EuroScore and IL-6 predict the course in ICU after cardiac surgery

Association of Acute Systemic Inflammation with Patient-Centric Postoperative Pulmonary Complications After Elective Cardiac Surgery

BACKGROUND

Postoperative pulmonary complications (PPCs) occur frequently after cardiac surgery. Absolute postoperative values of biomarkers of inflammation (interleukin [IL]-6, IL-8, and tumor necrosis factor-alpha [TNF-α]) and alveolar epithelial injury (soluble receptor for advanced glycation end-products [sRAGE]) have been associated with hypoxia and prolonged ventilation. However, relationships between these biomarkers and PPCs, contextualized to preoperative inflammation and perioperative lung injury risk factors, are uncertain. We aimed to determine associations between perioperative increases in biomarkers of inflammation and alveolar epithelial injury with a patient-centric PPC definition in adult cardiac surgical patients, accounting for the influence of intraoperative risk factors for lung injury.

METHODS

Adults undergoing elective cardiac surgery were eligible for this observational cohort study. Blood concentrations of IL-6, IL-8, TNF-α, and sRAGE were collected after anesthesia induction (baseline) and on postoperative day 1 (POD 1). The primary outcome was the occurrence of moderate or severe PPCs, graded using a validated scale, in POD 0 to 7. We estimated the association between POD 1 IL-6, IL-8, TNF-α, and sRAGE concentrations and moderate/severe PPC presence using separate logistic regression models for each biomarker, adjusted for baseline biomarker values and risk factors for postoperative lung injury (age, baseline PaO 2 /F i O 2 , left ventricle ejection fraction [LVEF], procedural type, cardiopulmonary bypass duration, and transfusions). Covariables were chosen based on relevance to lung injury and unadjusted between-group differences among patients with versus without PPCs. The secondary outcome was postoperative ventilation duration, which was log-transformed and analyzed using linear regression, adjusted using the same variables as the primary outcome.

RESULTS

We enrolled 204 patients from 2016 to 2018. Biomarkers were analyzed in 2023 among 175 patients with complete data. In adjusted analyses, POD 1 IL-8 and IL-6 were significantly associated with moderate/severe PPCs. The odds ratio (OR) for developing a PPC for every 50 pg/mL increase in POD 1 IL-8 was 7.19 (95% confidence interval [CI], 2.13-28.53, P = .003) and 1.42 (95% CI, 1.13-1.93, P = .01) for every 50 pg/mL increase in POD 1 IL-6. In adjusted analyses, postoperative ventilation duration was significantly associated with POD 1 sRAGE; each 50 pg/mL increase in sRAGE was associated with a 25% (95% CI, 2%-52%, P = .03) multiplicative increase in hours of ventilation. TNF-α was not significantly associated with PPCs or ventilation duration.

CONCLUSIONS

Acute systemic inflammation is significantly associated with PPCs after elective cardiac surgery in adults when taking into consideration preoperative inflammatory burden and perioperative factors that may influence postoperative lung injury.

Risk Factors of Prolonged Mechanical Ventilation in Post Coronary Artery Bypass Graft Patients: A Scoping Review

Prolonged mechanical ventilation (PMV) following CABG surgery is associated with increased patient morbidity and mortality. A consensus has yet to be reached regarding the time limit for PMV. Various studies have identified factors that influence PMV in patients following CABG surgery, but a review has yet to synthesize the results systematically. This review aimed to identify the definition and factors associated with PMV in patients following isolated CABG surgery. This scoping review used the framework developed by Arksey and O'Malley (2005). Primary sources of information were searched through 5 databases: PubMed, Scopus, Oxford Academy, Sage, and CINAHL and two search engines: Science Direct and Google Scholar, accessed on October 25, 2023. Eight articles with a total of 12,178 participants were included in this review. The PMV time limits used in the studies varied from >12 hours to >48 hours. The factors affecting PMV were grouped into preoperative, intraoperative and postoperative, with factors that have a high influence, including NYHA class, acute kidney injury and mediastinitis. Differences in the number of factors examined, criteria, characteristics, and time limits of the PMV used to make the study's results vary. Establishing guidelines regarding PMV time limits is essential according to current conditions.

Role of Preoperative Inflammatory Blood Cell Indexes as a Postoperative Risk Predictor Among Patients Undergoing On-Pump Cardiac Surgery

INTRODUCTION

Estimating patient risk before heart surgery (HS) is crucial. Perioperative inflammation is associated with several complications and mortality. This study investigated blood cell count inflammatory indices (BCCII) to predict risks, including neutrophil-to-lymphocyte ratio (NLR), derivate NLR (DNLR), neutrophil-to-platelet-lymphocyte ratio (NLPR), lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio (PLR), Systemic Inflammatory Index (SII), Systemic Inflammatory Reaction Index (SIRI), and Aggregate Index of Systemic Inflammation (AISI).

