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Kim EH, Lee JH, Kim HS, Jang YE, Ji SH, Kim WH, Kwak JG, Kim JT. Effects of intraoperative dexmedetomidine on the incidence of acute kidney injury in pediatric cardiac surgery patients: A randomized controlled trial. Paediatr Anaesth 2020; 30:1132-1138. [PMID: 32780926 DOI: 10.1111/pan.13995] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Perioperative dexmedetomidine use has been reported to reduce the incidence of postoperative acute kidney injury after adult cardiac surgery. However, large-scale randomized controlled trials evaluating the effect of dexmedetomidine use on acute kidney injury in pediatric patients are lacking. AIMS We investigated whether intraoperative dexmedetomidine could reduce the incidence of acute kidney injury in pediatric cardiac surgery patients. METHODS In total, 141 pediatric patients were randomly assigned to dexmedetomidine or control groups. After anesthetic induction, patients in the dexmedetomidine group were administered 1 µg/kg of dexmedetomidine over 10 minutes and an additional 0.5 µg/kg/h of dexmedetomidine during surgery. Additionally, 1 µg/kg of dexmedetomidine was infused immediately after cardiopulmonary bypass was initiated. The incidence of acute kidney injury was defined following Kidney Disease Improving Global Outcomes guidelines. RESULTS The final analysis included 139 patients. The incidence of acute kidney injury did not differ between dexmedetomidine and control groups (16.9% vs 23.5%; odds ratio 0.661; 95% CI 0.285 to 1.525; P = .33). Similarly, neither the incidence of abnormal postoperative estimated glomerular filtration rate values (P = .96) nor the incidence of arrhythmia, mechanical ventilation duration, length of stay in the intensive care unit, and hospitalization differed between the two groups. CONCLUSIONS Intraoperative dexmedetomidine did not reduce acute kidney injury incidence in pediatric cardiac surgery patients.
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Affiliation(s)
- Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woong-Han Kim
- Department of Cardiothoracic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Gun Kwak
- Department of Cardiothoracic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Cooper MG, Loadsman JA. The <i>Anaesthesia and Intensive Care</i> Jeanette Thirlwell Best Paper Award turns 21, and our first Junior Investigator Award. Anaesth Intensive Care 2019; 46:562-564. [PMID: 30447662 DOI: 10.1177/0310057x1804600603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - J A Loadsman
- Senior Staff Specialist, Department of Anaesthetics, Royal Prince Alfred Hospital and Conjoint Associate Professor, Sydney Medical School, University of Sydney
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Lomivorotov VV, Efremov SM, Abubakirov MN, Belletti A, Karaskov AM. Perioperative Management of Cardiovascular Medications. J Cardiothorac Vasc Anesth 2018; 32:2289-2302. [DOI: 10.1053/j.jvca.2018.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Indexed: 12/28/2022]
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Duncan D, Sankar A, Beattie WS, Wijeysundera DN. Alpha-2 adrenergic agonists for the prevention of cardiac complications among adults undergoing surgery. Cochrane Database Syst Rev 2018; 3:CD004126. [PMID: 29509957 PMCID: PMC6494272 DOI: 10.1002/14651858.cd004126.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The surgical stress response plays an important role on the pathogenesis of perioperative cardiac complications. Alpha-2 adrenergic agonists attenuate this response and may help prevent postoperative cardiac complications. OBJECTIVES To determine the efficacy and safety of α-2 adrenergic agonists for reducing mortality and cardiac complications in adults undergoing cardiac surgery and non-cardiac surgery. SEARCH METHODS We searched CENTRAL (2017, Issue 4), MEDLINE (1950 to April Week 4, 2017), Embase (1980 to May 2017), the Science Citation Index, clinical trial registries, and reference lists of included articles. SELECTION CRITERIA We included randomized controlled trials that compared α-2 adrenergic agonists (i.e. clonidine, dexmedetomidine or mivazerol) against placebo or non-α-2 adrenergic agonists. Included trials had to evaluate the efficacy and safety of α-2 adrenergic agonists for preventing perioperative mortality or cardiac complications (or both), or measure one or more relevant outcomes (i.e. death, myocardial infarction, heart failure, acute stroke, supraventricular tachyarrhythmia and myocardial ischaemia). DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality, extracted data and independently performed computer entry of abstracted data. We contacted study authors for additional information. Adverse event data were gathered from the trials. We evaluated included studies using the Cochrane 'Risk of bias' tool, and the quality of the evidence underlying pooled treatment effects using GRADE methodology. Given the clinical heterogeneity between cardiac and non-cardiac surgery, we analysed these subgroups separately. We expressed treatment effects as pooled risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS We included 47 trials with 17,039 participants. Of these studies, 24 trials only included participants undergoing cardiac surgery, 23 only included participants undergoing non-cardiac surgery and eight only included participants undergoing vascular surgery. The α-2 adrenergic agonist studied was clonidine in 21 trials, dexmedetomidine in 24 trials and mivazerol in two trials.In non-cardiac surgery, there was high quality evidence that α-2 adrenergic agonists led to a similar risk of all-cause mortality compared with control groups (1.3% with α-2 adrenergic agonists versus 1.7% with control; RR 0.80, 95% CI 0.61 to 1.04; participants = 14,081; studies = 16). Additionally, the risk of cardiac mortality was similar between treatment groups (0.8% with α-2 adrenergic agonists versus 1.0% with control; RR 0.86, 95% CI 0.60 to 1.23; participants = 12,525; studies = 5, high quality evidence). The risk of myocardial infarction was probably similar between treatment groups (RR 0.94, 95% CI 0.69 to 1.27; participants = 13,907; studies = 12, moderate quality evidence). There was no associated effect on the risk of stroke (RR 0.93, 95% CI 0.55 to 1.56; participants = 11,542; studies = 7; high quality evidence). Conversely, α-2 adrenergic agonists probably increase the risks of clinically significant bradycardia (RR 1.59, 95% CI 1.18 to 2.13; participants = 14,035; studies = 16) and hypotension (RR 1.24, 95% CI 1.03 to 1.48; participants = 13,738; studies = 15), based on moderate quality evidence.There was insufficient evidence to determine the effect of α-2 adrenergic agonists on all-cause mortality in cardiac surgery (RR 0.52, 95% CI 0.26 to 1.04; participants = 1947; studies = 16) and myocardial infarction (RR 1.01, 95% CI 0.43 to 2.40; participants = 782; studies = 8), based on moderate quality evidence. There was one cardiac death in the clonidine arm of a study of 22 participants. Based on very limited data, α-2 adrenergic agonists may have reduced the risk of stroke (RR 0.37, 95% CI 0.15 to 0.93; participants = 1175; studies = 7; outcome events = 18; low quality evidence). Conversely, α-2 adrenergic agonists increased the risk of bradycardia from 6.4% to 12.0% (RR 1.88, 95% CI 1.35 to 2.62; participants = 1477; studies = 10; moderate quality evidence), but their effect on hypotension was uncertain (RR 1.19, 95% CI 0.87 to 1.64; participants = 1413; studies = 9; low quality evidence).These results were qualitatively unchanged in subgroup analyses and sensitivity analyses. AUTHORS' CONCLUSIONS Our review concludes that prophylactic α-2 adrenergic agonists generally do not prevent perioperative death or major cardiac complications. For non-cardiac surgery, there is moderate-to-high quality evidence that these agents do not prevent death, myocardial infarction or stroke. Conversely, there is moderate quality evidence that these agents have important adverse effects, namely increased risks of hypotension and bradycardia. For cardiac surgery, there is moderate quality evidence that α-2 adrenergic agonists have no effect on the risk of mortality or myocardial infarction, and that they increase the risk of bradycardia. The quality of evidence was inadequate to draw conclusions regarding the effects of alpha-2 agonists on stroke or hypotension during cardiac surgery.
