Abstract Objective The aim of this study was to assess the prognostic value of different nutritional screening tools in patients undergoing cardiopulmonary bypass with regard to an adverse clinical ...course. Methods This prospective cohort study analyzed 894 adult patients who underwent cardiopulmonary bypass. Patients were screened using four nutritional screening tools: Nutritional Risk Screening 2002 (NRS-2002), the Malnutrition Universal Screening Tool (MUST), the Mini-Nutritional Assessment (MNA), and the Short Nutritional Assessment Questionnaire (SNAQ). Nutritional status was assessed using the Subjective Global Assessment. In-hospital mortality, postoperative complications, length of stay in the intensive care unit, and length of hospitalization were analyzed. Results The sensitivities of the SNAQ, MUST, and NRS-2002 to detect the malnutrition confirmed by the Subjective Global Assessment were 91.5%, 97.9%, and 38.3%, respectively, and the MNA showed a sensitivity of 81.8% for the elderly. Malnutrition detected by the SNAQ, MUST, and NRS-2002 was associated with postoperative complications (odds ratios ORs 1.75, 1.98, and 1.82, respectively) and a stay in the intensive care unit longer than 2 d (ORs 1.46, 1.56, and 2.8). Malnutrition as detected by the SNAQ and MUST was also associated with prolonged hospitalization (ORs 1.49 and 1.59). According to multivariate logistic regression analysis, postoperative complications were independently predicted by the European System for Cardiac Operative Risk Evaluation (OR 1.1, P < 0.0001), cardiopulmonary bypass time (OR 1.01, P < 0.0001), and malnutrition identified by the MUST (OR 1.2, P = 0.01). Conclusion The MUST independently predicts postoperative complications. The SNAQ and MUST have comparable accuracy in detecting malnutrition. Whether preoperative nutritional therapy would improve the outcome in malnourished patients needs to be studied.
OBJECTIVES
The aim of this study was to assess the prognostic value of different nutritional screening tools in patients undergoing cardiopulmonary bypass, with regard to adverse clinical outcome.
...METHODS
This prospective cohort study analysed 1193 adult patients who underwent cardiopulmonary bypass. Patients were screened using five nutritional screening tools: Subjective Global Assessment (SGA), Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), Mini-Nutritional Assessment (MNA) and Short Nutritional Assessment Questionnaire (SNAQ). In-hospital mortality, postoperative complications, length of stay in intensive care unit and length of hospitalization were analysed. Multivariate backward logistic regression analysis was used to assess the independent predictive value of the studied screening tools.
RESULTS
In accordance with univariate analysis, malnutrition detected by SNAQ, MUST, NRS-2002 and MNA was associated with postoperative complications (odds ratio OR 1.8, 95% confidence interval 95% CI 1.3-2.4; OR 1.9, 95% CI 1.4-2.6; OR 1.8, 95% CI 1.2-2.9 and OR 1.9, 95% CI 1.4-2.6). Malnutrition detected by MUST, NRS-2002, MNA and SGA was associated with intensive care unit stay >2 days (OR 1.5, 95% CI 1.1-2.1; OR 2.3, 95% CI 1.5-3.7; OR 1.7, 95% CI 1.2-2.2 and OR 2.7, 95% CI 1.6-4.6). Prolonged hospitalization (>20 days) was predicted by SNAQ, MUST and MNA (OR 1.4, 95% CI 1-1.9; OR 1.6, 95% CI 1.2-2.2 and OR 1.6, 95% CI 1.2-2.2). In accordance with multivariate analysis, only MUST and MNA independently predicted postoperative complications (OR 1.6, 95% CI 1.1-2.3 and OR 1.6, 95% CI 1.1-2.2). Other independent factors influencing postoperative complications were well-known logistic EuroSCORE (OR 1.06, 95% CI 1-1.1) and the duration of cardiopulmonary bypass in minutes (OR 1.01, 95% CI 1-1.01).
CONCLUSIONS
MUST and MNA both have independent predictive values with regard to postoperative complications. Taking into account simplicity, MUST is preferable for the cardiac surgical population.
Remote ischaemic preconditioning (RIPC) gained attention as a possibility to reduce myocardial injury after a subsequent sustained episode of myocardial ischaemia. This prospective randomized study ...was carried out to assess whether RIPC reduces myocardial injury in coronary artery bypass grafting patients. Eighty patients were assigned to remote preconditioning or control treatment. Ischaemic preconditioning was induced by three 5-min cycles of upper limb ischaemia and reperfusion after anaesthesia induction. Haemodynamic and markers of myocardial damage were analysed preoperatively and over 48 h postoperatively. The cardiac index was higher immediately after remote preconditioning in the main group. There were no differences in other haemodynamic, troponin I and creatine kinase-MB concentrations at any time point between groups. Thus, short-term remote preconditioning improves haemodynamics and does not reduce myocardial injury after coronary artery bypass surgery. Further study of high-risk patients may be needed to fully evaluate the clinical effect of RIPC.