METHODS

Data from a cohort of patients undergoing on-pump HS at a single center in Brazil were retrospectively analyzed. Data were obtained from medical records and a laboratory analyzer, and SPSS version 20.0 was used for index calculations and statistical analyses.

RESULTS

In total, 444 surgeries were performed, and 40 in-hospital deaths occurred. Except for PLR, all other indexes were independent predictors of death after multivariate adjustment (all p < 0.05). Discrimination performance was absent for PLR and AISI, and NLR, NLPR, and DNLR demonstrated the best area under the receiver operating characteristic curve (AUC > 0.7; all p < 0.0001). For survivors (n = 404), all indexes exhibited a correlation with the length of hospital stay (all p < 0.03), and NLR, NLPR, and DNLR were predictors (p < 0.026) of poor operative outcomes (acute myocardial infarction, cerebrovascular attack, cardiac arrest, low cardiac output, prolonged mechanical ventilation, renal failure, and sepsis).

CONCLUSIONS

All BCCII scores were associated with length of hospital stay. Apart from PLR, all indexes were independent predictors of in-hospital mortality. Accuracy was highest for NLR, NLPR, and DNLR; for survivors, these three factors were good predictors of poor operative outcomes.

Enhancing mortality prediction after coronary artery bypass graft: a machine learning approach utilizing EuroScore

Aim: We developed a machine learning model using EuroScore assumptions and preoperative and intraoperative risk factors to predict mortality after coronary artery bypass graft (CABG). Materials & methods: We retrospectively examined data from 108 CABG patients at King Abdullah University Hospital, classifying them into risk groups via EuroScore and predicting mortality through random forest classification. Results: High-risk patients displayed longer surgical times and significant factors such as age and surgery choice. The median EuroScore was 0.95 (0.5-6.4). The model yielded high AUC scores (0.98, 0.95) indicating strong predictive accuracy. Conclusion: Our findings showed that the machine learning models combined with the EuroScore significantly improve post-CABG mortality prediction. For further validation, larger datasets are needed.

Monocyte adhesion to and transmigration through endothelium following cardiopulmonary bypass shearing is mediated by IL-8 signaling

Introduction

The use of cardiopulmonary bypass (CPB) can induce sterile systemic inflammation that contributes to morbidity and mortality, especially in children. Patients have been found to have increased expression of cytokines and transmigration of leukocytes during and after CPB. Previous work has demonstrated that the supraphysiologic shear stresses existing during CPB are sufficient to induce proinflammatory behavior in non-adherent monocytes. The interactions between shear stimulated monocytes and vascular endothelial cells have not been well studied and have important translational implications. With these studies, we tested the hypothesis that non-physiological shear stress experienced by monocytes during CPB affects the integrity and function of the endothelial monolayer.

Methods

We have used an in vitro CPB model to study the interaction between THP-1 monocyte-like cells and human neonatal dermal microvascular endothelial cells (HNDMVECs). THP-1 cells were sheared in polyvinyl chloride (PVC) tubing at 2.1 Pa, twice of the physiological shear stress, for 2 h. ELISA, adhesion and transmigration assays, qPCR, and RNA silencing were used to assess the interactions between THP-1 cells and HNDMVECs were characterized after co-culture.

Results

We found that sheared THP-1 cells adhered to and transmigrated through the HNDMVEC monolayer more readily than static THP-1 controls. Sheared THP-1 cells disrupted the VE-cadherin and led to the reorganization of cytoskeletal F-actin of HNDMVECs. A higher level of IL-8 was detected in the sheared THP-1 and HNDMVEC co-culture medium compared to the static THP-1 and HNDMVEC medium. Further, treating HNDMVECs with IL-8 resulted in increased adherence of non-sheared THP-1 cells, and upregulation in HNDMVECs of vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1). Finally, inhibition of HNDMVECs CXCR2/IL-8 receptor with Reparixin and of IL-8 expression with siRNA blocked sheared THP-1 cell adhesion to the endothelial monolayer.

Conclusions

These results suggest that CPB-like sheared monocytes promote IL-8 production followed by increased endothelium permeability, and monocyte adhesion and transmigration. This study revealed a novel mechanism of post-CPB inflammation and will contribute to the development of targeted therapeutics to prevent and repair the damage to neonatal patients.

