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Ng RRG, Desai SR, Chu FSW, Sim MA, Chee SWL, Fuh JYH, Ti LK, Chew STH. Feasibility of continuous non-invasive delivery of oxygen monitoring in cardiac surgical patients: a proof-of-concept preliminary study. BMC Anesthesiol 2024; 24:187. [PMID: 38796436 PMCID: PMC11127411 DOI: 10.1186/s12871-024-02561-2] [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: 12/22/2023] [Accepted: 05/14/2024] [Indexed: 05/28/2024] Open
Abstract
PURPOSE Oxygen delivery (DO2) and its monitoring are highlighted to aid postoperative goal directed therapy (GDT) to improve perioperative outcomes such as acute kidney injury (AKI) after high-risk cardiac surgeries associated with multiple morbidities and mortality. However, DO2 monitoring is neither routine nor done postoperatively, and current methods are invasive and only produce intermittent DO2 trends. Hence, we proposed a novel algorithm that simultaneously integrates cardiac output (CO), hemoglobin (Hb) and oxygen saturation (SpO2) from the Edwards Life Sciences ClearSight System® and Masimo SET Pulse CO-Oximetry® to produce a continuous, real-time DO2 trend. METHODS Our algorithm was built systematically with 4 components - machine interface to draw data with PuTTY, data extraction with parsing, data synchronization, and real-time DO2 presentation using a graphic-user interface. Hb readings were validated. RESULTS Our algorithm was implemented successfully in 93% (n = 57 out of 61) of our recruited cardiac surgical patients. DO2 trends and AKI were studied. CONCLUSION We demonstrated a novel proof-of-concept and feasibility of continuous, real-time, non-invasive DO2 monitoring, with each patient serving as their own control. Our study also lays the foundation for future investigations aimed at identifying personalized critical DO2 thresholds and optimizing DO2 as an integral part of GDT to enhance outcomes in perioperative cardiac surgery.
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Affiliation(s)
- Roderica R G Ng
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Suneel R Desai
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
- Departments of Surgical Intensive Care and Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Felicia S W Chu
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Ming Ann Sim
- Department of Anaesthesia, National University Health System, Singapore, Singapore
| | - Sheryl W L Chee
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Jerry Y H Fuh
- Department of Mechanical Engineering, National University of Singapore, Singapore, Singapore
| | - Lian-Kah Ti
- Department of Anaesthesia, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sophia T H Chew
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Lukaszewski M. Dilemmas of Adopting Goal-Directed Perfusion in Extracorporeal Circulation: A Narrative Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:535-539. [PMID: 37997651 DOI: 10.1177/15569845231211904] [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] [Indexed: 11/25/2023]
Abstract
OBJECTIVE Extracorporeal circulation (ECC) is generally based on standards established in the last decade. In recent years, a concept of perfusion management during ECC, goal-directed perfusion (GDP), has emerged to create optimal conditions for oxygen delivery and extraction, initiated by Rannuci et al. The aim of the present work was to determine whether the ECC procedure can truly be optimized with the current state of knowledge and understanding of human physiology. METHODS Discussed articles from 2017 to 2022 were selected from the MEDLINE (PubMed) database using the keywords "cardiopulmonary bypass" AND "cardiac surgery" AND "oxygen delivery" with the conditions of "clinical trial" OR "randomized controlled trial." RESULTS The concept of GDP is an attempt to reproduce the physiological conditions of tissue respiration during ECC. Published articles, also due to their retrospective nature, are based on standards and recommendations that do not fully fit the field of physiological circulation. There are still insufficient tools to assess the relationship between volemia, perfusion pressure, and pump performance. Limitations include indications for vasoactive drugs. Methodology has rarely taken into account the period of starting and stopping the heart-lung machine, the most pronounced periods of circulatory destabilization with reduced oxygen delivery. CONCLUSIONS Problems associated with ECC such as acute kidney injury, liver failure, vasoplegic syndrome, and others must await its resolution. The use of advanced monitoring technology and data engineering may allow the development of baseline hemodynamic models, which may make the ECC procedure more physiologic and thus improve the safety of the procedure.