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Affiliation(s)
- Dallas Duncan
- University of TorontoDepartment of Anesthesia123 Edward Street12th FloorTorontoONCanadaM5G 1E2
| | - Ashwin Sankar
- University of TorontoDepartment of Anesthesia123 Edward Street12th FloorTorontoONCanadaM5G 1E2
| | - W Scott Beattie
- Toronto General Hospital, University Health NetworkDepartment of AnaesthesiaEN 3‐453 Toronto General Hospital, University Health Network200 Elizabeth StreetTorontoONCanadaM5G 2C4
| | - Duminda N Wijeysundera
- St. Michael's HospitalLi Ka Shing Knowledge Institute30 Bond StreetTorontoOntarioCanadaM5B 1W8
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Schetz M, Bove T, Morelli A, Mankad S, Ronco C, Kellum J. Prevention of Cardiac Surgery-Associated Acute Kidney Injury. Int J Artif Organs 2018; 31:179-89. [DOI: 10.1177/039139880803100211] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Numerous strategies have been evaluated to prevent early CSA-AKI. Although correction of hemodynamic problems is paramount, there are no clinical studies that compare different hemodynamic management or monitoring strategies with regard to their effect on kidney function. Pharmacologic strategies including diuretics, different classes of vasodilators and drugs with anti-inflammatory effects such as N-acetyl-cysteine, do not appear to be effective. Most of the studies are underpowered and use physiological rather than clinical endpoints. Further trials are warranted with fenoldopam and nesiritide (rhBNP). Observational and underpowered randomized studies show beneficial renal effects of off-pump technique and avoidance of aortic manipulation. There is very limited evidence for preoperative fluid loading and preemptive RRT. Potentially nephrotoxic agents should be used with caution in patients at risk of CSA-AKI. Tranexamic acid or aminocaproic acid should be preferred over aprotinin. No pharmacologic intervention has been adequately tested in the prevention of late CSA-AKI. A single-center study, including a predominance of patients after cardiac surgery, showed a decrease of kidney injury with tight glycemic control.
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Affiliation(s)
- M. Schetz
- Department of Intensive Care Medicine, University of Leuven, Leuven - Belgium
| | - T. Bove
- Department of Cardiothoracic Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan - Italy
| | - A. Morelli
- Department of Anesthesiology and Intensive Care, University of Rome, La Sapienza, Rome - Italy
| | - S. Mankad
- Division of Cardiology, The Mayo Clinic, Rochester, Minnesota - USA
| | - C. Ronco
- Department of Nephrology, Dialysis and Transplantation, St. Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
| | - J.A. Kellum
- Department of Critical Care Medicine. University of Pittsburgh, Pittsburgh, Pennsylvania - USA
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Tolwani A, Paganini E, Joannidis M, Zamperetti N, Verbine A, Vidyasagar V, Clark W, Ronco C. Treatment of Patients with Cardiac Surgery Associated-Acute Kidney Injury. Int J Artif Organs 2018; 31:190-6. [DOI: 10.1177/039139880803100212] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Members of the Acute Dialysis Quality Initiative (ADQI) participated in a 3-day conference in Vicenza in May 2007 to evaluate the available literature on this topic and draft consensus recommendations for research studies in this area. This report summarizes the available evidence and describes the key questions that will need to be addressed with the goal of standardizing the care of patients with cardiac surgery-associated acute kidney injury (CSA-AKI) and improving outcomes.
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Affiliation(s)
- A. Tolwani
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama - USA
| | - E. Paganini
- Dialysis and Extracorporeal Treatment, Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, Ohio - USA
| | - M. Joannidis
- Medical ICU, Department of Internal Medicine, Medical University of Innsbruck, Innsbruck - Austria
| | - N. Zamperetti
- Department of Anesthesia and Intensive Care Medicine, San Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
| | - A. Verbine
- Department of Nephrology, Dialysis and Renal Transplant, San Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
| | - V. Vidyasagar
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama - USA
| | - W. Clark
- Medical Strategy and Therapy Development, Gambro, Indianapolis, Indiana - USA
- Indiana University School of Medicine, Indianapolis, Indiana - USA
| | - C. Ronco
- Department of Nephrology, Dialysis and Renal Transplant, San Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
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Hering D, Winklewski PJ. R1 autonomic nervous system in acute kidney injury. Clin Exp Pharmacol Physiol 2017; 44:162-171. [DOI: 10.1111/1440-1681.12694] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/17/2016] [Accepted: 10/29/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Dagmara Hering
- Dobney Hypertension Centre; School of Medicine and Pharmacology; Royal Perth Hospital Unit; The University of Western Australia; Perth WA Australia
| | - Pawel J Winklewski
- Institute of Human Physiology; Medical University of Gdansk; Gdansk Poland
- Department of Clinical Sciences; Institute of Health Sciences; Pomeranian University of Slupsk; Slupsk Poland
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Myles PS, McIlroy D. Fast-Track Cardiac Anesthesia: Choice of Anesthetic Agents and Techniques. Semin Cardiothorac Vasc Anesth 2016; 9:5-16. [PMID: 15735840 DOI: 10.1177/108925320500900102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fast-track cardiac anesthesia (FTCA) incorporates early tracheal extubation, decreased length of intensive care unit (ICU) and hospital stay, and (ideally) should avoid or reduce complications to safely achieve cost-savings. A growing body of evidence from randomized trials has identified many anesthetic interventions that can improve outcome after cardiac surgery. These include new short-acting hypnotic, opioid, and neuromuscular blocking drugs. An effective FTCA program requires the appropriate selection of suitable patients, a lowdose opioid anesthetic technique, early tracheal extubation, a short stay in the ICU, and coordinated perioperative care. It is also dependent on the avoidance of postoperative complications such as excessive bleeding, myocardial ischemia, low cardiac output state, arrhythmias, sepsis, and renal failure. These complications will have a much greater adverse effect on hospital length of stay and healthcare costs. A number of clinical trials have identified interventions that can reduce some of these complications. The adoption of effective treatments into clinical practice should improve the effectiveness of FTCA.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia & Pain Management, Alfred Hospital, Victoria, Australia.
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9
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Perioperative dexmedetomidine reduces the incidence and severity of acute kidney injury following valvular heart surgery. Kidney Int 2016; 89:693-700. [DOI: 10.1038/ki.2015.306] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/25/2015] [Accepted: 07/02/2015] [Indexed: 11/08/2022]
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Ammar AS, Mahmoud KM, Kasemy ZA, Helwa MA. Cardiac and renal protective effects of dexmedetomidine in cardiac surgeries: A randomized controlled trial. Saudi J Anaesth 2016; 10:395-401. [PMID: 27833481 PMCID: PMC5044722 DOI: 10.4103/1658-354x.177340] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cardiac and renal injuries are common insults after cardiac surgeries that contribute to perioperative morbidity and mortality. Dexmedetomidine has been shown to protect several organs against ischemia/reperfusion-(I/R) induced injury. We performed a randomized controlled trial to assess the effect of dexmedetomidine on cardiac and renal I/R injury in patients undergoing cardiac surgeries. MATERIALS AND METHODS Fifty patients scheduled for elective cardiac surgeries were randomized to dexmedetomidine group that received a continuous infusion of dexmedetomidine initiated 5 min before cardiopulmonary bypass (1 μg/kg over 15 min, followed by 0.5 μg/kg/h) until 6 h after surgery, whereas the control group received an equivalent volume of physiological saline. Primary outcome measures included myocardial-specific proteins (troponin-I, creatine kinase-MB), urinary-specific kidney proteins (N-acetyl-beta-D-glucosaminidase, alpha-1-microglobulin, glutathione transferase-pi, glutathione transferase alpha), serum proinflammatory cytokines (tumor necrosis factor alpha and interleukin-1 beta), norepinephrine, and cortisol levels. They were measured within 5 min of starting anesthesia (T0), at the end of surgery (T1), 12 h after surgery (T2), 24 h after surgery (T3), 36 h postoperatively (T4), and 48 h postoperatively (T5). Furthermore, creatinine clearance and serum cystatin C were measured before starting surgery as a baseline, and at days 1, 4, 7 after surgery. RESULTS Dexmedetomidine reduced cardiac and renal injury as evidenced by lower concentration of myocardial-specific proteins, kidney-specific urinary proteins, and pro-inflammatory cytokines. Moreover, it caused higher creatinine clearance and lower serum cystatin C. CONCLUSION Dexmedetomidine provided cardiac and renal protection during cardiac surgery.