Biomarkers of inflammation and coagulation after minimally invasive mitral valve surgery: a prospective comparison to conventional surgery

OBJECTIVES

Minimally invasive cardiac surgery techniques are increasingly used but have longer cardiopulmonary bypass time, which may increase inflammatory response and negatively affect coagulation. Our aim was to compare biomarkers of inflammation and coagulation as well as transfusion rates after minimally invasive mitral valve repair and mitral valve surgery using conventional sternotomy.

DESIGN

A prospective non-randomized study was performed enrolling 71 patients undergoing mitral valve surgery (35 right mini-thoracotomy and 36 conventional sternotomy procedures). Blood samples were collected pre- and postoperatively to assess inflammatory response. Thromboelastometry (ROTEM) was performed to assess coagulation, and transfusion rates were monitored.

RESULTS

The minimally invasive group had longer cardiopulmonary bypass times compared to the sternotomy group: 127 min ([115-146] vs 79 min [65-112], p < 0.001) and were cooled to a lower temperature during cardiopulmonary bypass, 34 °C vs 36 °C (p = 0.04). IL-6 was lower in the minimally invasive group compared to the conventional sternotomy group when measured at the end of the surgical procedure, (38 [23-69] vs 61[41-139], p = 0.008), but no differences were found at postoperative day 1 or postoperative day 3. The transfusion rate was lower in the minimally invasive group (14%) compared to full sternotomy (35%, p = 0.04) and the chest tube output was reduced, (395 ml [190-705] vs 570 ml [400-1040], p = 0.04).

CONCLUSIONS

Our data showed that despite the longer use of extra corporal circulation during surgery, minimally invasive mitral valve repair is associated with reduced inflammatory response, lower rates of transfusion, and reduced chest tube output.

Alterations in novel inflammatory biomarkers during perioperative cardiovascular surgeries involving cardiopulmonary bypass: a retrospective propensity score matching study

Background

Cardiopulmonary bypass (CPB) triggers a strong inflammatory response in cardiovascular surgery patients during the perioperative period. This article mainly focuses on the perioperative application of novel inflammatory biomarkers in cardiovascular surgeries involving CPB.

Methods

Patients were divided into a CPB group and a non-CPB group according to whether they underwent CPB during cardiovascular surgery. Novel inflammatory biomarkers and clinical results were recorded. The neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), platelet × neutrophil/lymphocyte ratio (SII), and monocyte × platelet × neutrophil/lymphocyte ratio (PIV) were calculated. The primary outcomes were perioperative prognosis between the CPB and non-CPB groups. The secondary outcomes included perioperative alterations of novel inflammatory biomarkers in the CPB group and predictive values of novel inflammatory biomarkers for postoperative infection and acute kidney injury.

Results

A total of 332 patients were initially included in the study. Before propensity score matching (PSM), there were 96 patients in the CPB group and 236 patients in the non-CPB group. After PSM, both groups included 58 patients each. Compared with the non-CPB group, the CPB group had a higher proportion of intraoperative transfusion of blood products (63.79% vs. 6.90%, P < 0.001), specifically for red blood cells (58.62% vs. 3.45%, P < 0.001) and plasma (41.38% vs. 1.72, P < 0.001), exhibited a higher drainage fluid volume within 24 h [380 (200-550) ml vs. 200 (24-330) ml, P = 0.002], and required longer durations of mechanical ventilation [14.3 (6.6-21.3) h vs. 5.75 (4.08-10.1) h, P < 0.001] and ICU stay [48.78 (44.92-89.38) h vs. 27.16 (21.67-46.25) h, P < 0.001]. After surgery, NLR [14.00 (9.93-23.08) vs. 11.55 (7.38-17.38), P = 0.043] was higher in the CPB group, while the PIV, PLR, and SII in the CPB group were lower than those in the non-CPB group on the first day after surgery.

Conclusions

Cardiovascular surgeries involving CPB exhibit a poorer prognosis compared to non-CPB procedures. Novel inflammatory biomarkers, including PLR, PIV, and SII, may offer valuable insights into the degree of postoperative inflammation, with NLR emerging as a potentially reliable prognostic indicator.

The Effect of CytoSorb on Inflammatory Markers in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

The effectiveness of CytoSorb at removing inflammatory mediators in critically ill patients is controversial.

DATA SOURCES

Electronic databases were searched from inception to May 2023.

STUDY SELECTION

Randomized controlled trials reporting the effects of CytoSorb therapy on inflammatory parameters in critically ill patients with hyperinflammatory conditions were included.