Levosimendan is a calcium sensitizer and adenosine triphosphate-dependent potassium channel opener, which exerts sustained hemodynamic, symptomatic, and organ-protective effects. It is registered for ...the treatment of acute heart failure, and when inotropic support is considered appropriate. In the past 15 years, levosimendan has been widely used in clinical practice and has also been tested in clinical trials to stabilize at-risk patients undergoing cardiac surgery. Recently, 3 randomized, placebo-controlled, multicenter studies (LICORN, CHEETAH, and LEVO-CTS) have been published reporting on the perioperative use of levosimendan in patients with compromised cardiac ventricular function. Taken together, many smaller trials conducted in the past suggested beneficial outcomes with levosimendan in perioperative settings. By contrast, the latest 3 studies were neutral or inconclusive. To understand the reasons for such dissimilarity, a group of experts from Austria, Belgium, Finland, France, Germany, Italy, Switzerland, and Russia, including investigators from the 3 most recent studies, met to discuss the study results in the light of both the previous literature and current clinical practice. Despite the fact that the null hypothesis could not be ruled out in the recent multicenter trials, we conclude that levosimendan can still be viewed as a safe and effective inodilator in cardiac surgery.
Postoperative delirium (POD) is considered one of the most severe complications, resulting in impaired cognitive function, extended hospitalization, and higher treatment costs. The challenge of early ...POD diagnosis becomes particularly significant in cardiac surgery cases, as the incidence of this complication exceeds 50 % in certain patient categories. While it is known that neuroinflammation, neurotransmitter imbalances, disruptions in neuroendocrine regulation, and interneuronal connections contribute significantly to the development of POD, the molecular, genetic mechanisms of POD in cardiac surgery patients, along with potential metabolomic diagnostic markers, remain inadequately understood. In this study, blood plasma was collected from a group of patients over 65 years old after cardiac surgery involving artificial circulation. The collected samples were analyzed for sphingomyelin content and quantity using high-performance liquid chromatography coupled with mass spectrometry (HPLC-MS/MS) methods. The analysis revealed four significantly different sphingomyelin contents in patients with POD compared to those who did not develop POD (control group). Employing gene network reconstruction, we perceived a set of 82 regulatory enzymes affiliated with the genetic coordination of the sphingolipid metabolism pathway. Within this set, 47 are assumed to be regulators of gene expression, governing the transcription of enzymes pivotal to the metabolic cascade. Complementing this, an additional assembly of 35 regulators are considered to be regulators of activity, degradation, and translocation dynamics of enzymes integral to the aforementioned pathway. Analysis of the overrepresentation of diseases with which these regulatory proteins are associated showed that the regulators can be categorized into two groups, associated with cardiovascular pathologies (CVP) and neuropsychiatric diseases (NPD), respectively. The regulators associated with CVP are expectedly related to the effects on myocardial tissue during surgery. It is hypothesized that dysfunction of NPD-associated regulators may specifically account for the development of POD after cardiac surgery. Thus, the identified regulatory genes may provide a basis for planning further experiments, in order to study disorders at the level of expression of these genes, as well as impaired function of proteins encoded by them in patients with POD. The identified significant sphingolipids can be considered as potential markers of POD.
Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to evaluate the effects of nitric oxide (NO) supplementation to the ...CPB circuit on the development of cardiac surgery–associated AKI.
This prospective randomized controlled study included 96 patients with moderate risk of renal complications who underwent elective cardiac surgery with CPB. The study protocol was registered at ClinicalTrials.gov (identifier NCT03527381). Patients were randomly allocated to either NO supplementation to the CPB bypass circuit (NO treatment group; n = 48) or usual care (control group; n = 48). In the NO treatment group, 40-ppm NO was administered during the entire CPB period. The primary outcome was the incidence of AKI.
NO treatment was associated with a significant decrease in AKI incidence (10 cases 20.8% vs 20 cases 41.6% in the control group; relative risk, 0.5; 95% confidence interval, 0.26-0.95; P = .023) and a higher median urine output during CPB (2.6 mL/kg/h interquartile range (IQR), 2.1-5.08 mL/kg/h vs 1.7 mL/kg/h IQR, 0.80-2.50 mL/kg/h; P = .0002). The median urinary neutrophil gelatinase-associated lipocalin level at 4 hours after surgery was significantly lower in the NO treatment group (1.12 ng/mL IQR, 0.75-5.8 ng/mL vs 4.62 ng/mL IQR, 2.02-34.55 ng/mL; P = .005). In the NO treatment group, concentrations of NO metabolites were significantly increased at 5 minutes postclamping, at 5 minutes after declamping, and at the end of the operation. Concentrations of proinflammatory and anti-inflammatory mediators and free plasma hemoglobin did not differ significantly between the 2 groups.