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Affiliation(s)
- A S Ammar
- Asst. Professor in Anesthesiology Department, Minoufiya Faculty of Medicine, Minoufiya University, Minoufiya, Egypt
| | - K M Mahmoud
- Asst. Professor in Anesthesiology Department, Minoufiya Faculty of Medicine, Minoufiya University, Minoufiya, Egypt
| | - Z A Kasemy
- Lecturer in Public Health, Statistics and Community Medicine Department, Minoufiya Faculty of Medicine, Minoufiya University, Minoufiya, Egypt
| | - M A Helwa
- Lecturer in Clinical Pathology Department, Minoufiya Faculty of Medicine, Minoufiya University, Minoufiya, Egypt
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Abstract
Approximately 18% of patients undergoing cardiac surgery experience AKI (on the basis of modern standardized definitions of AKI), and approximately 2%-6% will require hemodialysis. The development of AKI after cardiac surgery portends poor short- and long-term prognoses, with those developing RIFLE failure or AKI Network stage III having an almost 2-fold increase in the risk of death. AKI is caused by a variety of factors, including nephrotoxins, hypoxia, mechanical trauma, inflammation, cardiopulmonary bypass, and hemodynamic instability, and it may be affected by the clinician's choice of fluids and vasoactive agents as well as the transfusion strategy used. The risk of AKI may be ameliorated by avoidance of nephrotoxins, achievement of adequate glucose control preoperatively, and use of goal-directed therapy hemodynamic strategies. Remote ischemic preconditioning is an exciting future strategy, but more work is needed before widespread implementation. Unfortunately, there are no pharmacologic agents known to reduce the risk of AKI or treat established AKI.
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Affiliation(s)
| | | | - Mitchell H Rosner
- Medicine, University of Virginia Health System, Charlottesville, Virginia
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12
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Garg AX, Kurz A, Sessler DI, Cuerden M, Robinson A, Mrkobrada M, Parikh C, Mizera R, Jones PM, Tiboni M, Rodriguez RG, Popova E, Rojas Gomez MF, Meyhoff CS, Vanhelder T, Chan MTV, Torres D, Parlow J, de Nadal Clanchet M, Amir M, Bidgoli SJ, Pasin L, Martinsen K, Malaga G, Myles P, Acedillo R, Roshanov P, Walsh M, Dresser G, Kumar P, Fleischmann E, Villar JC, Painter T, Biccard B, Bergese S, Srinathan S, Cata JP, Chan V, Mehra B, Leslie K, Whitlock R, Devereaux PJ. Aspirin and clonidine in non-cardiac surgery: acute kidney injury substudy protocol of the Perioperative Ischaemic Evaluation (POISE) 2 randomised controlled trial. BMJ Open 2014; 4:e004886. [PMID: 24568963 PMCID: PMC3939660 DOI: 10.1136/bmjopen-2014-004886] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Perioperative Ischaemic Evaluation-2 (POISE-2) is an international 2×2 factorial randomised controlled trial of low-dose aspirin versus placebo and low-dose clonidine versus placebo in patients who undergo non-cardiac surgery. Perioperative aspirin (and possibly clonidine) may reduce the risk of postoperative acute kidney injury (AKI). METHODS AND ANALYSIS After receipt of grant funding, serial postoperative serum creatinine measurements began to be recorded in consecutive patients enrolled at substudy participating centres. With respect to the study schedule, the last of over 6500 substudy patients from 82 centres in 21 countries were randomised in December 2013. The authors will use logistic regression to estimate the adjusted OR of AKI following surgery (compared with the preoperative serum creatinine value, a postoperative increase ≥26.5 μmol/L in the 2 days following surgery or an increase of ≥50% in the 7 days following surgery) comparing each intervention to placebo, and will report the adjusted relative risk reduction. Alternate definitions of AKI will also be considered, as will the outcome of AKI in subgroups defined by the presence of preoperative chronic kidney disease and preoperative chronic aspirin use. At the time of randomisation, a subpopulation agreed to a single measurement of serum creatinine between 3 and 12 months after surgery, and the authors will examine intervention effects on this outcome. ETHICS AND DISSEMINATION The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this POISE-2 AKI substudy. Ethics approval was obtained for additional kidney data collection in consecutive patients enrolled at participating centres, which first began for patients enrolled after January 2011. In patients who provided consent, the remaining longer term serum creatinine data will be collected throughout 2014. The results of this study will be reported no later than 2015. CLINICAL TRIAL REGISTRATION NUMBER NCT01082874.
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Affiliation(s)
- Amit X Garg
- Western University/London Health Sciences Centre, London, Canada
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Ren J, Zhang H, Huang L, Liu Y, Liu F, Dong Z. Protective effect of dexmedetomidine in coronary artery bypass grafting surgery. Exp Ther Med 2013; 6:497-502. [PMID: 24137215 PMCID: PMC3786847 DOI: 10.3892/etm.2013.1183] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 06/03/2013] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to observe the impact of dexmedetomidine on postoperative myocardial injury in patients undergoing off-pump coronary artery bypass (OPCAB) grafting. One hundred and sixty-two patients who were undergoing OPCAB surgery were randomly divided into control and dexmedetomidine groups (groups C and Dex, respectively). Following the first vascular anastomosis grafting, the patients in group Dex received a continuous intravenous infusion of 0.2–0.5 μg/kg/h dexmedetomidine, until they were transferred to the Cardiac Surgery intensive care unit (ICU) for 12 h. Patients in group C received physiological saline intraoperatively and an intravenous infusion of 2–4 mg/kg/h isopropylphenol for postoperative sedation. Invasive arterial pressure and heart rate were continuously monitored for 5 min subsequent to entry into the operating theatre (T0), immediately following surgery (T1), 12 h post-surgery (T2), 24 h post-surgery(T3), 48 h post-surgery(T4) and 72 h post-surgery (T5). Blood samples were taken to determine the plasma levels of cardiac troponin I (cTnI) and creatine kinase-MB (CK-MB) at each time point. At 72 h post-surgery, a dynamic electrocardiogram was monitored. The blood pressure, heart rate, levels of cTnI, CK-MB, norepinephrine and cortisol, and postoperative arrhythmic events in the patients in group Dex all decreased compared with those in group C. The duration of mechanical ventilation and ICU residence time were also shorter than those in the control group (P<0.05). Dexmedetomidine reduced post-surgical myocardial injury in patients who had undergone OPCAB surgery.
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Affiliation(s)
- Jianjun Ren
- Department of Anesthesiology, The Second Affiliated Hospital, Hebei Medical University, Shijiazhuang, Hebei 050000
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Tonner PH, Paris A. [α2-Agonists in anesthesia and intensive care]. ACTA ACUST UNITED AC 2012; 40:474-9. [PMID: 22028131 DOI: 10.1002/pauz.201100442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Peter H Tonner
- Klinikum Links der Weser gGmbH, Klinik für Anästhesie, Operative und Allgemeine Intensivmedizin, Notfallmedizin, Bremen.
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Anger KE, Szumita PM, Baroletti SA, Labreche MJ, Fanikos J. Evaluation of dexmedetomidine versus propofol-based sedation therapy in mechanically ventilated cardiac surgery patients at a tertiary academic medical center. Crit Pathw Cardiol 2010; 9:221-226. [PMID: 21119342 DOI: 10.1097/hpc.0b013e3181f4ec4a] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Management of pain and sedation therapy is a vital component of optimizing patient outcomes; however, the ideal pharmacotherapy regimen has not been identified in the postoperative cardiac surgery population. We sought to evaluate efficacy and safety outcomes between postoperative mechanically ventilated cardiac surgery patients receiving dexmedetomidine versus propofol therapy upon arrival to the intensive care unit (ICU). We conducted a single center, descriptive study of clinical practice at a 20-bed cardiac surgery ICU in a tertiary academic medical center. Adult mechanically ventilated postcardiac surgery patients who received either dexmedetomidine or propofol for sedation therapy upon admission to the ICU between October 20, 2006 and December 15, 2006 were evaluated. A pharmacy database was used to identify patients receiving dexmedetomidine or propofol therapy for perioperative sedation during cardiac surgery. Patients were matched according to surgical procedure type. Fifty-six patients who received either dexmedetomidine (n = 28) or propofol (n = 28) were included in the analysis. No differences in the ICU length of stay (58.67 ± 32.61 vs. 61 ± 33.1 hours; P = 0.79) and duration of mechanical ventilation (16.21 ± 6.05 vs. 13.97 ± 4.62 hours; P = 0.13) were seen between the propofol and dexmedetomidine groups, respectively. Hypotension (17 [61%] vs. 9 [32%]; P = 0.04), morphine use (11 [39.3%] vs. 1 [3.6%]; P = 0.002), and nonsteroidal anti-inflammatory use (7 [25%] vs. 1 [3.6%]; P = 0.05) occurred more during dexmedetomidine therapy versus propofol. Dexmedetomidine therapy resulted in a higher incidence of hypotension and analgesic consumption compared with propofol-based sedation therapy. Further evaluation is needed to assess differences in clinical outcomes of propofol and dexmedetomidine-based therapy in mechanically ventilated cardiac surgery patients.