DATA EXTRACTION

Two authors screened articles for eligibility, extracted data, and assessed the risk of bias, conflicts of interest, and certainty of evidence (CoE). The primary outcome was interleukin (IL)-6 at 1 day after initiation of the therapy. Secondary outcomes included various inflammatory markers at 1, 2, 3, and 5 days and mortality. Data were pooled if at least three trials reported the outcome of interest. We conducted meta-analyses of the data using a random-effects model.

DATA SYNTHESIS

Seventeen trials ( n = 855) were included. Fourteen trials were judged to have notable concern about conflicts of interest. Seven trials were performed in medical ICU patients with hyperinflammatory conditions and 10 in complex cardiovascular surgery under cardiopulmonary bypass. Hemoadsorption with CytoSorb was not associated with lower IL-6 at 1 day (mean difference -5.98 [95% CI, -30.44 to 18.48] pg/mL), 2 days, 3 days, or 5 days after initiation of the treatment, as well as the concentration of procalcitionin. The levels of C-reactive protein were not lower with CytoSorb at 1, 2, and 3 days. The use of CytoSorb was associated with higher mortality at latest follow-up (relative risk = 1.22 [95% CI, 1.02-1.45]) and at 30 days. CoE ranged from low to very low.

CONCLUSIONS

The use of CytoSorb hemoadsorption in a mixed population of critically ill patients with hyperinflammatory conditions does not exhibit a consistent decrease in IL-6 and other inflammatory parameters within the first 5 days of treatment. The significant uncertainty surrounding these findings highlights the need for further investigations.

Effects of multimodal low-opioid anesthesia protocol during on-pump coronary artery bypass grafting: a prospective cohort study

BACKGROUND

The most favorable anesthesia protocol during on-pump coronary artery bypass grafting (CABG) in patients with coronary heart disease remains unclear, despite previous publications regarding the interaction between anesthesia protocol and postoperative complications. The aim of the study was to compare the effect of a multimodal low-opioid anesthesia protocol (MLOP) on early postoperative complications during on-pump CABG.

METHODS

A single-center prospective cohort study including 120 patients undergoing on-pump CABG aged 18 to 65 years, divided into two groups according to undergoing MLOP or routine-opioid anesthesia protocol (ROP). The analyzed parameters were plasma IL-6 levels, complications, duration of mechanical ventilation, length of intensive care unit stay, and hospitalization.

RESULTS

In the MLOP group, the levels of IL-6 at the end of the surgery were 25.6% significantly lower compared to the ROP group (33.4 ± 9.4 vs. 44.9 ± 15.9, p < 0.0001), the duration of mechanical ventilation was significantly shorter (2.0 (2.0; 3.0) h vs. 4.0 (3.0; 5.0) h, p < 0.001), the incidence of low cardiac output syndrome was almost two and half times lower (7 (11.7%) vs. 16 (26.7%), p = 0.037), and also the incidence of postoperative atrial fibrillation was significantly lower (9 (15.0%) vs. 19 (31.7%), p = 0.031).

CONCLUSION

Our study confirms that using MLOP was characterized by significantly lower levels of IL-6 at the end of surgery and a lower incidence of low cardiac output syndrome and postoperative atrial fibrillation than ROP.

TRIAL REGISTRATION

The study is registered in clinicaltrials.gov №NCT05514652.

Impact of CytoSorb® on interleukin-6 in cardiac surgery

Objective

Cardiac surgery is known to activate a cascade of inflammatory mediators leading to a systemic inflammatory response. Hemadsorption (HA) devices such as CytoSorb® have been postulated to mitigate an overshooting immune response, which is associated with increased morbidity and mortality, and thus improve outcome. We aimed to investigate the effect of CytoSorb® on interleukin (IL)-6 levels in patients undergoing complex cardiac surgery in comparison to a control group.

Methods

A total of 56 patients (28 CytoSorb®, 28 control) undergoing acute and elective cardiac surgery between January 2020 and February 2021 at the Department of Cardiac and Vascular Surgery, Clinic Floridsdorf, Vienna, were retrospectively analyzed. The primary endpoint was the difference in IL-6 levels between the CytoSorb® and control group. Secondary endpoint was periprocedural mortality.

Results

CytoSorb®, installed in the bypass circuit, had no significant effect on IL-6 levels. IL-6 peaked on the first postoperative day (HA: 775.3 ± 838.4 vs. control: 855.5 ± 1,052.9 pg/ml, p = 0.856). In total, three patients died in the HA group, none in the control (logistic regression model, p = 0.996). Patients with an increased Euroscore II of 7 or more showed a reduced IL-6 response compared to patients with an Euroscore II below 7 (178.3 ± 63.1 pg/ml vs. 908.6 ± 972.6 pg/ml, p-value = 0.00306).

