg and 58.2 ± 7.9 mmHg and the mean lower limit of autoregulation was 48.8 ± 8.3 mmHg and 45.5 ± 6.7 mmHg when generated via the hemoglobin volume index and cerebral oxygenation index, respectively. CONCLUSIONS Postoperative noninvasive autoregulation monitoring after cardiac surgery in children can be reliably and safely performed using the hemoglobin volume index and cerebral oxygenation index and provides robust data. This monitoring can be used to identify individual hemodynamic targets to optimize autoregulation, which differs from those recommended in the literature. Further evaluation of this subject is needed.
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Affiliation(s)
- Julian Zipfel
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Berit Wikidal
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Bernadett Schwaneberg
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Martin U Schuhmann
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Harry Magunia
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Michael Hofbeck
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Tuebingen, Germany
| | - Simon Schmid
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Felix Neunhoeffer
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
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Kotani Y, Kataoka Y, Izawa J, Fujioka S, Yoshida T, Kumasawa J, Kwong JS. High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass. Cochrane Database Syst Rev 2022; 11:CD013494. [PMID: 36448514 PMCID: PMC9709767 DOI: 10.1002/14651858.cd013494.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB. OBJECTIVES To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence. MAIN RESULTS We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB. AUTHORS' CONCLUSIONS A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Junichi Izawa
- Division of Critical Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
- Department of Preventive Services, Kyoto University Graduate School of Public Health, Kyoto, Japan
| | - Shoko Fujioka
- Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Jikei University Kashiwa Hospital, Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
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Ushio M, Egi M, Fujimoto D, Obata N, Mizobuchi S. Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium. J Cardiothorac Vasc Anesth 2022; 36:4062-4069. [PMID: 35915006 DOI: 10.1053/j.jvca.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/04/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD). DESIGN A single-center retrospective observational study. SETTING University teaching hospital. PARTICIPANTS A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR = 1.72 [1.01-2.92]), <70 mmHg (OR = 1.83 [1.03-3.26]), and <75 mmHg (OR = 1.94 [1.02-3.69]). CONCLUSIONS A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.
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Affiliation(s)
- Masahiro Ushio
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan.
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Daichi Fujimoto
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Norihiko Obata
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
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Czosnyka M, Santarius T, Donnelly J, van den Dool REC, Sperna Weiland NH. Pro-Con Debate: The Clinical (Ir)relevance of the Lower Limit of Cerebral Autoregulation for Anesthesiologists. Anesth Analg 2022; 135:734-743. [DOI: 10.1213/ane.0000000000006123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Devinney MJ, VanDusen KW, Kfouri JM, Avasarala P, Spector AR, Mathew JP, Berger M. The potential link between obstructive sleep apnea and postoperative neurocognitive disorders: current knowledge and possible mechanisms. Can J Anaesth 2022; 69:1272-1287. [PMID: 35982354 PMCID: PMC9924301 DOI: 10.1007/s12630-022-02302-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE This narrative review examines the current evidence on whether obstructive sleep apnea (OSA) is associated with postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The mechanisms that could predispose OSA patients to these disorders are also explored. SOURCE Relevant literature was identified by searching for pertinent terms in Medline®, Pubmed, ScopusTM, and Google scholar databases. Case reports, abstracts, review articles, original research articles, and meta-analyses were reviewed. The bibliographies of retrieved sources were also searched to identify relevant papers. PRINCIPAL FINDINGS Seven studies have investigated the association between OSA and POD, with mixed results. No studies have examined the potential link between OSA and POCD. If these relationships exist, they could be mediated by several mechanisms, including increased neuroinflammation, blood-brain barrier breakdown, cerebrovascular disease, Alzheimer's disease neuropathology, disrupted cerebral autoregulation, sleep disruption, sympathovagal imbalance, and/or disrupted brain bioenergetics. CONCLUSION There is very limited evidence that OSA plays a role in postoperative neurocognitive disorders because few studies have been conducted in the perioperative setting. Additional perioperative prospective observational cohort studies and randomized controlled trials of sleep apnea treatment are needed. These investigations should also assess potential underlying mechanisms that could predispose patients with OSA to postoperative neurocognitive disorders. This review highlights the need for more research to improve postoperative neurocognitive outcomes for patients with OSA.