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Affiliation(s)
- Kevin E Anger
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA.
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Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore P, Oudemans-van Straaten HM, Ronco C, Schetz MRC, Woittiez AJ. Prevention of acute kidney injury and protection of renal function in the intensive care unit. Expert opinion of the Working Group for Nephrology, ESICM. Intensive Care Med 2010; 36:392-411. [PMID: 19921152 DOI: 10.1007/s00134-009-1678-y] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 08/13/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. METHOD A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system. CONCLUSIONS AND RECOMMENDATIONS Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest specific vasodilators [corrected] under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention. ELECTRONIC SUPPLEMENTARY MATERIAL The online version of this article (doi:10.1007/s00134-009-1678-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael Joannidis
- Medical Intensive Care Unit, Department of Internal Medicine I, Medical University Innsbruck, Anichstasse 31, 6020 Innsbruck, Austria.
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Rubino AS, Onorati F, Caroleo S, Galato E, Nucera S, Amantea B, Santini F, Renzulli A. Impact of clonidine administration on delirium and related respiratory weaning after surgical correction of acute type-A aortic dissection: results of a pilot study. Interact Cardiovasc Thorac Surg 2010; 10:58-62. [DOI: 10.1510/icvts.2009.217562] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Wijeysundera DN, Bender JS, Beattie WS. Alpha-2 adrenergic agonists for the prevention of cardiac complications among patients undergoing surgery. Cochrane Database Syst Rev 2009:CD004126. [PMID: 19821319 DOI: 10.1002/14651858.cd004126.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The surgical stress response plays an important role on the pathogenesis of perioperative cardiac complications. Alpha-2 adrenergic agonists attenuate this response and may thereby prevent cardiac complications. OBJECTIVES This review assessed the efficacy and safety of preoperative (within 24 hours), intraoperative, and postoperative (first 48 hours) alpha-2 adrenergic agonists for preventing mortality and cardiac complications after surgery performed under either general or neuraxial anaesthesia, or both. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August week 4 2008), EMBASE (1980 to week 36 2008), the Science Citation Index, and reference lists of articles. SELECTION CRITERIA We included randomized controlled trials that compared alpha-2 adrenergic agonists (clonidine, dexmedetomidine, or mivazerol) against placebo or non-alpha-2 adrenergic agonists. Included studies had to report on mortality, myocardial infarction, myocardial ischaemia, or supraventricular tachyarrhythmia. DATA COLLECTION AND ANALYSIS Three authors independently assessed trial quality and extracted data. Two authors independently performed computer entry of abstracted data. We contacted study authors for additional information. Adverse event data were gathered from the trials. MAIN RESULTS We included 31 studies (4578 participants). Study quality was generally inadequate, with only six studies clearly reporting methods for blinding and allocation concealment. Overall, alpha-2 adrenergic agonists reduced mortality (relative risk (RR) 0.66; 95% CI 0.44 to 0.98; P = 0.04) and myocardial ischaemia (RR 0.68; 95% CI 0.57 to 0.81; P < 0.0001). However, their effects appeared to vary with the surgical procedure. The most encouraging data pertained to vascular surgery, where they reduced mortality (RR 0.47; 95% CI 0.25 to 0.90; P = 0.02), cardiac mortality (RR 0.36; 95% CI 0.16 to 0.79; P = 0.01), and myocardial infarction (RR 0.66; 95% CI 0.46 to 0.94; P = 0.02). With regard to adverse effects, alpha-2 adrenergic agonists significantly increased perioperative hypotension (RR 1.32; 95% CI 1.07 to 1.62; P = 0.009) and bradycardia (RR 1.66; 95% CI 1.14 to 2.41; P = 0.008). AUTHORS' CONCLUSIONS Our study provides encouraging evidence that alpha-2 adrenergic agonists may reduce cardiac risk, especially during vascular surgery. Nonetheless, these data remain insufficient to make firm conclusions about their efficacy and safety. A large randomized trial of alpha-2 adrenergic agonists is therefore warranted. Additionally, future research must determine which specific alpha-2 adrenergic agonist should be used, and whether it is safe to combine them with other perioperative interventions (for example beta-adrenergic blockade).
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Affiliation(s)
- Duminda N Wijeysundera
- Department of Anesthesia, Toronto General Hospital and University of Toronto, EN 3-450, Toronto General Hospital,, 200 Elizabeth Street, Toronto, Ontario, Canada, M5G 2C4
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[Perioperative pharmacological myocardial protection. Systematic literature-based process optimization]. Anaesthesist 2008; 57:655-69. [PMID: 18597062 DOI: 10.1007/s00101-008-1396-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Patients with major cardiac risk factors have been suggested to benefit from perioperative beta-blockade. However, the scientific literature on perioperative beta-blockade needs to be interpreted carefully. So far treatment recommendations for millions of patients are based on heterogeneous data from randomized trials with divergent study results. The evidence for a beneficial effect of perioperative beta-blockers is sufficient only for a limited subpopulation of high cardiac risk patients undergoing vascular surgery. Perioperative beta-blocker treatment is not useful in patients with intermediate risk and may even be harmful in patients with low cardiac risk. Therefore, an individualized risk-benefit analysis is an important prerequisite for a rational therapy that may be based on a standardized protocol including the Revised Cardiac Risk Index. Such a protocol is presented in this article. A recently reported trial (POISE) demonstrated that perioperative treatment with high doses of oral metoprolol efficiently reduces the incidence of cardiovascular events. However, due to severe adverse effects (hypotension, bradycardia, stroke) the total mortality was increased. Thus, dose adjustments, safety aspects, and monitoring of beta-blocker therapy seem to be mandatory. So far evidence from relevant trials about how to best implement perioperative beta-blockade is lacking. This article offers a simple clinical concept for this purpose.
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21st ESICM Annual Congress. Intensive Care Med 2008. [PMCID: PMC2799007 DOI: 10.1007/s00134-008-1240-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rosner MH, Portilla D, Okusa MD. Cardiac surgery as a cause of acute kidney injury: pathogenesis and potential therapies. J Intensive Care Med 2008; 23:3-18. [PMID: 18230632 DOI: 10.1177/0885066607309998] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cardiopulmonary bypass surgery occurs in nearly 1 million patients per year. Acute kidney injury requiring dialysis can occur in up to 1% of these patients. The development of acute kidney injury is associated with substantial morbidity and mortality independent of all other factors, and many patients are left dependent on dialysis therapies. The pathogenesis of acute kidney injury involves multiple pathways. Hemodynamic, inflammatory, and nephrotoxic factors are involved and overlap each other in leading to kidney injury. Clinical studies have identified risk factors for acute kidney injury that can be used to effectively determine the risk of acute kidney injury in patients undergoing bypass surgery. These high-risk patients can then be targeted for renal protective strategies. Thus far, no single strategy has conclusively demonstrated its ability to prevent renal injury post-bypass surgery. Novel anti-inflammatory agents are in development and offer hope as potential therapies.
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Affiliation(s)
- Mitchell H Rosner
- Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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Takada M, Dohi S, Akamatsu S, Suzuki A. Effects of Pericardial Lidocaine on Hemodynamic Parameters and Responses in Dogs Anesthetized With Midazolam and Fentanyl. J Cardiothorac Vasc Anesth 2007; 21:393-9. [PMID: 17544893 DOI: 10.1053/j.jvca.2006.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Tachycardia during anesthesia should be avoided, especially during off-pump coronary artery bypass graft surgery. Decreasing heart rate without reducing cardiac contractility is an ideal goal. To achieve this, the authors attempted to block the cardiac nerves by pericardial administration of local anesthetic. DESIGN A prospective study. SETTING A laboratory. PARTICIPANTS Anesthetized, mechanically ventilated dogs (n = 69). INTERVENTIONS The pericardial space was infused with 2.5 or 5 mL of 1% lidocaine, 5 mL of 2% lidocaine, or normal saline solution. The hemodynamic changes and the cardiac responses to atropine or isoproterenol were measured during cardiac nerve blockade. To examine the inhibitory action of pericardial lidocaine on arrhythmias, an electrical fibrillator was installed. Furthermore, the blood level of lidocaine was measured. MEASUREMENTS AND MAIN RESULTS Pericardial injection of lidocaine significantly decreased heart rate without a change in stroke volume. Under pericardial lidocaine, the tachycardia response to isoproterenol was similar to that observed without pericardial lidocaine, but response to atropine was significantly reduced. Pericardial lidocaine increased the voltage thresholds for inducing arrhythmias and ventricular fibrillation. Intravenous injection of lidocaine elevated the plasma concentration of lidocaine immediately, whereas the plasma concentration peaked at 10 minutes after pericardial administration. CONCLUSIONS Pericardial lidocaine (1) decreased heart rate without affecting stroke volume, (2) preserved the tachycardiac response to isoproterenol but completely blocked the response to atropine, and (3) increased the voltage thresholds for arrhythmias and ventricular fibrillation induced by an electrical fibrillator. These results suggest that pericardial lidocaine may be useful for controlling heart rate during off-pump coronary artery bypass graft surgery.