Conclusions

No significant reduction of IL-6 levels or periprocedural mortality through intraoperative HA with CytoSorb® in patients undergoing cardiac surgery was observed. However, this study was able to show a reduced immunologic response in patients with a high Euroscore II. The routine application of CytoSorb® in cardiac surgery to reduce inflammatory mediators has to be scrutinized in future prospective randomized studies.

Study on the Characteristics of Early Cytokine Storm Response to Cardiac Surgery

Cardiac surgery can provoke an acute cytokine storm that may contribute to the development of postoperative multiple organ dysfunction syndrome. We prospectively observed patients undergoing cardiac surgery and divided them into two groups: the severe group and the mild group. Healthy individuals were enrolled acting as the control group for comparison. Plasma samples and clinical data were recorded at the initiation of cardiac-pulmonary bypass (CPB) and 3, 6, 12, 24, and 48 h after initiation of CPB. Cytokine levels were detected using the Luminex® technique. Thirty-nine adults were enrolled in this study (14 in the severe group, 15 in the mild group, and 10 in the control group). Cytokine concentrations were significantly higher in the severe group. Principal component analysis was used to establish a cytokine storm intensity curve, which represented the overall trend of 10 cytokines. The peak concentrations of interleukin (IL)-6, IL-10, and IL-16 were 425.1, 198.5, and 623.0 pg/mL, which were more than 1,200, 1,800, and 240 times the normal level, respectively. The maximum cytokine storm intensity predated the maximum Vasoactive-Inotropic Score (VIS) and Sequential Organ Failure Assessment (SOFA) score in the severe group. Cytokine storm response to cardiac surgery occurred early and was associated with disease severity. Interventions to cytokine storm should be initiated early as guided by cytokine storm biomarkers such as IL-6, IL-10, and IL-16 in severe patients undergoing cardiac surgery. Clinical Trial Registration: ChiCTR1900021351.

A new hematologic predictor of major adverse events after cardiac surgery: red cell distribution width to lymphocyte ratio

BACKGROUND

The perioperative risk factors that cause severe morbidity and prolongation of postoperative hospital stay after cardiac surgery should be determined. Various scores have been used to predict morbidity and mortality. Preoperative blood counts are considered potential biomarkers of inflammation and oxidative stress. Inflammatory and immune imbalances may have a significant impact on postoperative adverse events. The present study aimed to investigate the association and potential predictive properties of red cell distribution width/ lymphocyte ratio (RLR) for major adverse events in adult patients who underwent coronary surgery with cardiopulmonary bypass.

METHODS

After approval from the ethics committee, pre- and post-operative data of 700 patients were obtained from the electronic database of the hospital, intra- and post-operative anesthesia, and intensive care unit follow-up charts. We performed a stepwise multiple logistic regression analysis to investigate the association of RLR with major adverse events in adult patients who underwent coronary surgery with cardiopulmonary bypass.

RESULTS

Among 700 patients, 47 (6.7%) had major adverse events after surgery. Multivariate logistic regression analysis showed that age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.03-1.12; P < 0.001), mean platelet volume (OR, 1.49; 95% CI, 1.07-2.06; P = 0.017), and RLR (OR, 1.21; 95% CI, 1.02-1.43; P = 0.026) were significantly associated with major adverse events.

CONCLUSIONS

RLR indicates the balance between inflammatory and immune responses. Therefore, it can be used to predict adverse events following coronary surgery.

Monocyte Adhesion and Transmigration Through Endothelium Following Cardiopulmonary Bypass Shearing is Mediated by IL-8 Signaling

Background

The use of cardiopulmonary bypass (CPB) can induce sterile systemic inflammation that contributes to morbidity and mortality, especially in children. Patients have been found to have increased expression of cytokines and transmigration of leukocytes during and after CPB. Previous work has demonstrated that the supraphysiologic shear stresses present during CPB are sufficient to induce proinflammatory behavior in non-adherent monocytes. The interactions between shear stimulated monocytes and vascular endothelial cells have not been well studied and have important translational implications.

Methods

To test the hypothesis that non-physiological shear stress experienced by monocytes during CPB affects the integrity and function of the endothelial monolayer via IL-8 signaling pathway, we have used an in vitro CPB model to study the interaction between THP-1 monocyte-like cells and human neonatal dermal microvascular endothelial cells (HNDMVECs). THP-1 cells were sheared in polyvinyl chloride (PVC) tubing at 2.1 Pa, twice of physiological shear stress, for 2 hours. Interactions between THP-1 cells and HNDMVECs were characterized after coculture.

