Remote ischemic preconditioning (RIPC) has been shown to enhance the tolerance of remote organs to cope with a subsequent ischemic event. We hypothesized that RIPC reduces postoperative ...neurocognitive dysfunction (POCD) in patients undergoing complex cardiac surgery.
We conducted a prospective, randomized, double-blind, controlled trial including 180 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomized either to RIPC or to control group. Primary endpoint was postoperative neurocognitive dysfunction 5-7 days after surgery assessed by a comprehensive test battery. Cognitive change was assumed if the preoperative to postoperative difference in 2 or more tasks assessing different cognitive domains exceeded more than one SD (1 SD criterion) or if the combined Z score was 1.96 or greater (Z score criterion).
According to 1 SD criterion, 52% of control and 46% of RIPC patients had cognitive deterioration 5-7 days after surgery (p = 0.753). The summarized Z score showed a trend to more cognitive decline in the control group (2.16±5.30) compared to the RIPC group (1.14±4.02; p = 0.228). Three months after surgery, incidence and severity of neurocognitive dysfunction did not differ between control and RIPC. RIPC tended to decrease postoperative troponin T release at both 12 hours 0.60 (0.19-1.94) µg/L vs. 0.48 (0.07-1.84) µg/L and 24 hours after surgery 0.36 (0.14-1.89) µg/L vs. 0.26 (0.07-0.90) µg/L.
We failed to demonstrate efficacy of a RIPC protocol with respect to incidence and severity of POCD and secondary outcome variables in patients undergoing a wide range of cardiac surgery. Therefore, definitive large-scale multicenter trials are needed.
ClinicalTrials.gov NCT00877305.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this ...period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids (P < 0.05) and less epinephrine administration (P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term ...outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients.
We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery.
The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P = 0.12).
Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.
OBJECTIVE:Dynamic variables of fluid responsiveness such as pulse pressure variation (PPV) and stroke volume variation (SVV) have been shown to reliably predict the response to fluid administration ...in different patient populations. The influence of increased intra-abdominal pressure (IAP) on the predictive ability of these variables is currently under debate. Therefore, the present study was designed to evaluate whether PPV and SVV are suitable for predicting fluid responsiveness during elevated IAP.
DESIGN:Prospective controlled experimental study.
SETTING:Animal research laboratory.
SUBJECTS:14 anesthetized and mechanically ventilated pigs.
INTERVENTIONS:Pigs were studied at different experimental stagesnormovolemia at baseline conditions, after induction of pneumoperitoneum (PP) by increasing IAP up to 25 mm Hg, followed by releasing PP and performing a fluid load with 1000 cc hydroxyl-ethyl starch 6%, and finally after inducing PP again. Cardiac output, stroke volume, central venous pressure, and pulmonary artery occlusion pressure were obtained by pulmonary artery thermodilution. Additionally, global end-diastolic volume (GEDV) was measured by transpulmonary thermodilution. PPV and SVV were monitored continuously by pulse contour analysis.
MEASUREMENTS AND MAIN RESULTS:PP induced significant changes in peak airway pressure, esophageal pressure, chest wall compliance, SVV, PPV, central venous pressure, and pulmonary artery occlusion pressure independent of loading conditions. As assessed by receiver operating characteristic curve analysis, PPV, SVV, and GEDV accurately predicted fluid responsiveness before IAP was increased (area under the curve0.90, 0.91 and 0.91). A PPV value of ≥11.5%, a SVV value of ≥9.5%, and a GEDV value of ≤963 mL accurately predicted an increase in stroke volume ≥15%. After increasing IAP, the ability of SVV to predict fluid responsiveness was abolished, whereas it was preserved with both PPV and GEDV, although the threshold value for PPV dramatically increased up to ≥20.5%.
CONCLUSIONS:In this animal model PPV and GEDV proved to be sensitive and specific predictors of fluid responsiveness even during increased IAP.
Oscillometric, non-invasive blood pressure measurement (NIBP) is the first choice of blood pressure monitoring in the majority of low and moderate risk surgeries. In patients with morbid obesity, ...however, it is subject to several limitations. The aim was to compare arterial pressure monitoring by NIBP and a non-invasive finger-cuff technology (Nexfin®) with the gold-standard invasive arterial pressure (IAP).