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Affiliation(s)
- Motoshi Takada
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.
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Abstract
PURPOSE OF REVIEW Perioperative cardiac risk reduction using perioperative beta-blockade is being widely adopted. Recent research has identified a second-line agent, perioperative clonidine, that can be used to reduce the risk of perioperative cardiac mortality. Perioperative clonidine has some advantages over perioperative beta-blockers because it has less risk of bronchospasm in asthmatics and it comes in a transcutaneous form that can be used in patients who are not taking oral medications ('NPO'). RECENT FINDINGS Clonidine has been used for many purposes, including reduction of blood pressure in hypertension, reduction in alcohol and drug withdrawal phenomena, reduction in nicotine withdrawal symptoms during smoking cessation, analgesia, reduction in stress response, and now as an anti-ischemic agent to reduce the risk of perioperative myocardial ischemia and perioperative mortality. SUMMARY Administration of perioperative clonidine can reduce the risk of perioperative myocardial ischemia and mortality in patients undergoing non-cardiac surgery. Perioperative clonidine comes in a patch form that can be used in patients who are not taking medications by mouth, and can be used when beta-blockers are contraindicated (for asthmatics or patients with high-grade atrioventricular block).
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Affiliation(s)
- Arthur W Wallace
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA.
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Shilling AM, Durieux ME. Pharmacologic modulation of operative risk in patients who have cardiac disease. Anesthesiol Clin 2006; 24:365-79. [PMID: 16927934 DOI: 10.1016/j.atc.2006.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiac complications continue to compose a major proportion of serious postoperative morbidity and mortality, and it is appropriate, therefore, that this area has received a lot of attention in the search for pharmacologic modulation of surgical outcomes. Despite numerous studies, conclusive data does not exist, making it difficult to recommend a course of action. beta-blockade has not only made it into national protocols, but is even considered as a quality assessment measure. However, the data are not quite as conclusive as it may sometimes appear. There have been few studies, with a small number of negative outcomes, and, at times, significant methodological concerns. The positive outcomes of meta-analyses rest essentially on a single trial in a highly selected patient population. Although use of beta-blockers in patients who have documented coronary artery disease and are undergoing major vascular procedures appears supported, it is premature to recommend beta-blockade for all patients with cardiac risk. Because these drugs are not without risks, it might be advisable to be restrained in their use until the results of the large-scale randomized POISE trial are available. For clonidine and statins, the data are even more tenuous, and largely based on retrospective reviews (with the exception of postprocedure use of statins, which is well supported). Here again, the results of large-scale prospective trials must become available before recommendations can be made. Finally, promising data indicate that it might be possible to modulate by pharmacologic means the neurocognitive decline that is frequently associated with cardiac surgery, and which is often considered by patients to be the most troublesome complication of the intervention.
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Affiliation(s)
- Ashley M Shilling
- Department of Anesthesia, University of Virginia Health System, Old Medical School, Room 4748, Charlottesville, VA 22908-0710, USA.
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Hadj A, Esmore D, Rowland M, Pepe S, Schneider L, Lewin J, Rosenfeldt F. Pre-operative Preparation for Cardiac Surgery Utilising a Combination of Metabolic, Physical and Mental Therapy. Heart Lung Circ 2006; 15:172-81. [PMID: 16713353 DOI: 10.1016/j.hlc.2006.01.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2005] [Revised: 01/11/2006] [Accepted: 01/19/2006] [Indexed: 02/05/2023]
Abstract
UNLABELLED Cardiac surgery represents major metabolic, physical and mental stresses associated with an increased production of reactive oxygen species. These stresses may hamper post-operative recovery, increasing hospitalisation times and operative mortality. We conducted a quality assurance and feasibility study to evaluate and monitor the safety and efficacy of a new program of combined pre-operative metabolic (enhanced antioxidant), physical and mental therapy to counter these stresses prior to cardiac surgery. METHODS Sixteen cardiac surgery patients received metabolic therapy consisting of the antioxidants coenzyme Q(10) (CoQ(10)) (300 mg) and alpha-lipoic acid (300 mg), combined with magnesium orotate (1200 mg), and omega-3 fatty acids (3g) given daily for a mean 36+/-7 days up until the day of operation. Patients also received a regimen of physical therapy incorporating non-exhaustive, light exercise and stretching techniques. Mental therapy in the form of stress reduction, relaxation and music was also provided. Blood levels of CoQ(10) and malondialdehyde (MDA) were measured and a quality of life (QoL) questionnaire (SF-36) was administered before, after the program and 1 month after surgery. A patient satisfaction survey was conducted at six weeks post-operatively. RESULTS During the pre-operative period, treated patients (n=16) showed significant improvements in QoL composite scores, physical (33.5+/-4.1 to 41.0+/-4.5, p=0.005) and mental (44.3+/-4.5 to 54.1+/-5.3, p=0.006). CoQ(10) levels increased from 725.6+/-96.1 nmol/l to 3019.9+/-546.4 nmol/l (p=0.006), MDA levels decreased from 2.2+/-0.9 microM to 1.4+/-0.7 microM (p=0.013) and systolic blood pressure decreased from 140+/-4.0 mmHg to 132+/-3.0 mmHg (p=0.002). One month after surgery the treated group (n=14) demonstrated significant improvements from pre-operative baseline in QoL composite scores, physical (38.9+/-4.0 to 57.9+/-5.4, p=0.01) and mental (50.3+/-5.6 to 69.3+/-4.8, p=0.03) compared to a previously reported similar group of cardiac surgery patients (n=74) whose physical and mental scores decreased from 43.0 to 42.8 (p=0.05) and 53.8 to 49.8, respectively (p=0.05). CONCLUSION These preliminary results suggest that a program of combined metabolic, physical and mental preparation before cardiac surgery is safe, feasible and may improve quality of life, lower systolic blood pressure, reduce levels of oxidative stress and thus has the potential to enhance post-operative recovery.
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Affiliation(s)
- Anthony Hadj
- Cardiac Surgical Research Unit, Department of Cardiothoracic Surgery, Monash University, Alfred Hospital, Melbourne, Vic., Australia
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Aantaa R, Jalonen J. Perioperative use of α2-adrenoceptor agonists and the cardiac patient. Eur J Anaesthesiol 2006; 23:361-72. [PMID: 16507202 DOI: 10.1017/s0265021506000378] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2006] [Indexed: 11/07/2022]
Abstract
The centrally acting alpha2-adrenoceptor agonists clonidine and dexmedetomidine have been used with success to provide haemodynamic stability for patients undergoing surgery. Particularly in the case of patients with overt or underlying cardiac disease the actions of alpha2-adrenoceptor agonists, which include maintenance of stable systemic blood pressure and low heart rate and a reduction in overall oxygen consumption, can be expected to reduce the risk of procedure-related cardiac events. This expectation has been corroborated in clinical trials with clonidine, dexmedetomidine and mivazerol and meta-analyses; additional large controlled trials would be instructive in establishing a robust estimate of the scale of the benefit. In addition, alpha2-adrenoceptor agonists used as premedication have been shown to substantially reduce anaesthetic requirements among surgical patients, and the use of these agents has been associated with a reduced risk of postoperative delirium, which may be expected to improve considerably the postoperative course for at-risk patients. Dexmedetomidine is the only alpha2-adrenoceptor agonist currently approved for use in the intensive care unit. A distinctive feature of dexmedetomidine in that setting is that in addition to haemodynamic stability it confers a distinctive and advantageous quality of sedation: patients are tranquil but responsive to requests from attending staff. This review examines the pharmacological principles underlying the use of alpha2-adrenoceptor agonists as adjuncts to surgery and clinical experience in that indication.