Results

We found that sheared THP-1 cells adhered to and transmigrated through the HNDMVEC monolayer more readily than static controls. When co-culturing, sheared THP-1 cells also disrupted in the VE-cadherin and led to reorganization of cytoskeletal F-actin of HNDMVECs. Treating HNDMVECs with IL-8 resulted in upregulation of vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1) while also increasing the adherence of non-sheared THP-1 cells. Preincubating HNDMVECs with Reparixin, an inhibitor of CXCR2/IL-8 receptor inhibited sheared THP-1 cell adhesion to the HNDMVECs.

Conclusions

These results suggested that IL-8 not only increases the endothelium permeability during monocyte migration, but also affects the initial adhesion of monocytes in a CPB setup. This study revealed a novel mechanism of post-CPB inflammation and will contribute to the development of targeted therapeutics to prevent and repair the damage to neonatal patients.

Highlights

Shear stress in a CPB-like environment promoted the adhesion and transmigration of monocytes to and through endothelial monolayer.

Treating endothelial monolayer with sheared monocytes led to disruption of VE-cadherin and reorganization of F-actin.

Interaction between sheared monocytes resulted in a significant increase of IL-8 release.

Inhibiting IL-8 receptor prevented sheared monocyte adhesion, while IL-8 promoted naive monocyte adhesion.

Intraoperative use of cell saver devices decreases the rate of hyperlactatemia in patients undergoing cardiac surgery

Objective

This study was aimed to elucidate the effect of the intraoperative cell saver (CS) on hyperlactatemia of patients who underwent cardiac surgery.

Design

A sub-analysis of the CS was performed, which is a historial control trial of patients undergoing cardiac surgery.

Setting

This was a retrospective single-center and not blinded study.

Participants

We examined the occurrence of hyperlactatemia retrospectively in patients of CS group (n = 78) who were included in prospective trial and received valvular surgery, where CS was used during the procedure. Patients subjected to valvular surgery before February 2021 were adopted in control group (n = 79).

Interventions

Arterial blood was sampled (1) before cardiopulmonary bypass, (2) during bypass (3) immediately after bypass, (4) on ICU admission and (5) every 4 h up to 24 h postoperatively.

Measurements and main results

A lower incidence of hyperlactatemia (32.1% vs. 57.0%; P = 0.001) was observed in patients from the CS group. Furthermore, the blood lactate concentration was higher in control group than in CS group during CPB, post CPB, on ICU admission and lasted until 20 h after the operation. Multivariable analysis revealed that intraoperative use of CS was expected to be a protective factor against hyperlactatemia in this study (OR = 0.31, 95% CI 0.15-0.63, P = 0.001).

Conclusion

Intraoperative use of a CS device was associated with a lower incidence of hyperlactatemia. Whether such device use is valuable to limiting hyperlactatemia in cardiac patients after surgery requires further evaluation in larger prospective studies.

Postoperative Hyperuricemia-A Risk Factor in Elective Cardiosurgical Patients

Hyperuricemia is a well-known cardiovascular risk factor. The aim of our study was to investigate the connection between postoperative hyperuricemia and poor outcomes after elective cardiac surgery compared to patients without postoperative hyperuricemia. In this retrospective study, a total of 227 patients after elective cardiac surgery were divided into two groups: 42 patients with postoperative hyperuricemia (mean age 65.14 ± 8.9 years) and a second group of 185 patients without it (mean age 62.67 ± 7.45 years). The time spent on mechanical ventilation (hours) and in the intensive care unit (days) were taken as the primary outcome measures while the secondary measure comprised postoperative complications. The preoperative patient characteristics were similar. Most of the patients were men. The EuroSCORE value of assessing the risk was not different between the groups nor the comorbidities. Among the most common comorbidities was hypertension, seen in 66% of all patients (69% in patients with postoperative hyperuricemia and 63.7% in those without it). A group of patients with postoperative hyperuricemia had a prolonged time of treatment in the intensive care unit (p = 0.03), as well as a prolonged duration of mechanical ventilation (p < 0.01) and a significantly higher incidence of the following postoperative complications: circulatory instability and/or low cardiac output syndrome (LCOS) (χ2 = 4486, p < 0.01), renal failure and/or continuous venovenous hemodiafiltration (CVVHDF's) (χ2 = 10,241, p < 0.001), and mortality (χ2 = 5.22, p < 0.01). Compared to patients without postoperative hyperuricemia, elective cardiac patients with postoperative hyperuricemia have prolonged postoperative treatment in intensive care units, extended durations of mechanically assisted ventilation, and a higher incidence of postoperative circulatory instability, renal failure, and death.