In this secondary analysis of a prospective observational, single centre cohort study, systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP) were measured at 16 defined perioperative time points including posture changes, fluid bolus administration and pneumoperitoneum (PP) in patients undergoing laparoscopic bariatric surgery. Absolute arterial pressures by NIBP, Nexfin® and IAP were compared using correlation and Bland Altman analyses. Interchangeability was defined by a mean difference ≤ 5 mmHg (SD ≤8 mmHg). Percentage error (PE) was calculated as an additional statistical estimate. For hemodynamic trending, concordance rates were analysed according to the Critchley criterion.
Sixty patients (mean body mass index of 49.2 kg/m
) were enrolled and data from 56 finally analysed. Pooled blood pressure values of all time points showed a significant positive correlation for both NIPB and Nexfin® versus IAP. Pooled PE for NIBP versus IAP was 37% (SAP), 35% (DAP) and 30% (MAP), for Nexfin versus IAP 23% (SAP), 26% (DAP) and 22% (MAP). Correlation of MAP was best and PE lowest before induction of anesthesia for NIBP versus IAP (r = 0.72; PE 24%) and after intraoperative fluid bolus administration for Nexfin® versus IAP (r = 0.88; PE: 17.2%). Concordance of MAP trending was 90% (SAP 85%, DAP 89%) for NIBP and 91% (SAP 90%, DAP 86%) for Nexfin®. MAP trending was best during intraoperative ATP positioning for NIBP (97%) and at induction of anesthesia for Nexfin® (97%).
As compared with IAP, interchangeability of absolute pressure values could neither be shown for NIBP nor Nexfin®, however, NIBP showed poorer overall correlation and precision. Overall trending ability was generally high with Nexfin® surpassing NIBP. Nexfin® may likely render individualized decision-making in the management of different hemodynamic stresses during laparoscopic bariatric surgery, particularly where NIBP cannot be reliably established.
The non-interventional, observational study was registered retrospectively at ( NCT03184285 ) on June 12, 2017.
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In morbidly obese patients undergoing laparoscopic bariatric surgery, the combination of obesity-related comorbidities, pneumoperitoneum and extreme posture changes constitutes a high risk of ...perioperative hemodynamic complications. Thus, an advanced hemodynamic monitoring including continuous cardiac index (CI) assessment is desirable. While invasive catheterization may bear technical difficulties, transesophageal echocardiography is contraindicated due to the surgical procedure. Evidence on the clinical reliability of alternative semi- or non-invasive cardiac monitoring devices is limited. The aim was to compare the non-invasive vascular unloading to a semi-invasive pulse contour analysis reference technique for continuous CI measurements in bariatric surgical patients.
This prospective observational study included adult patients scheduled for elective, laparoscopic bariatric surgery after obtained institutional ethics approval and written informed consent. CI measurements were performed using the vascular unloading technique (Nexfin®) and semi-invasive reference method (FloTrac™). At 10 defined measurement time points, the influence of clinically indicated body posture changes, passive leg raising, fluid bolus administration and pneumoperitoneum was evaluated pre- and intraoperatively. Correlation, Bland-Altman and concordance analyses were performed.
Sixty patients (mean BMI 49.2 kg/m
) were enrolled into the study and data from 54 patients could be entered in the final analysis. Baseline CI was 3.2 ± 0.9 and 3.3 ± 0.8 l/min/m
, respectively. Pooled absolute CI values showed a positive correlation (r
= 0.76, P < 0.001) and mean bias of of - 0.16 l/min/m
(limits of agreement: - 1.48 to 1.15 l/min/m
) between the two methods. Pooled percentage error was 56.51%, missing the criteria of interchangeability (< 30%). Preoperatively, bias ranged from - 0.33 to 0.08 l/min/m
with wide limits of agreement. Correlation of CI was best (r
= 0.82, P < 0.001) and percentage error lowest (46.34%) during anesthesia and after fluid bolus administration. Intraoperatively, bias ranged from - 0.34 to - 0.03 l/min/m
with wide limits of agreement. CI measurements correlated best during pneumoperitoneum and after fluid bolus administration (r
= 0.77, P < 0.001; percentage error 35.95%). Trending ability for all 10 measurement points showed a concordance rate of 85.12%, not reaching the predefined Critchley criterion (> 92%).
Non-invasive as compared to semi-invasive CI measurements did not reach criteria of interchangeability for monitoring absolute and trending values of CI in morbidly obese patients undergoing bariatric surgery.
The study was registered retrospectively on June 12, 2017 with the registration number NCT03184272 .
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Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and ...transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.