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Affiliation(s)
- Marceli Lukaszewski
- Department for Anaesthesiology and Intensive Care Therapy, Sokolowski Specialized Hospital Wałbrzych, Poland
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4
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Do-Nguyen CC, Sturmer DL, Yang G, Hawkins RB, Engoren M, Wolverton J, Heung M, Zhang M, Likosky DS. Oxygen Delivery Thresholds During Cardiopulmonary Bypass and Risk for Acute Kidney Injury. Ann Thorac Surg 2023; 116:607-613. [PMID: 37271444 DOI: 10.1016/j.athoracsur.2023.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) in cardiac surgery patients is multifactorial and associated with low oxygen delivery (DO2) during cardiopulmonary bypass. METHODS Cardiac surgical patients undergoing full cardiopulmonary bypass between May 1, 2016 and December 31, 2021 were included, whereas those on preoperative dialysis, undergoing circulatory arrest procedures, or lacking minute-to-minute physiologic data were excluded. A 5-minute running average of indexed DO2 (DO2i, mL/min/m2) was calculated ([pump flow] × [hemoglobin] × 1.36 [hemoglobin saturation] + 0.003 [arterial oxygen tension]/body surface area). AKI was defined using established Kidney Disease: Improving Global Outcomes criteria. The threshold of nadir DO2i on the effect of AKI was estimated using risk-adjusted Constrained Broken-Stick models. RESULTS Postoperative AKI occurred among 1155 patients (29.4%), with 276 (7.0%) having stage 2 to 3 AKI. The median nadir DO2i was lower for those with (vs without) AKI (197.9 mL/min/m2 [interquartile range {IQR}, 166.3-233.2] vs 217.2 mL/min/m2 [IQR, 184.5-252.2], P < .001) and stage 2 to 3 AKI relative to stage 1 or none (186.9 mL/min/m2 [IQR, 160.1-220.5] vs 213.8 mL/min/m2 [IQR, 180.4-249.4]). In risk-adjusted analyses the estimated threshold for nadir DO2i was 231.2 mL/min/m2 (95% CI, 173.6-288.8) for any AKI and 103.3 (95% CI, 68.4-138.3) for stage 2 to 3 AKI. CONCLUSIONS Decreasing nadir DO2i was associated with an increased risk of AKI. The identified nadir DO2i thresholds suggest management and treatment of nadir DO2i during cardiopulmonary bypass may decrease a patient's postoperative AKI risk.
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Affiliation(s)
- Chi Chi Do-Nguyen
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - David L Sturmer
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Robert B Hawkins
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Milo Engoren
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jeremy Wolverton
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
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Mukaida H, Matsushita S, Minami Y, Sato G, Usuba M, Kondo R, Asai T, Amano A. Risk factors for postoperative delirium on oxygen delivery-guided perfusion. J Cardiothorac Surg 2022; 17:193. [PMID: 35987682 PMCID: PMC9392930 DOI: 10.1186/s13019-022-01938-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Studies have demonstrated the efficacy of oxygen delivery-guided perfusion (ODGP) in preventing postoperative acute kidney injury, but the benefit of ODGP for delirium has not been confirmed. We retrospectively investigated the risk factors for postoperative delirium in patients who underwent ODGP (with oxygen delivery index [DO2i] > 300 mL/min/m2).
Methods
Consecutive patients who underwent on-pump cardiovascular surgery with ODGP from January 2018 to December 2020 were retrospectively analyzed. In addition to examining patients’ DO2i during cardiopulmonary bypass (CPB), we quantified the two primary DO2 components-hematocrit (Hct) and pump flow. Delirium was defined based on the Intensive Care Delirium Screening Checklist (ICDSC). Patients were divided into three groups: no delirium (ICDSC score = 0), subsyndromal delirium (ICDSC score = 1–3), and clinical delirium (ICDSC score ≥ 4).
Results
Multivariate analysis identified only the number of red blood cell (RBC) units transfused, intubation time, and the cumulative time below the Hct threshold of 25% as predictive factors of postoperative delirium. Although patients with higher ICDSC scores had greater hemodilution during CPB, ODGP resulted in a higher pump flow, and DO2i was maintained above 300 mL/min/m2, with no significant difference between the three groups.
Conclusions
A low Hct level during CPB with ODGP, the number of RBC units transfused, and intubation time were associated with postoperative delirium. Further investigations are needed to determine the ability of ODGP to prevent low Hct during CPB.
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Broadwin M, Palmeri M, Kelting T, Groom R, Robich M, Lucas FL, Kramer R. Goal Directed Perfusion Is Not Associated with a Decrease in Acute Kidney Injury in Patients Predicted to Be at High Risk for Acute Renal Failure after Cardiac Surgery. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2022; 54:128-134. [PMID: 35928338 PMCID: PMC9302403 DOI: 10.1182/ject-128-134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/04/2022] [Indexed: 06/15/2023]
Abstract
Small increases in serum creatinine postoperatively reflect an acute kidney injury (AKI) that likely occurred during cardiopulmonary bypass (CPB). Maintaining adequate oxygen delivery (DO2) during CPB, known as GDP (goal-directed perfusion), improves outcomes. Whether GDP improves outcomes of patients at high risk for acute renal failure (ARF) is unknown. Forty-seven adult patients undergoing cardiac surgery with CPB utilizing GDP with Cleveland Clinic Acute Renal Failure Score of 3 or greater were compared with a matched cohort of patients operated upon using a flow-directed strategy. CPB flow in the GDP cohort was based on a DO2 goal of 260 mL/min/m2. Serum creatinine values were used to determine whether postoperative AKI occurred according to AKIN (Acute Kidney Injury Network) guidelines. We examined the distribution of all variables using proportions for categorical variables and means (standard deviations) for continuous variables and compared treatment groups using t tests for categorical variables and tests for differences in distributions for continuous and count variables. We used inverse probability of treatment weighting to adjust for treatment selection bias. In adjusted models, GDP was not associated with a decrease in AKI (odds ratio [OR]: .97; confidence interval [CI]: .62, 1.52), but was associated with higher odds of ARF (OR: 3.13; CI: 1.26, 7.79), mortality (OR: 3.35; CI: 1.14, 9.89), intensive care unit readmission (OR: 2.59; CI: 1.31, 5.15), need for intraoperative red blood cell transfusion (OR: 2.02; CI: 1.26, 3.25), and postoperative platelet transfusion (OR: 1.78; CI: 1.05, 3.01) when compared with the historic cohort. In patients who are at high risk for postoperative renal failure, GDP was not associated with a decrease in AKI when compared to the historical cohort managed traditionally by determining CPB flows based on body surface area. Surprisingly, the GDP cohort performed significantly worse than the retrospective control group in terms of ARF, mortality, intensive care unit readmission, and RBC and platelet transfusions.