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Affiliation(s)
- Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
- Duke Hospital South, 3094 MS 01, 40 Medicine Circle, Rm 4324, Orange Zone, Durham, NC, 27710, USA.
| | - Keith W VanDusen
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jad M Kfouri
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Pallavi Avasarala
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Andrew R Spector
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Li X, Cheng W, Zhang J, Li D, Wang F, Cui N. Early alteration of peripheral blood lymphocyte subsets as a risk factor for delirium in critically ill patients after cardiac surgery: A prospective observational study. Front Aging Neurosci 2022; 14:950188. [PMID: 36118695 PMCID: PMC9477480 DOI: 10.3389/fnagi.2022.950188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022] Open
Abstract
Objective There is a high incidence of delirium among patients with organ dysfunction undergoing cardiac surgery who need critical care. This study aimed to explore the risk factors for delirium in critically ill patients undergoing cardiac surgery and the predictive value of related risk factors. Methods We conducted a prospective observational study on adult critically ill patients who underwent cardiac surgery between January 2019 and August 2021. Patients were consecutively assigned to delirium and non-delirium groups. Univariate analysis and multivariate logistic analysis were used to determine the risk factors for delirium. Receiver operating characteristic curves and a nomogram were used to identify the predictive value of related risk factors. Results Delirium developed in 242 of 379 (63.9%) participants. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were 14.2 ± 5.6 and 18 ± 8.4, respectively. Patients with delirium had longer cardiopulmonary bypass time (149.6 ± 59.1 vs. 126.7 ± 48.5 min, p < 0.001) and aortic cross-clamp time (98.7 ± 51.5 vs. 86.1 ± 41.6 min, p = 0.010) compared with the non-delirium group. The area under the curve was 0.824 for CD4+ T cell count and 0.862 for CD4/CD8 ratio. Multivariate analysis demonstrated that age [odds ratio (OR) 1.030, p = 0.038], duration of physical restraint (OR 1.030, p < 0.001), interleukin-6 (OR 1.001, p = 0.025), CD19+ B cell count (OR 0.996, p = 0.016), CD4+ T cell count (OR 1.005, p < 0.001) and CD4/CD8 ratio (OR 5.314, p < 0.001) were independent risk factors for delirium. A nomogram revealed that age, cardiopulmonary bypass duration, CD4+ T cell count and CD4/CD8 ratio were independent predictors of delirium. Conclusion Age, duration of physical restraint, CD4+ T cell count and CD4/CD8 ratio were reliable factors for predicting delirium in critically ill patients after cardiac surgery. The receiver operating characteristic curves and nomogram suggested a potential role for CD4+ T cells in mediating potential neuroinflammation of delirium.
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Affiliation(s)
- Xiao Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Wei Cheng
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Jiahui Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Dongkai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Fei Wang
- Department of Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- *Correspondence: Na Cui,
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Yang X, Huang X, Li M, Jiang Y, Zhang H. Identification of individuals at risk for postoperative cognitive dysfunction (POCD). Ther Adv Neurol Disord 2022; 15:17562864221114356. [PMID: 35992893 PMCID: PMC9386869 DOI: 10.1177/17562864221114356] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Postoperative cognitive dysfunction (POCD) is common, occurring in around 10-54% of individuals within first few weeks after surgery. Although the majority of POCD is less commonly persistent later than 3 months following surgery, the condition increases length of stay (LOS), mortality and long-term cognitive decline, raising the need for a broad screening to identify individuals at risk for POCD during the perioperative period. In this narrative review, we summarize preoperative, intraoperative and postoperative risk factors for POCD reported in last 5 years and discuss neuropsychological tools and potential biomarkers and time points for assessment that might be suitable for clinical use. We aim to provide crucial information for developing a strategy of routine screening for POCD, which may assist with better identification of at-risk individuals for early interventions. Very importantly, the utilization of a standardized strategy may also allow higher consistency and comparability across different studies.