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Affiliation(s)
- R Aantaa
- Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland
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Abstract
Acute renal failure (ARF) occurs in up to 30% of patients who undergo cardiac surgery, with dialysis being required in approximately 1% of all patients. The development of ARF is associated with substantial morbidity and mortality independent of all other factors. The pathogenesis of ARF involves multiple pathways. Hemodynamic, inflammatory, and nephrotoxic factors are involved and overlap each other in leading to kidney injury. Clinical studies have identified risk factors for ARF that can be used to determine effectively the risk for ARF in patients who undergo bypass surgery. These high-risk patients then can be targeted for renal protective strategies. Thus far, no single strategy has demonstrated conclusively its ability to prevent renal injury after bypass surgery. Several compounds such as atrial natriuretic peptide and N-acetylcysteine have shown promise, but large-scale trials are needed.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, Department of Internal Medicine, University of Virginia Health System, Box 800133, Charlottesville, VA 22908, USA.
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Morris J, Acheson M, Reeves M, Myles PS. Effect of clonidine pre-medication on propofol requirements during lower extremity vascular surgery: a randomized controlled trial. Br J Anaesth 2005; 95:183-8. [PMID: 15951325 DOI: 10.1093/bja/aei172] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pre-medication with clonidine reduces the requirement for volatile agents during general anaesthesia. This may also be true for anaesthesia with propofol, but the amount of dose reduction has not been measured. Because clonidine also affects cardiac output and thus regional blood flow it could alter the pharmacokinetics of propofol. This randomized, double-blind placebo-controlled trial aimed to study the effect of clonidine pre-medication on dose requirement for propofol during lower extremity vascular surgery using the bispectral index (BIS) as a measure of anaesthetic depth. METHODS After oral pre-medication with either clonidine 3 microg kg(-1) or placebo, 39 subjects had lower limb vascular surgery using propofol infusion for anaesthesia. Anaesthetic depth was adjusted to a BIS of 45. Predicted plasma propofol concentrations were noted every 30 min from a target-controlled propofol infusion pump and arterial samples were taken at the same time for propofol measurements. RESULTS Patients in both groups were anaesthetized to similar depths of anaesthesia as indicated by BIS readings (P=0.44). The groups had comparable mean (95% CI) arterial concentrations of propofol, 4.8 (3.5-6.1) microg ml(-1) in the patients given clonidine, and 4.6 (3.4-5.7) microg ml(-1) in the patients given placebo (P=0.81). However, the average plasma concentration predicted by the target-controlled infusion was less in the clonidine group [3.2 (2.9-3.5)] than in the group given placebo [3.6 (3.3-3.9)] microg ml(-1) (P<0.05). CONCLUSIONS Pre-medication with clonidine reduces the requirement for propofol, which is a pharmacokinetic effect and not a pharmacodynamic central sedative effect.
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Affiliation(s)
- J Morris
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Abstract
Acute renal dysfunction is a common serious complication of cardiac surgery. Although a diversity of mechanisms exist by which the kidney can be damaged during cardiac surgery, atheroembolism, ischemia-reperfusion, and inflammation are believed to be primary contributors to perioperative renal insult. In addition, the high metabolic demands of active tubular reabsorption and the oxygen diffusion shunt characteristic of renal circulation make the kidney particularly vulnerable to ischemic injury. Remote effects of acute renal injury likely contribute to the strong association of this condition with other major postoperative morbidities and mortality and justify the search for renoprotective agents, even when dialysis is never required. Nonpharmacologic preventive strategies include procedure planning that is based on risk stratification, avoidance of nephrotoxins, and meticulous perioperative clinical care, including optimizing intravascular volume and attention to modifiable risk factors such as minimizing hemodilution. Although numerous pharmacologic interventions to prevent or treat acute renal injury have shown promise in animal models, randomized placebo-controlled clinical trials that have looked at measures of significant adverse outcomes such as death and dialysis have not confirmed a benefit.
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Affiliation(s)
- Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Bolsin SN, Stow P, Bucknell S. Early Audit of Renal Complications in a New Cardiac Surgery Service in Australia. Heart Lung Circ 2004; 13:298-301. [PMID: 16352211 DOI: 10.1016/j.hlc.2004.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the incidence of renal failure in a cardiac surgery service commencing in Australia. DESIGN Prospective data collection and retrospective database analysis. SETTING A tertiary referral, university teaching hospital in the state of Victoria, Australia. PARTICIPANTS The first 502 patients undergoing cardiac surgery in this institution from commencement of the service. RESULTS The overall rate of renal failure was low in comparison to other studies at 0.2% (95% CI 0.04-1.3%). The rate of postoperative renal dysfunction was also low at 4.2% (95% CI 2.7-6.5%). CONCLUSIONS The safety of the new service with respect to this complication of cardiac surgery was good when compared with published data. However the lack of uniform definitions of renal failure following cardiac surgery make comparisons between studies difficult. Uniform reporting of this complication would facilitate comparisons between units and quality assurance activities in this field.
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Affiliation(s)
- Stephen N Bolsin
- Department of Perioperative Medicine, Anaesthesia and Pain Management, Geelong Hospital, Ryrie Street, Geelong, Vic. 3220, Australia.
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Rosenfeldt F, Miller F, Nagley P, Hadj A, Marasco S, Quick D, Sheeran F, Wowk M, Pepe S. Response of the Senescent Heart to Stress: Clinical Therapeutic Strategies and Quest for Mitochondrial Predictors of Biological Age. Ann N Y Acad Sci 2004; 1019:78-84. [PMID: 15246998 DOI: 10.1196/annals.1297.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The aging heart has an impaired response to many kinds of stress. In clinical practice, there is a need for senescence-specific therapies to protect against stress and for biochemical markers of senescence to identify those patients most in need of therapy. In isolated rat hearts, in human tissues, and in a clinical trial, we have shown previously that coenzyme Q(10) has the ability to protect the heart against stress especially in senescence. We recently have devised a regimen of therapy to protect the senescent heart against stress, combining metabolic therapy (coenzyme Q(10), alpha lipoic acid, magnesium orotate, and omega 3 polyunsaturated fatty acids) with physical exercise and mental stress reduction. The preliminary results of this program are promising. In an endeavor to predict the likely response of individual senescent hearts to stress, we correlated the tissue load of mitochondrial DNA deletions and total cellular mitochondrial DNA copy number in human cardiac tissue with recovery of the same tissue from ischemia/reperfusion stress. We found that these mitochondrial markers actually were less predictive of impaired response to stress than age alone. We conclude that the aging heart has a diminished capacity to recover from stress that is not readily predictable by cardiac content of intact mitochondrial DNA and that this recovery can be improved by metabolic therapy combined with physical exercise and mental stress reduction.
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Affiliation(s)
- Franklin Rosenfeldt
- Cardiac Surgical Research Unit, Alfred Hospital and Baker Heart Research Institute (Wynn Domain), Melbourne, Prahran Victoria 3181, Australia.
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Chassot PG, van der Linden P, Zaugg M, Mueller XM, Spahn DR. Off-pump coronary artery bypass surgery: physiology and anaesthetic management †. Br J Anaesth 2004; 92:400-13. [PMID: 14970136 DOI: 10.1093/bja/aeh064] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increasing interest is being shown in beating heart (off-pump) coronary artery surgery (OPCAB) because, compared with operations performed with cardiopulmonary bypass, OPCAB surgery may be associated with decreased postoperative morbidity and reduced total costs. Its appears to produce better results than conventional surgery in high-risk patient populations, elderly patients, and those with compromised cardiac function or coagulation disorders. Recent improvements in the technique have resulted in the possibility of multiple-vessel grafting in all coronary territories, with a graft patency comparable with conventional surgery. During beating-heart surgery, anaesthetists face two problems: first, the maintenance of haemodynamic stability during heart enucleation necessary for accessing each coronary artery; and second, the management of intraoperative myocardial ischaemia when coronary flow must be interrupted during grafting. The anaesthetic technique is less important than adequate management of these two major constraints. However, experimental and recent clinical data suggest that volatile anaesthetics have a marked cardioprotective effect against ischaemia, and might be specifically indicated. OPCAB surgery requires team work between anaesthetists and surgeons, who must be aware of each other's constraints. Some surgical aspects of the operation are reviewed along with physiological and anaesthetic data.