Immunophenotyping of Monocyte Migration Markers and Therapeutic Effects of Selenium on IL-6 and IL-1β Cytokine Axes of Blood Mononuclear Cells in Preoperative and Postoperative Coronary Artery Disease Patients

Multivessel coronary artery disease (CAD) is characterized by underlying chronic vascular inflammation and occlusion in the coronary arteries, where these patients undergo coronary artery bypass grafting (CABG). Since post-cardiotomy inflammation is a well known phenomenon after CABG, attenuation of this inflammation is required to reduce perioperative morbidity and mortality. In this study, we aimed to phenotype circulating frequencies and intensities of monocyte subsets and monocyte migration markers, respectively, and to investigate the plasma level of inflammatory cytokines and chemokines between preoperative and postoperative CAD patients and later, to intervene the inflammation with sodium selenite. We found a higher amplitude of inflammation, postoperatively, in terms of CCR1high monocytes and significantly increased pro-inflammatory cytokines, IL-6, IL-8, and IL-1RA. Further, in vitro intervention with selenium displayed mitigating effects on the IL-6/STAT-3 axis of mononuclear cells derived from postoperative CAD patients. In addition, in vitro selenium intervention significantly reduced IL-1β production as well as decreased cleaved caspase-1 (p20) activity by preoperative (when stimulated) as well as postoperative CAD mononuclear cells. Though TNF-α exhibited a positive correlation with blood troponin levels in postoperative CAD patients, there was no obvious effect of selenium on the TNF-α/NF-κB axis. In conclusion, anti-inflammatory selenium might be utilized to impede systemic inflammatory cytokine axes to circumvent aggravating atherosclerosis and further damage to the autologous bypass grafts during the post-surgical period.

High summation of preoperative and postoperative Interleukin-6 levels predicts prolonged mechanical ventilation in patients with acute DeBakey type I aortic dissection: A single center retrospective study

Objective

This study aimed to investigate the predictive effect of preoperative and postoperative interleukin-6 (IL-6) levels on the duration of mechanical ventilation in patients with acute DeBakey Type I aortic dissection (I-AAD) after emergency surgery.

Methods

We retrospectively enrolled 381 patients with I-AAD who underwent surgery in our hospital, between June 2018 and June 2022. Patients were divided into two groups according to whether prolonged mechanical ventilation (PMV) occurred after surgery. The baseline data, biochemical indicators at admission, surgical data, biochemical indicators at postoperative 6 h, and the postoperative data of the two groups were recorded and analyzed.

Results

The PMV group comprised 199 patients, and the non-PMV group 182. The postoperative in-hospital mortality was different between the two groups (11.1% vs. 3.3%, p = 0.004). The length of intensive care unit and hospitalization time in the PMV group were significantly longer than those in the non-PMV group. Multiple regression analysis showed postoperative IL-6 (post-IL-6) ≥67.1 pg/mL and summation of preoperative and postoperative IL-6 (total IL-6) ≥83.4 pg/mL were associated risk factors for PMV [odds ratio (OR) 3.259, 95% confidence interval (CI) 1.922-5.524, p < 0.001], [(OR) 4.515, 95% CI 2.241-9.098, p < 0.001]. Furthermore, determined by the receiver operating characteristics(ROC) curve, the cut-off point was total IL-6 ≥83.4 pg/mL (area under curve(AUC) = 0.825). The sensitivity and specificity of predicting postoperative PMV of patients with I-AAD were 91.5% and 78.2%, respectively (95% CI 0.782-0.868, p < 0.001).

Conclusion

For predicting postoperative PMV in patients with I-AAD, post IL-6 ≥67.1 pg/mL is potentially valuable and summation of preoperative and postoperative IL-6 (total IL-6) ≥83.4 pg/mL has a more pronounced predictive value.

Elevated pulsatility index of the superior mesenteric artery indicated prolonged mechanical ventilation in patients after cardiac valve surgery

Purpose

This study examined whether alterations in Doppler parameters of superior mesenteric artery (SMA) are associated with prolonged mechanical ventilation (PMV) in patients who underwent cardiac valve surgery.

Methods

Hemodynamic and SMA Doppler parameters were collected at intensive care unit(ICU) admission. The duration of mechanical ventilation was monitored. PMV was defined as mechanical ventilation ≥96 h.