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Affiliation(s)
| | | | - Min Li
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yuan Jiang
- Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, No.278, Baoguang Avenue Middle Section, Xindu District, Chengdu 610599, China
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Perioperative Neurofilament Light Plasma Concentrations and Cognition before and after Cardiac Surgery: A Prospective Nested Cohort Study. Anesthesiology 2022; 137:303-314. [PMID: 35984933 DOI: 10.1097/aln.0000000000004327] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neurofilament light is a marker of neuronal injury and can be measured in blood. Postoperative increases in neurofilament light have been associated with delirium after noncardiac surgery. However, few studies have examined the association of neurofilament light changes with postdischarge cognition in cardiac surgery patients, who are at highest risk for neuronal injury and cognitive decline. The authors hypothesized that increased neurofilament light (both baseline and change) would be associated with worse neuropsychological status up to 1 yr after cardiac surgery. METHODS This observational study was nested in a trial of cardiac surgery patients, in which blood pressure during bypass was targeted using cerebral autoregulation monitoring. Plasma concentrations of neurofilament light were measured at baseline and postoperative day 1. Neuropsychological testing was performed at baseline, 1 month after surgery, and 1 yr after surgery. Primary outcomes were baseline and change from baseline in a composite z-score of all cognitive tests. RESULTS Among 167 patients, cognitive outcomes were available in 80% (134 of 167) and 61% (102 of 167) at 1 month and 1 yr after surgery, respectively. The median baseline concentration of neurofilament light was 18.2 pg/ml (interquartile range, 13.4 to 28.1), and on postoperative day 1 was 28.5 pg/ml (interquartile range, 19.3 to 45.0). Higher baseline log neurofilament light was associated with worse baseline cognitive z-score (adjusted slope, -0.60; 95% CI, -0.90 to -0.30; P < 0.001), no change in z-score from baseline to 1 month (0.11; 95% CI, -0.19 to 0.41; P = 0.475), and improvement in z-score from baseline to 1 yr (0.56; 95% CI, 0.31 to 0.81; P < 0.001). Whereas some patients had an improvement in cognition at 1 yr and others a decline, an increase in neurofilament light from baseline to postoperative day 1 was associated with a greater decline in cognition at 1 yr. CONCLUSIONS Higher baseline neurofilament light concentration was associated with worse baseline cognition but improvement in cognition at 1 yr. A postoperative increase in neurofilament light was associated with a greater cognitive decline at 1 yr. EDITOR’S PERSPECTIVE
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Li T, Dong T, Cui Y, Meng X, Dai Z. Effect of regional anesthesia on the postoperative delirium: A systematic review and meta-analysis of randomized controlled trials. Front Surg 2022; 9:937293. [PMID: 35959124 PMCID: PMC9360531 DOI: 10.3389/fsurg.2022.937293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/06/2022] [Indexed: 12/21/2022] Open
Abstract
Objective Postoperative delirium (POD) starts in the recovery room and occurs up to 5 days after surgery. However, the POD guidelines issued by the European Society of Anesthesiology (ESA) suggest that the effect of regional anesthesia on POD is controversial. This meta-analysis aims to investigate whether perioperative regional anesthesia reduced the incidence of POD. Methods Standard Published randomized controlled trails (RCTs) were searched from bibliographic databases to identify all evidence that reported regional anesthesia assessing incident delirium following diverse surgeries. The primary outcome was the incidence of POD, and the secondary outcomes were POD scores, pain scores, and emergence time. The relative risk (RR) for dichotomous outcomes and the weighted or standardized mean difference (WMD, SMD) for continuous outcomes were estimated using a random-effects model. Results Twenty RCTs with 2110 randomized participants undergoing different surgeries were included. Meta-analysis showed that regional anesthesia was associated with less POD incidence compared to general anesthesia (total intravenous anesthesia (TIVA) or inhalation anesthesia) (relative risk (RR) = 0.62, 95% confidence interval (CI) = 0.45–0.85)). Subgroup analysis showed that the decrease in POD incidence was associated with a nerve block (0.46, 95% CI = 0.32–0.67) and regional-combined-general anesthesia (0.42, 95% CI = 0.29–0.60). Regional anesthesia significantly reduced POD incidence in the recovery room after pediatric surgeries (0.41, 95% CI = 0.29–0.56). Regional anesthesia also reduced the POD score (SMD −0.93, 95% CI = −1.55 to −0.31) and pain score (SMD −0.95, 95% CI = −1.72 to −0.81). There was no significant difference in emergence time between regional anesthesia and general anesthesia (WMD −1.40, 95% CI = −3.83 to 6.63). Conclusions There was a significant correlation between regional anesthesia and the decrease in POD incidence, POD score, and pain score.