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Affiliation(s)
- P-G Chassot
- Departments of Anaesthesiology and Cardiovascular Surgery, University Hospital Lausanne (CHUV), CH-1011 Lausanne, Switzerland
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Ikeda Y, Nishikawa K, Ohashi K, Mori T, Asada A. Epidural clonidine suppresses the baroreceptor-sympathetic response depending on isoflurane concentrations in cats. Anesth Analg 2003; 97:748-754. [PMID: 12933395 DOI: 10.1213/01.ane.0000075841.37183.a4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epidural administration of clonidine induces hypotension and bradycardia secondary to decreased sympathetic nerve activity. In this study, we sought to elucidate the change in baroreflex response caused by epidural clonidine. Thirty-six cats were allocated to six groups (n = 6 each) and were given either thoracic epidural clonidine 4 micro g/kg or lidocaine 2 mg/kg during 0.5, 1.0, or 1.5 minimum alveolar anesthetic concentration (MAC) isoflurane anesthesia. Heart rate (HR), mean arterial blood pressure (MAP), and cardiac sympathetic nerve activity (CSNA) were measured. Depressor and pressor responses were induced by IV nitroprusside 10 micro g/kg and phenylephrine 10 micro g/kg, respectively. Baroreflex was evaluated by the change in both CSNA and HR relative to the peak change in MAP (deltaCSNA/deltaMAP and deltaHR/deltaMAP, respectively). These measurements were performed before and 30 min after epidural drug administration. Epidural clonidine and lidocaine decreased HR, MAP, and CSNA by similar extents. deltaCSNA/deltaMAP and deltaHR/deltaMAP for depressor response were suppressed with epidural lidocaine and clonidine in all groups but the clonidine 0.5 MAC isoflurane group (0.197 +/- 0.053 to 0.063 +/- 0.014 and 0.717 +/- 0.156 to 0.177 +/- 0.038, respectively, by epidural lidocaine [P < 0.05] but 0.221 +/- 0.028 to 0.164 +/- 0.041 and 0.721 +/- 0.177 to 0.945 +/- 0.239, respectively, by epidural clonidine during 0.5 MAC isoflurane). Those for pressor response were suppressed in all groups. We conclude that thoracic epidural clonidine suppresses baroreflex gain during isoflurane anesthesia >1.0 MAC but may offer certain advantages compared with epidural lidocaine during 0.5 MAC isoflurane by virtue of preserving baroreflex sensitivity when inadvertent hypotension occurs.
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Affiliation(s)
- Yoshikazu Ikeda
- *Department of Anesthesiology and Intensive Care Medicine, Osaka City University Medical School, Osaka, Japan; and †Department of Anesthesia, Hoshigaoka Kosei-nenkin Hospital, Osaka, Japan
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Wijeysundera DN, Naik JS, Beattie WS. Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: a meta-analysis. Am J Med 2003; 114:742-52. [PMID: 12829201 DOI: 10.1016/s0002-9343(03)00165-7] [Citation(s) in RCA: 280] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To investigate the effects of alpha(2)-adrenergic agonists on perioperative mortality and cardiovascular complications in adults undergoing surgery. METHODS MEDLINE (1966 to May 2002), EMBASE (1980 to May 2002), the Cochrane Clinical Trials Register, the Science Citation Index, and bibliographies of included articles were searched without language restriction. Randomized trials comparing preoperative, intraoperative, or postoperative (first 48 hours) administration of clonidine, dexmedetomidine, or mivazerol with controls were included. Studies had to report any of the following outcomes: mortality, myocardial infarction, ischemia, or supraventricular tachyarrhythmia. Treatment effects were calculated using the fixed-effects model. Heterogeneity was assessed using the Q test. RESULTS Twenty-three trials comprising 3395 patients were included. Overall, alpha(2)-adrenergic agonists reduced mortality (relative risk [RR] = 0.64; 95% confidence interval [CI]: 0.42 to 0.99; P = 0.05) and ischemia (RR = 0.76; 95% CI: 0.63 to 0.91; P = 0.003) significantly. They also reduced mortality (RR = 0.47; 95% CI: 0.25 to 0.90; P = 0.02) and myocardial infarction (RR = 0.66; 95% CI: 0.46 to 0.94; P = 0.02) during vascular surgery. During cardiac surgery, alpha(2)-adrenergic agonists reduced ischemia (RR = 0.71; 95% CI: 0.54 to 0.92; P = 0.01) and were associated with trends toward lower mortality (RR = 0.49; 95% CI: 0.12 to 1.98; P = 0.3) and a reduced risk of myocardial infarction (RR = 0.83; 95% CI: 0.35 to 1.96; P = 0.7). CONCLUSION Alpha-2 adrenergic agonists reduce mortality and myocardial infarction following vascular surgery. During cardiac surgery, they reduce ischemia and may also have effects on mortality and myocardial infarction. Large randomized trials are needed to evaluate these agents during cardiac and vascular surgery.
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Garwood S, Swamidoss CP, Davis EA, Samson L, Hines RL. A case series of low-dose fenoldopam in seventy cardiac surgical patients at increased risk of renal dysfunction. J Cardiothorac Vasc Anesth 2003; 17:17-21. [PMID: 12635055 DOI: 10.1053/jcan.2003.5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the usefulness of low-dose fenoldopam mesylate in patients at risk of developing renal dysfunction after cardiac surgery requiring cardiopulmonary bypass. DESIGN A prospective, single-center, observational study. SETTING University teaching hospital. PARTICIPANTS Seventy patients scheduled for elective cardiac surgery with one or more predefined risk factors for renal dysfunction. INTERVENTIONS After induction of anesthesia, fenoldopam (0.03 microg/kg/min) was administered throughout surgery and into the postoperative period, until the patient was stable and weaned from all other vasoactive agents. Perioperatively, fenoldopam was also used as a second-line antihypertensive agent as required. MEASUREMENTS AND MAIN RESULTS No patient developed renal failure that required dialysis, whereas 7.1% (5/70) developed non-dialysis-dependent renal dysfunction. Four out of these 5 patients had 2 or more risk factors (9.5%). Higher preoperative creatinine levels, a history of hypertension, myocardial infarction within 5 days of surgery, and a preoperative diagnosis of chronic renal insufficiency were all good predictors of postoperative non-dialysis-dependent renal dysfunction. Discharge serum creatinine levels were lower than preoperative levels (1.16 +/- 0.36 mg/dL v 1.26 +/- 0.34 mg/dL, p < 0.05). CONCLUSION These findings suggest that renal function was preserved in patients at increased risk for renal dysfunction after cardiac surgery when low-dose fenoldopam was used in the perioperative period. However, a randomized, controlled trial is required to establish efficacy.
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Affiliation(s)
- Susan Garwood
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520, USA.
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Kiebzak GM, Pierson LM, Campbell M, Cook JW. Use of the SF36 general health status survey to document health-related quality of life in patients with coronary artery disease: effect of disease and response to coronary artery bypass graft surgery. Heart Lung 2002; 31:207-13. [PMID: 12011811 DOI: 10.1067/mhl.2002.124299] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine if the SF36 general health status survey has the sensitivity to detect physical function impairments before surgery and the expected improvement in health-related quality of life variables after elective coronary artery bypass graft (CABG) surgery. DESIGN A prospective, nonrandomized study design was used. OUTCOME MEASURES The SF36 general health status survey comprises 36 multiple choice questions sorted into 8 categories, or subscales, that describe overall health status. The scores of this survey were used to measure the outcome. INTERVENTION The SF36 was administered before surgery and at 12-month follow-up. Patients were also queried about the occurrence of angina with normal activities of daily living. RESULTS Before surgery (n = 81), scores for all SF36 subscales (with the exception of mental health) were lower than published normative data, indicating the disease burden of coronary artery disease. At 12-month follow-up, scores in 6 of 8 subscales improved significantly; general health and role-emotional scores did not change. These changes in SF36 scores at follow-up paralleled a decreased occurrence of angina; before CABG surgery, 75% of patients (61 of 81) had angina; at 12-month follow-up, only 3.7% of patients (3 of 81) had angina. CONCLUSIONS The SF36 can be used effectively to document changes in health-related quality of life variables in patients with coronary artery disease after CABG surgery.