Results

A total of 132 patients admitted to ICU after cardiac valve surgery were evaluated for enrollment, of whom 105 were included. Patients were assigned to the control (n = 63) and PMV (n = 42) groups according to the mechanical ventilation duration. The pulsatility index(SMA-PI) and resistive index of SMA (SMA-RI) were 3.97 ± 0.77 and 0.88 (0.84-0.90) in the PMV group after cardiac valve surgery, which was lower than the SMA-PI (2.95 ± 0.71, p < 0.0001) and SMA-RI of controls (0.8, 0.77-0.88, p < 0.0001). SMA-PI at admission had favorable prognostic significance for PMV (AUC = 0.837, p < 0.0001).

Conclusions

An elevated SMA-PI is common in patients after cardiac valve surgery with PMV. Increased SMA-PI could help predict PMV after cardiac valve surgery. Using point-of-care ultrasound to measure SMA-PI at ICU admission is an acceptable and reproducible method for identifying patients with PMV.

Does Mental Distress Predict Cardiac Surgical Outcome?

BACKGROUND

 Mental distress is suspected to influence the morbidity of cardiac patients. Evaluating mental distress in cardiac patients is rare and the impact on surgical outcome is still not certified.

METHODS

 In 94 cardiac surgical patients, mental distress was assessed by the Patient Health Questionnaire-4 (PHQ-4). We defined length of stay in hospital and on intensive care unit as well as time of mechanical ventilation as outcomes on surgery. Age, physical activity, diabetes, overweight, PHQ-4, and an inflammation marker were tested for their predictive value on outcomes.

RESULTS

 Reportedly prevalence of generalized anxiety was 16.0% and depression rate was 13.8%. Length of stay in hospital was 13 ± 8 days, time of mechanical ventilation was 10 (0-1,207) hours, and length of stay on intensive care unit was 3 ± 6 days. Length of stay in hospital was significantly predicted by age (p = 0.048), low physical activity (p = 0.029), and high C-reactive protein (CRP; p = 0.031). Furthermore, CRP was the only significant predictor of time of mechanical ventilation and length of stay on intensive care unit.

CONCLUSION

 Outcome was not predicted by mental distress. However, inflammation marker CRP was predictive for outcome, potentially caused by higher cardiovascular risk profile. Additionally, depression was referred to be associated with inflammation. Probably, the small sample and the timing of assessment were responsible for the missing relation between mental distress and outcome. We presume a relation with low physical activity and depression. Nevertheless, further randomized studies are needed to pay more attention on patients' distress to intervene preoperatively to improve postoperative outcome.

Utility of IL-6 in the Diagnosis, Treatment and Prognosis of COVID-19 Patients: A Longitudinal Study

COVID-19 has caused devastating effects worldwide ever since its origin in December 2019. IL-6 is one of the chief markers used in the management of COVID-19. We conducted a longitudinal study to investigate the role of IL-6 in diagnosis, treatment, and prognosis of COVID-19-related cytokine storm. Patients with COVID-19 who were admitted at AIIMS Rishikesh from March to December 2020 were included in the study. Patients with no baseline IL-6 value at admission and for whom clinical data were not available were excluded. Clinical and laboratory data of these patients were collected from the e-hospital portal and entered in an excel sheet. Correlation was seen with other inflammatory markers and outcomes were assessed using MS Excel 2010 and SPSS software. A total of 131 patients were included in the study. Of these, 74.8% were males, with mean age 55.03 ± 13.57 years, and mean duration from symptom onset being 6.69 ± 6.3 days. A total of 82.4% had WHO severe category COVID-19, with 46.56% having severe hypoxia at presentation and 61.8% of them having some comorbidity. Spearman rank correlation coefficient of IL-6 with D-dimer was 0.203, with LDH was -0.005, with ferritin was 0.3, and with uric acid was 0.123. A total of 11 patients received Tocilizumab at a mean duration from symptom onset of 18.09 days, and 100% mortality was observed. Deaths were reported more in the group with IL-6 ≥ 40 pg/mL (57.1% vs. 40.2%, p = 0.06). ICU admissions and ventilator requirement were higher in the IL-6 ≥ 40 pg/mL group (95.9% vs. 91.4%, p = 0.32 and 55.1% vs. 37.8%, p = 0.05). The study showed that IL-6 can be used as a possible "thrombotic cytokine marker". Higher values of IL-6 (≥40 pg/mL) are associated with more deaths, ICU admissions, and ventilator requirement.