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Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Tiantian Dong
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Yuanshan Cui
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xiangrui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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Comparison of different metrics of cerebral autoregulation in association with major morbidity and mortality after cardiac surgery. Br J Anaesth 2022; 129:22-32. [PMID: 35597624 PMCID: PMC9428920 DOI: 10.1016/j.bja.2022.03.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 01/25/2022] [Accepted: 03/10/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cardiac surgery studies have established the clinical relevance of personalised arterial blood pressure management based on cerebral autoregulation. However, variabilities exist in autoregulation evaluation. We compared the association of several cerebral autoregulation metrics, calculated using different methods, with outcomes after cardiac surgery. METHODS Autoregulation was measured during cardiac surgery in 240 patients. Mean flow index and cerebral oximetry index were calculated as Pearson's correlations between mean arterial pressure (MAP) and transcranial Doppler blood flow velocity or near-infrared spectroscopy signals. The lower limit of autoregulation and optimal mean arterial pressure were identified using mean flow index and cerebral oximetry index. Regression models were used to examine associations of area under curve and duration of mean arterial pressure below thresholds with stroke, acute kidney injury (AKI), and major morbidity and mortality. RESULTS Both mean flow index and cerebral oximetry index identified the cerebral lower limit of autoregulation below which MAP was associated with a higher incidence of AKI and major morbidity and mortality. Based on magnitude and significance of the estimates in adjusted models, the area under curve of MAP < lower limit of autoregulation had the strongest association with AKI and major morbidity and mortality. The odds ratio for area under the curve of MAP < lower limit of autoregulation was 1.05 (95% confidence interval, 1.01-1.09), meaning every 1 mm Hg h increase of area under the curve was associated with an average increase in the odds of AKI by 5%. CONCLUSIONS For cardiac surgery patients, area under curve of MAP < lower limit of autoregulation using mean flow index or cerebral oximetry index had the strongest association with AKI and major morbidity and mortality. Trials are necessary to evaluate this target for MAP management.
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Descamps R, Lautier A, Brotons F, Hanouz JL, Fischer MO. Targeting individualised mean arterial pressure in cardiac surgery: results of a retrospective cohort study. Anaesth Crit Care Pain Med 2022; 41:101066. [PMID: 35490862 DOI: 10.1016/j.accpm.2022.101066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Richard Descamps
- Department of Anaesthesiology and Critical Care, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France.
| | - Audrey Lautier
- Department of Anaesthesiology and Critical Care, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
| | - François Brotons
- Department of Anaesthesiology and Critical Care, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
| | - Jean-Luc Hanouz
- Department of Anaesthesiology and Critical Care, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
| | - Marc-Olivier Fischer
- Department of Anaesthesiology and Critical Care, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
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Lewis C, Dokucu ME, Brown CH, Balmert L, Srdanovic N, Madhan AS, Samra SS, Csernansky J, Grafman J, Hogue CW. Postoperative but not preoperative depression is associated with cognitive impairment after cardiac surgery: exploratory analysis of data from a randomized trial. BMC Anesthesiol 2022; 22:157. [PMID: 35606688 PMCID: PMC9125857 DOI: 10.1186/s12871-022-01672-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this study we hypothesize that depression is associated with perioperative neurocognitive dysfunction and altered quality of life one month after surgery. METHODS Data were obtained as part of a study evaluating cerebral autoregulation monitoring for targeting arterial pressure during cardiopulmonary bypass. Neuropsychological testing was performed before surgery and one month postoperatively. Testing included the Beck Depression Inventory, a depression symptoms questionnaire (0-63 scale), as well as anxiety and quality of life assessments. Depression was defined as a Beck Depression Inventory score > 13. RESULTS Beck Depression data were available from 320 patients of whom cognitive domain endpoints were available from 88-98% at baseline and 69-79% after surgery. This range in end-points data was due to variability in the availability of each neuropsychological test results between patients. Depression was present in 50 (15.6%) patients before surgery and in 43 (13.4%) after surgery. Baseline depression was not associated with postoperative domain-specific neurocognitive function compared with non-depressed patients. Those with depression one month after surgery, though, had poorer performance on tests of attention (p = 0.017), memory (p = 0.049), verbal fluency (p = 0.010), processing speed (p = 0.017), and fine motor speed (p = 0.014). Postoperative neurocognitive dysfunction as a composite outcome occurred in 33.3% versus 14.5% of patients with and without postoperative depression (p = 0.040). Baseline depression was associated with higher anxiety and lower self-ratings on several quality of life domains, these measures were generally more adversely affected by depression one month after surgery. CONCLUSIONS The results of this exploratory analysis suggests that preoperative depression is not associated with perioperative neurocognitive dysfunction, but depression after cardiac surgery may be associated with impairment in in several cognitive domains, a higher frequency of the composite neurocognitive outcome, and altered quality of life. TRIAL REGISTRATION www. CLINICALTRIALS gov, NCT00981474 (parent study).