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Affiliation(s)
- Gary M Kiebzak
- Miller Orthopaedic Clinic, Charlotte, North Carolina, USA
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O'Connor CJ, Tuman KJ. Epidural anesthesia and analgesia for coronary artery bypass graft surgery: still forbidden territory? Anesth Analg 2001; 93:523-5. [PMID: 11524312 DOI: 10.1097/00000539-200109000-00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The metabolic changes that occur after cardiac surgery result from a complex interaction between the effects of surgery and extracorporeal circulation per se, the inflammatory response to surgical trauma and extracorporeal circulation, perioperative use of hypothermia, the cardiovascular and neuroendocrine responses characteristic to cardiac surgery, and the drugs and blood products used to support circulation during and after operation. These changes include among others increased oxygen consumption and energy expenditure and increased secretion of insulin, growth hormone, adrenocorticotrophic hormone, cortisol, epinephrine and norepinephrine. Other changes include decreased total-Trijodthyronine levels, hyperglycemia, hyperlactatemia, increased glutamate, aspartate and free fatty acid concentrations, hypokalemia, an increased production of inflammatory cytokines and increased consumption of complement and adhesion molecules. There is evidence that better control of metabolic abnormalities improves the patients' outcome.
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Affiliation(s)
- S M Jakob
- Department of Intensive Care Medicine, University Hospital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
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Blake DW. Dexmedetomidine and hemodynamic responses to simulated hemorrhage in experimental heart failure. Anesth Analg 2000; 91:1112-7. [PMID: 11049892 DOI: 10.1097/00000539-200011000-00012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED alpha(2)-Adrenoreceptor agonists may counteract the increased basal sympathetic nervous activity in patients with congestive heart failure (CHF), but they may also compromise reflex responses to hypovolemia. We have tested responses to simulated hemorrhage (central hypovolemia) after IV dexmedetomidine in normal animals and in experimental chronic CHF. Rabbits (n = 14) were treated with IV doxorubicin (or control saline) for 8 weeks inducing biventricular dilatation and myocardial damage. Cardiac output (CO) was measured continuously with a transit-time Doppler implanted on the ascending aorta. Progressive inflation of a cuff around the inferior vena cava (simulated hemorrhage) was used to reduce cardiac index at a constant rate. Arterial baroreceptor-mediated vasoconstrictor and heart rate responses were tested with repeated cuff inflations. Although resting CO was reduced in CHF, the blood pressure and heart rate changes with dexmedetomidine were not exaggerated. The slope of the vasoconstrictor response to graded hypovolemia was attenuated by dexmedetomidine with an earlier onset of decompensation. There was no added effect of CHF on the response until the dose of dexmedetomidine was sufficient to reduce resting CO in addition to arterial blood pressure and heart rate. IMPLICATIONS As an adjunct to anesthesia, dexmedetomidine may be useful in reducing basal sympathetic nervous activity. This study in experimental animals suggests this may be achieved without compromising protective responses to decreased blood volume.
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Affiliation(s)
- D W Blake
- Department of Pharmacology, Anesthesia Research Unit, University of Melbourne, Victoria, Australia.
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Hunt JO, Hendrata MV, Myles PS. Quality of life 12 months after coronary artery bypass graft surgery. Heart Lung 2000; 29:401-11. [PMID: 11080320 DOI: 10.1067/mhl.2000.110578] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The primary purpose of this study was to assess the relationship between preoperative risk factors, postoperative chronic pain, sleep, and gender on perceptions of quality of life (QoL) in a sample of 123 coronary artery bypass graft (CABG) surgery patients 12 months after surgery. A secondary purpose was to determine whether there is concordance between spousal and patient reporting of QoL after CABG surgery. DESIGN A cross-sectional comparative study. SETTING The study setting included patients living in the community, who had had CABG surgery 12 months earlier at The Alfred hospital, a major metropolitan public acute care center, in Melbourne, Australia. PARTICIPANTS Study participants were 123 adult patients (mean age = 64 years) who had undergone CABG surgery and had participated in a recent clinical trial. These patients were followed up to 12 months. The patient's spouse or next of kin (NoK) was asked questions about their perception of change in the patient's QoL. INSTRUMENTS Results were assessed using The Medical Outcome Study Short Form-36 (SF-36) questionnaire and additional questions given at 12 months after CABG surgery. The Cleveland Clinic Clinical Severity Score (CSS) was used preoperatively as a tool to predict QoL outcome. RESULTS Significant improvements in QoL, as measured by the SF-36, were seen in physical functioning (P <.0001), bodily pain (P =.024), social functioning (P =.011), and role limitations resulting from emotional status (P =.003). Other significant associations (P =.002) were found between poor QoL and patients who reported severe pain or poor quality sleep. Low-risk patients, as identified by the preoperative CSS, were more likely to have improved QoL at 12 months. Alteration in QoL was reported equally by patients and their spouses or NoK. Short-term memory impairment was reported by 41% of spouses or NoK. CONCLUSIONS CABG surgery results in improved QoL for the majority of patients with extensive coronary artery disease. Nevertheless, some patients continue to have severe pain, sleep disturbances, and altered relationship with their spouse or NoK 12 months after surgery.
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Affiliation(s)
- J O Hunt
- Alfred Hospital, Prahran, Victoria, Australia
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Blake DW. Dexmedetomidine and Hemodynamic Responses to Simulated Hemorrhage in Experimental Heart Failure. Anesth Analg 2000. [DOI: 10.1213/00000539-200011000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Blake DW, Ludbrook J, Van Leeuwen AF. Dexmedetomidine and haemodynamic responses to acute central hypovolaemia in conscious rabbits. Clin Exp Pharmacol Physiol 2000; 27:801-9. [PMID: 11022973 DOI: 10.1046/j.1440-1681.2000.03345.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
1. Effects of the alpha2-adrenoceptor agonist dexmedetomidine on vasoconstrictor and heart rate (HR) responses to acute central hypovolaemia were studied in eight chronically instrumented rabbits. We compared intravenous (i.v.) and fourth ventricular (V4) dexmedetomidine (0.1-10 microg/kg) and the reversal of effects by the alpha2-adrenoceptor antagonist idazoxan and the opioid agonist alfentanil. 2. Gradual inflation of an inferior vena cava (IVC) cuff reduced cardiac index (CI) by 8%/min, with progressive vasoconstriction and increased HR. In control rabbits, at approximately 40% baseline CI, there was sudden decompensation with failure of vasoconstriction and a fall in mean arterial pressure (MAP). 3. Dexmedetomidine (i.v. and V4) reduced resting MAP and HR and caused an earlier decompensation during central hypovolaemia. Intravenous dexmedetomidine (3 and 10 microg/kg) also reduced the slope of the initial vasoconstrictor response and the maximum HR. 4. The effects of dexmedetomidine were reversed by the antagonist idazoxan, which prevented the decompensation phase. Intravenous alfentanil was also effective in restoring the vasoconstrictor response and delaying decompensation with hypovolaemia after dexmedetomidine. Combining dexmedetomidine with an opioid, such as alfentanil, may provide the benefit of reduced sympathetic tone without increased risk of cardiovascular collapse.
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Affiliation(s)
- D W Blake
- Department of Pharmacology, University of Melbourne Parkville, Victoria, Australia.
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Abstract
Since the first report of alpha2-adrenoceptor agonists, the list of clinical indications for this class of drugs continues to expand. Alpha2-adrenoceptor agonists have several beneficial actions during the perioperative period. They exert a central sympatholytic action, thus improving haemodynamic stability in response to endotracheal intubation and surgical stress, reducing anaesthetic and opioid requirements, and causing sedation, anxiolysis and analgesia. Furthermore, alpha2-adrenoceptor agonists may offer benefits in the prophylaxis and treatment of perioperative myocardial ischaemia and their role in pain management and regional anaesthesia is increasing. The development of new, highly selective compounds which not only reduce anaesthetic requirements but induce anaesthesia by themselves may provide a new concept for the administration of anaesthesia.
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Affiliation(s)
- J Scholz
- Department of Anaesthesiology and Intensive Care Medicine, Christian-Albrechts University of Kiel, Kiel, Germany.
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Quintin L, Ghignone M. Risks associated with peri-operative use of alpha2-adrenoceptor agonists. Best Pract Res Clin Anaesthesiol 2000. [DOI: 10.1053/bean.2000.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tonner PH, Scholz J. Pre-anaesthetic administration of alpha2-adrenoceptor agonists. Best Pract Res Clin Anaesthesiol 2000. [DOI: 10.1053/bean.2000.0085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Reducing the Morbidity and Mortality of High-Risk Surgical Patients. YEARBOOK OF INTENSIVE CARE AND EMERGENCY MEDICINE 2000. [DOI: 10.1007/978-3-662-13455-9_29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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