The ability of stroke volume variation (SVV), pulse pressure variation (PPV) and global end-diastolic volume (GEDV) for prediction of fluid responsiveness in presence of pleural effusion is unknown. ...The aim of the present study was to challenge the ability of SVV, PPV and GEDV to predict fluid responsiveness in a porcine model with pleural effusions.
Pigs were studied at baseline and after fluid loading with 8 ml kg(-1) 6% hydroxyethyl starch. After withdrawal of 8 ml kg(-1) blood and induction of pleural effusion up to 50 ml kg(-1) on either side, measurements at baseline and after fluid loading were repeated. Cardiac output, stroke volume, central venous pressure (CVP) and pulmonary occlusion pressure (PAOP) were obtained by pulmonary thermodilution, whereas GEDV was determined by transpulmonary thermodilution. SVV and PPV were monitored continuously by pulse contour analysis.
Pleural effusion was associated with significant changes in lung compliance, peak airway pressure and stroke volume in both responders and non-responders. At baseline, SVV, PPV and GEDV reliably predicted fluid responsiveness (area under the curve 0.85 (p<0.001), 0.88 (p<0.001), 0.77 (p = 0.007). After induction of pleural effusion the ability of SVV, PPV and GEDV to predict fluid responsiveness was well preserved and also PAOP was predictive. Threshold values for SVV and PPV increased in presence of pleural effusion.
In this porcine model, bilateral pleural effusion did not affect the ability of SVV, PPV and GEDV to predict fluid responsiveness.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Purpose The ability of the global end-diastolic volume index (GEDVI) and respiratory variations in left ventricular outflow tract velocity (ΔVTILVOT ) for prediction of fluid responsiveness ...is still under debate. The aim of the present study was to challenge the predictive power of GEDVI and ΔVTILVOT compared with pulse pressure variation (PPV) and stroke volume variation (SVV) in a large patient population. Material and Methods Ninety-two patients were studied before coronary artery surgery. Each patient was monitored with central venous pressure (CVP), the PiCCO system (Pulsion Medical Systems, Munich, Germany), and transesophageal echocardiography. Responders were defined as those who increased their stroke volume index by greater than 15% (ΔSVITPTD >15%) during passive leg raising. Results Central venous pressure showed no significant correlation with ΔSVITPTD ( r = −0.06, P = .58), in contrast to PPV ( r = 0.71, P < .0001), SVV ( r = 0.61, P < .0001), GEDVI ( r = −0.54, P < .0001), and ΔVTILVOT ( r = 0.54, P < .0001). The best area under the receiver operating characteristic curve (AUC) predicting ΔSVITPTD greater than 15% was found for PPV (AUC, 0.82; P < .0001) and SVV (AUC, 0.77; P < .0001), followed by ΔVTILVOT (AUC, 0.74; P < .0001) and GEDVI (AUC, 0.71; P = .0006), whereas CVP was not able to predict fluid responsiveness (AUC, 0.58; P = .18). Conclusions In contrast to CVP, GEDVI and ΔVTILVOT reliably predicted fluid responsiveness under closed-chest conditions. Pulse pressure variation and SVV showed the highest accuracy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objectives The reliability of dynamic and volumetric variables of fluid responsiveness in the presence of pericardial effusion is still elusive. The aim of the present study was to investigate their ...predictive power in a porcine model with hemodynamic relevant pericardial effusion. Design A single-center animal investigation. Participants Twelve German domestic pigs. Interventions Pigs were studied before and during pericardial effusion. Instrumentation included a pulmonary artery catheter and a transpulmonary thermodilution catheter in the femoral artery. Hemodynamic variables like cardiac output (COPAC ) and stroke volume (SVPAC ) derived from pulmonary artery catheter, global end-diastolic volume (GEDV), stroke volume variation (SVV), and pulse-pressure variation (PPV) were obtained. Measurements and Main Results At baseline, SVV, PPV, GEDV, COPAC , and SVPAC reliably predicted fluid responsiveness (area under the curve 0.81 p = 0.02, 0.82 p = 0.02, 0.74 p = 0.07, 0.74 p = 0.07, 0.82 p = 0.02). After establishment of pericardial effusion the predictive power of dynamic variables was impaired and only COPAC and SVPAC and GEDV allowed significant prediction of fluid responsiveness (area under the curve 0.77 p = 0.04, 0.76 p = 0.05, 0.83 p = 0.01) with clinically relevant changes in threshold values. Conclusions In this porcine model, hemodynamic relevant pericardial effusion abolished the ability of dynamic variables to predict fluid responsiveness. COPAC, SVPAC, and GEDV enabled prediction, but their threshold values were significantly changed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
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