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Affiliation(s)
- Choy Lewis
- Department of Anesthesiology, The Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 251 East Huron St, Feinberg 5-704, Chicago, IL, 60611, USA
| | - Mehmet E Dokucu
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charles H Brown
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren Balmert
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nina Srdanovic
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ashwin Shaan Madhan
- Medical Student, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sahej Singh Samra
- Medical Student, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Csernansky
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jordan Grafman
- Department of Physical Medicine & Rehabilitation, Neurology, Cognitive Neurology and Alzheimer's Center, Department of Psychiatry, Northwestern University Feinberg School of Medicine, Weinberg College of Arts and Sciences, Northwestern University, Chicago, IL, USA
| | - Charles W Hogue
- Department of Anesthesiology, The Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 251 East Huron St, Feinberg 5-704, Chicago, IL, 60611, USA.
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46
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Vacas S, Canales C, Deiner SG, Cole DJ. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative. Anesth Analg 2022; 135:316-328. [PMID: 35584550 PMCID: PMC9288500 DOI: 10.1213/ane.0000000000006090] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.
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Affiliation(s)
- Susana Vacas
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Cecilia Canales
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel J Cole
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Manquat E, Ravaux H, Kindermans M, Joachim J, Serrano J, Touchard C, Mateo J, Mebazaa A, Gayat E, Vallée F, Cartailler J. Impact of impaired cerebral blood flow autoregulation on electroencephalogram signals in adults undergoing propofol anaesthesia: a pilot study. BJA OPEN 2022; 1:100004. [PMID: 37588691 PMCID: PMC10430849 DOI: 10.1016/j.bjao.2022.100004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/26/2022] [Indexed: 08/18/2023]
Abstract
Background Cerebral autoregulation actively maintains cerebral blood flow over a range of MAPs. During general anaesthesia, this mechanism may not compensate for reductions in MAP leading to brain hypoperfusion. Cerebral autoregulation can be assessed using the mean flow index derived from Doppler measurements of average blood velocity in the middle cerebral artery, but this is impractical for routine monitoring within the operating room. Here, we investigate the possibility of using the EEG as a proxy measure for a loss of cerebral autoregulation, determined by the mean flow index. Methods Thirty-six patients (57.5 [44.25; 66.5] yr; 38.9% women, non-emergency neuroradiology surgery) anaesthetised using propofol were prospectively studied. Continuous recordings of MAP, average blood velocity in the middle cerebral artery, EEG, and regional cerebral oxygen saturation were made. Poor cerebral autoregulation was defined as a mean flow index greater than 0.3. Results Eighteen patients had preserved cerebral autoregulation, and 18 had altered cerebral autoregulation. The two groups had similar ages, MAPs, and average blood velocities in the middle cerebral artery. Patients with altered cerebral autoregulation exhibited a significantly slower alpha peak frequency (9.4 [9.0, 9.9] Hz vs 10.5 [10.1, 10.9] Hz, P<0.001), which persisted after adjusting for age, norepinephrine infusion rate, and ASA class (odds ratio=0.038 [confidence interval, 0.004, 0.409]; P=0.007). Conclusion In this pilot study, we found that loss of cerebral autoregulation was associated with a slower alpha peak frequency, independent of age. This work suggests that impaired cerebral autoregulation could be monitored in the operating room using the existing EEG setup. Clinical trial registration NCT03769142.
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Affiliation(s)
- Elsa Manquat
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- AP-HP-Inria, Laboratoire Daniel Bernoulli, Paris, France
| | - Hugues Ravaux
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Manuel Kindermans
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jona Joachim
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - José Serrano
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Cyril Touchard
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Joaquim Mateo
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM, UMR-942, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM, UMR-942, Paris, France
| | - Fabrice Vallée
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- Laboratoire de Mécanique des Solides (LMS), Ecole Polytechnique/CNRS/Institut Polytechnique de Paris, France
- INSERM, UMR-942, Paris, France
| | - Jérôme Cartailler
- Department of Anesthesiology, Burn and Critical Care, St-Louis-Lariboisiere University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM, UMR-942, Paris, France
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McEwen CC, Amir T, Qiu Y, Young J, Kennedy K, Grocott HP, Kessani H, Mazer D, Brudney S, Kavosh M, Jacobsohn E, Vedel A, Wang E, Whitlock RP, Belley-Coté EP, Spence J. Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:374-386. [PMID: 35014001 DOI: 10.1007/s12630-021-02171-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION PROSPERO (CRD42020177376); registered: 5 July 2020.