NO administration in patients at moderate risk of renal complications undergoing elective cardiac surgery with CPB was associated with a lower incidence of AKI.
This study evaluated the effects of nitric oxide (NO) supplementation to the cardiopulmonary bypass (CPB) circuit on the development of acute kidney injury (AKI) in patients undergoing elective cardiac surgery with CPB (n = 96). Patients received NO supplementation to the CPB circuit (NO treatment group; n = 48) or usual care (control group; n = 48). In the NO treatment group, patients were given 40-ppm NO during the entire CPB period. The control group received sham treatment. NO oxide treatment was associated with a significant decrease in the incidence of AKI (P = .023) and a higher urine output during CPB (P = .0002). Urinary neutrophil gelatinase-associated lipocalin (uNGAL) levels at 4 h after surgery were significantly lower in the NO treatment group (P = .005). In the NO treatment group, concentrations of NO metabolites increased significantly at 5 minutes postclamping (P = .0073), at 5 minutes after declamping (P = .00014), and at the end of surgery (P = .028). Concentrations of proinflammatory and anti-inflammatory mediators and free plasma hemoglobin did not differ significantly between the 2 groups. In summary, NO administration was associated with decreased incidence of AKI in our patients undergoing elective cardiac surgery. CSA-AKI, Cardiac surgery-associated acute kidney injury; KDIGO, Kidney Disease Improving Global Outcomes guidelines; MetHb, methemoglobin. Display omitted
Objectives To investigate the efficacy and safety of fibrinogen concentrate (FC) in surgical patients. Design Meta-analysis of randomized controlled studies (RCTs). Setting Perioperative. ...Participants Adult and pediatric surgical patients. Interventions A search of PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, Transfusion Evidence Library, Google Scholar, and the proceedings from major international anesthesiology meetings up to February 1, 2016 for RCTs that compared FC with placebo or other comparators. Measurements and Main Results The primary outcome was all-cause mortality. Pooled risk ratios and mean differences (MDs) were computed with either fixed-effects or random-effects models. The study included 14 RCTs comprising 1,035 patients; the majority of patients underwent cardiac surgery. All-cause mortality was lower in the fibrinogen group (4/432 0.9% v 15/430 3.5%; risk ratio 0.26; 95% confidence interval CI 0.09-0.78; p = 0.02; heterogeneity statistic (l2) = 0%). The use of FC was associated with reduced bleeding (MD –127 mL; 95% CI –207 to –47; p = 0.002; I2= 54%) and a lower number of red blood cells units transfused versus comparator (MD –0.9; 95% CI –1.3 to –0.5; p<0.001; I2 = 42%). There were no differences in the rates of thrombotic events and myocardial infarction. Conclusions In surgical patients, FC was associated with reduced bleeding and a lower number of red blood cell units transfused, and it also might reduce mortality. However, none of the analyzed trials was powered for estimation of survival and adverse events with FC use. Half of the included studies were of high or moderate risk of bias. The evidence primarily came from cardiac surgery settings.
Objective To test the hypothesis that levosimendan is more effective than intra-aortic balloon pump (IABP) support in cardiac surgical patients with low left ventricular ejection fraction to decrease ...cardiac troponin I levels (primary endpoint) and improve hemodynamics. Design Prospective randomized trial. Setting Tertiary cardiothoracic referral center. Participants Ninety patients with coronary artery disease and left ventricular ejection fraction <35% who underwent surgery with cardiopulmonary bypass. Intervention Patients were assigned randomly to 1 of 3 groups. Group A received a prophylactic IABP one day before surgery. Group B received a prophylactic IABP one day before surgery and a levosimendan infusion at a dose of 0.1 μg/kg/min with an initial bolus (12 μg/kg for 10 minutes) after anesthesia induction. Group C received a levosimendan infusion at a dose of 0.1 μg/kg/min with an initial bolus (12 μg/kg for 10 minutes) after anesthesia induction. Hemodynamic and biochemical data and rate of complications were analyzed. Measurements and Main Results The cardiac troponin I level in group C 6 hours after surgery was lower than in group A ( p = 0.048). The cardiac index in group A was significantly lower than in groups B and C. The intensive care unit stay was significantly shorter in group C than in groups A and B ( p = 0.001). The need for inotropic support, the rate of complications, and mortality among groups did not differ. Conclusions The infusion of levosimendan after anesthesia induction in cardiac surgical patients contributes to lower cardiac troponin I levels and improved hemodynamics compared with a preoperative IABP.
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