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Affiliation(s)
- Mark Broadwin
- Lehigh Valley Health Network, Department of Surgery, Allentown, Pennsylvania
| | - Monica Palmeri
- Maine Medical Center, Division of Cardiovascular Surgery, Portland, Maine
| | - Tyler Kelting
- Maine Medical Center, Division of Cardiovascular Surgery, Portland, Maine
| | | | - Michael Robich
- Tufts University Medical Center, Department of Cardiac Surgery, Boston, Massachusetts; and
| | - F. Lee Lucas
- Center for OUtcomes Research and Evaluation, Maine Medical Center, Portland, Maine
| | - Robert Kramer
- Maine Medical Center, Division of Cardiovascular Surgery, Portland, Maine
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The lower threshold of hypothermic oxygen delivery to prevent neonatal acute kidney injury. Pediatr Res 2022; 91:1741-1747. [PMID: 34274961 DOI: 10.1038/s41390-021-01654-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/24/2021] [Accepted: 06/30/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Oxygen delivery during cardiopulmonary bypass (CPB) is closely related to postoperative acute kidney injury (AKI). The value of critical indexed oxygen delivery (DO2i) is a key indicator to reflect oxygen supply in cardiovascular surgery. However, the target DO2i value for neonates undergoing hypothermic CPB remains unclear. METHODS One hundred and twenty-six consecutive newborns (≤28 days) undergoing arterial switch operations were retrospectively divided into two groups according to AKI occurrence. Baseline characteristics, intraoperative variables, and clinical outcomes were collected. Multivariate logistic regression analysis and receiver-operating characteristic curve were performed to investigate the association between DO2i and AKI. RESULTS Neonates in the no-AKI group (n = 67) had significantly higher nadir bypass flow and DO2i during the hypothermic phase compared with the AKI group (n = 59). AKI group had remarkably higher incidences of hepatic dysfunction and peritoneal dialysis requirement compared with newborns without AKI. Mixed venous oxygen saturation (SvO2) was comparable between the two groups. Base excess (BE)(P = 0.011) value during the hypothermic phase of the AKI group was higher than the no-AKI group. Multivariate analysis showed that hypothermic DO2i was negatively associated with AKI. The cut-off value of hypothermic DO2i was 269 mL min-1 m-2. CONCLUSIONS The importance of hypothermic DO2i should be highlighted, even when SvO2 was satisfactory. A lower threshold of DO2i > 269 mL min-1 m-2 may help protect neonates from the risk of postoperative AKI. IMPACT The key message of our article is that the lower threshold of DO2i > 269 mL min-1 m-2 may help protect neonates from the risk of AKI after on-pump hypothermic cardiovascular surgery. The critical DO2i value for neonates undergoing hypothermic CPB remains unclear, and our study may add new evidence for this matter based on the 6-year experience of our center. In this study, the lowest critical value of DO2i in neonatal hypothermic CPB is determined for the first time, which provides a reference for intra-CPB management strategy to improve the postoperative outcomes of newborns.
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Lazar HL. Commentary: Optimizing oxygen delivery during cardiopulmonary bypass to minimize morbidity and mortality: Have our goals been achieved? J Thorac Cardiovasc Surg 2021; 164:1009-1010. [PMID: 33487429 DOI: 10.1016/j.jtcvs.2020.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston University School of Medicine, Boston, Mass.
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Kramer RS, Kelting T. Commentary: Goal-directed or flow-directed perfusion? J Thorac Cardiovasc Surg 2020; 164:1008-1009. [PMID: 33454092 DOI: 10.1016/j.jtcvs.2020.12.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Robert S Kramer
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Maine Medical Center, Portland, Maine.
| | - Tyler Kelting
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Maine Medical Center, Portland, Maine
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