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Affiliation(s)
- Charlotte C McEwen
- Department of Surgery (Cardiac Surgery), McMaster University, Hamilton, ON, Canada
| | - Takhliq Amir
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Kevin Kennedy
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hilary P Grocott
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hesham Kessani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Scott Brudney
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Eric Jacobsohn
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Vedel
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eugene Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.,Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Coté
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada.,Departments of Medicine (Cardiology and Critical Care) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. .,Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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49
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Vu EL, Brady K, Hogue CW. High-resolution perioperative cerebral blood flow autoregulation measurement: a practical and feasible approach for widespread clinical monitoring. Br J Anaesth 2022; 128:405-408. [PMID: 34996592 DOI: 10.1016/j.bja.2021.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022] Open
Abstract
A growing body of evidence demonstrates that excursions of BP below or above the limits of cerebral blood flow autoregulation are associated with complications in patients with neurological injury or for those undergoing cardiac surgery. Moreover, recent evidence suggests that maintaining MAP above the lower limit of cerebral autoregulation during cardiopulmonary bypass reduces the frequency of postoperative delirium and is associated with improved memory 1 month after surgery. Continuous measurement of BP in relation to cerebral autoregulation limits using a virtual patient monitoring platform processing near-infrared spectroscopy digital signals offers the hope of bringing this application to the bedside.
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Affiliation(s)
- Eric L Vu
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kenneth Brady
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charles W Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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50
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Bydén M, Segernäs A, Thulesius H, Vanky F, Ahlgren E, Skoog J, Zachrisson H. Cerebrovascular Reserve Capacity as a Predictor of Postoperative Delirium: A Pilot Study. Front Surg 2022; 8:658849. [PMID: 34993226 PMCID: PMC8724247 DOI: 10.3389/fsurg.2021.658849] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Postoperative delirium is a common complication after cardiac surgery with cardiopulmonary bypass (CPB). Compromised regulation of the cerebral circulation may be a predisposing factor for delirium. However, the potential relationship between cerebrovascular reserve capacity and delirium is unknown. The aim of this study was to investigate if impaired cerebrovascular reserve capacity was associated with postoperative delirium. Methods: Forty-two patients scheduled for cardiac surgery with CPB were recruited consecutively. All patients underwent preoperative transcranial Doppler (TCD) ultrasound with calculation of breath-hold index (BHI). BHI < 0.69 indicated impaired cerebrovascular reserve capacity. In addition, patients were examined with preoperative neuropsychological tests such as MMSE (Mini Mental State Examination) and AQT (A Quick Test of cognitive speed). Postoperative delirium was assessed using Nursing Delirium Screening Scale (Nu-DESC) in which a score of ≥2 was considered as delirium. Results: Six patients (14%) scored high for postoperative delirium and all demonstrated impaired preoperative cerebrovascular reserve capacity. Median (25th-75th percentile) BHI in patients with postoperative delirium was significantly lower compared to the non-delirium group [0.26 (-0.08-0.44) vs. 0.83 (0.57-1.08), p = 0.002]. Preoperative MMSE score was lower in patients who developed postoperative delirium (median, 25th-75th percentile; 26.5, 24-28 vs. 28.5, 27-29, p = 0.024). Similarly, patients with postoperative delirium also displayed a slower performance during the preoperative cognitive speed test AQT color and form (mean ± SD; 85.8 s ± 19.3 vs. 69.6 s ± 15.8, p = 0.043). Conclusion: The present findings suggest that an extended preoperative ultrasound protocol with TCD evaluation of cerebrovascular reserve capacity and neuropsychological tests may be valuable in identifying patients with increased risk of developing delirium after cardiac surgery.
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Affiliation(s)
- Moa Bydén
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anna Segernäs
- Primary Health Care Center in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hans Thulesius
- Department of Clinical Sciences, Malmö, Lund University Faculty of Medicine, Lund, Sweden.,Department of Medicine and Optometry, Linnaeus University Faculty of Health Social Work and Behavioral Sciences, Kalmar, Sweden
| | - Farkas Vanky
- Department of Thoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Eva Ahlgren
- Department of Thoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Johan Skoog
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Helene Zachrisson
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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