Whether remote ischemic preconditioning (transient ischemia and reperfusion of the arm) can improve clinical outcomes in patients undergoing coronary-artery bypass graft (CABG) surgery is not known. ...We investigated this question in a randomized trial.
We conducted a multicenter, sham-controlled trial involving adults at increased surgical risk who were undergoing on-pump CABG (with or without valve surgery) with blood cardioplegia. After anesthesia induction and before surgical incision, patients were randomly assigned to remote ischemic preconditioning (four 5-minute inflations and deflations of a standard blood-pressure cuff on the upper arm) or sham conditioning (control group). Anesthetic management and perioperative care were not standardized. The combined primary end point was death from cardiovascular causes, nonfatal myocardial infarction, coronary revascularization, or stroke, assessed 12 months after randomization.
We enrolled a total of 1612 patients (811 in the control group and 801 in the ischemic-preconditioning group) at 30 cardiac surgery centers in the United Kingdom. There was no significant difference in the cumulative incidence of the primary end point at 12 months between the patients in the remote ischemic preconditioning group and those in the control group (212 patients 26.5% and 225 patients 27.7%, respectively; hazard ratio with ischemic preconditioning, 0.95; 95% confidence interval, 0.79 to 1.15; P=0.58). Furthermore, there were no significant between-group differences in either adverse events or the secondary end points of perioperative myocardial injury (assessed on the basis of the area under the curve for the high-sensitivity assay of serum troponin T at 72 hours), inotrope score (calculated from the maximum dose of the individual inotropic agents administered in the first 3 days after surgery), acute kidney injury, duration of stay in the intensive care unit and hospital, distance on the 6-minute walk test, and quality of life.
Remote ischemic preconditioning did not improve clinical outcomes in patients undergoing elective on-pump CABG with or without valve surgery. (Funded by the Efficacy and Mechanism Evaluation Program a Medical Research Council and National Institute of Health Research partnership and the British Heart Foundation; ERICCA ClinicalTrials.gov number, NCT01247545.).
Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction, one of the most common complications of this surgical cohort. Acute kidney injury (AKI) is ...associated with increased short-term morbidity and mortality and has been the focus of much research. There is increasing recognition of the role of AKI as the key pathophysiological state leading to the disease entities acute and chronic kidney disease (AKD and CKD). In this narrative review, we will consider the epidemiology of renal dysfunction after cardiac surgery on CPB and the clinical manifestations across the spectrum of disease. We will discuss the transition between different states of injury and dysfunction, and, importantly, the relevance to clinicians. The specific facets of kidney injury on extracorporeal circulation will be described and the current evidence evaluated for the use of perfusion-based techniques to reduce the incidence and mitigate the complications of renal dysfunction after cardiac surgery.
Abstract Objectives The aim of this pilot study was to assess feasibility of a perioperative care bundle for enhanced recovery after cardiac surgery (ERACS). Design A prospective observational audit. ...Setting A major urban teaching and university hospital and tertiary referral center. Participants Patients undergoing cardiac surgery: 53 patients studied before implementation of ERACS (pre-ERACS group) and 52 patients after (ERACS group). Interventions Based on recommendations from a consensus review in colorectal surgery, the following enhanced recovery perioperative care bundle was applied: detailed preoperative information, avoidance of prolonged fasting periods preoperatively, preoperative carbohydrate beverages, optimization of analgesia with avoidance of long-acting opioids, prevention of postoperative nausea and vomiting, early enteral nutrition postoperatively, and early mobilization. Measurements and Main Results We hypothesized that length of hospital stay would be reduced with ERACS. Secondary outcome variables included a composite of postoperative complications and pain scores. Whereas the length of stay in the group of patients receiving the bundle of enhanced recovery interventions remained unchanged compared to the non-ERACS group, there was a statistically significant reduction in the number of patients in the ERACS group presenting with one or more postoperative complications (including hospital-acquired infections, acute kidney injury, atrial fibrillation, respiratory failure, postoperative myocardial infarction and death). Additionally, postoperative pain scores were significantly improved in the ERACS group. Conclusions This pilot study demonstrates that ERACS is feasible and has the potential for improved postoperative morbidity after cardiac surgery. A larger multi-center quality improvement study implementing perioperative care bundles would be the next step to further assess outcomes in ERACS patients.
Preoperative frailty may predispose patients to poorer outcomes in cardiac surgery; however, there are limited data concerning how preoperative frailty predicts patient-centred outcomes, such as ...patient-reported disability. Our objective was to evaluate the association between preoperative frailty and postoperative disability.
Patients were prospectively evaluated using the Comprehensive Assessment of Frailty score, separating patients into frail and non-frail cohorts. Disability levels were quantified using the WHO Disability Assessment Schedule (WHODAS) 2.0 in percentage of the maximum disability score, with disability defined as a value ≥25%.
Frail patients had increased median inter-quartile range disability scores of 31 16–45% preoperatively, 29 9–54% at 1 month, and 15 3–31% at 3 months postoperatively, compared with disability scores in non-frail patients of 10 5–17%, 17 6–29%, and 2.1 0–12.0%, respectively. Preoperative frailty was associated with a reduced likelihood of patients being free of disability and alive at 3 months; adjusted odds ratio 0.51 (for age, European System for Cardiac Operative Risk Evaluation II, and WHODAS 2.0: 12-Part Questionnaire score); P=0.045. The trajectory of disability scores, assessed in percentage change from the preoperative baseline, showed non-frail patients had increased disability burden at 1 month, whereas frail patients had reduced disability burden (+4.2% vs –2.1%; P=0.04). Although the disability burden decreased for both groups at 3 months, this was most marked for frail patients (–6.3% vs –10.4%; P=0.02).
Disability burden in frail patients improves continuously postoperatively, whereas in non-frail patients, it worsens at 1 month before improving at 3 months postoperatively. This positive trajectory of patient-centred outcomes in frail patients should be considered in preoperative decision-making.
Does intraoperative optimization of both depth of anesthesia and regional cerebral tissue oxygenation (rScO2) in elderly patients reduce postoperative cognitive decline (primary outcome) or delirium ...(secondary outcome)?
Prospective randomized controlled single blind trial.
A single major urban teaching and university hospital and tertiary referral center.
Patients, 65 years of age and older, undergoing elective coronary artery bypass graft surgery on cardiopulmonary bypass.
Intraoperative depth of anesthesia bispectral index (BIS) values were targeted at 50 ± 10. Regional cerebral tissue desaturations of more than 15% of the pre-induction value, or below 50%, were avoided.
Eighty-two patients were included, and mean depth of anesthesia values using BIS were significantly higher during surgery in the intervention group with 40.6 (7.3) versus 35.4 (6.7) in the control group, mean (standard deviation), p = 0.004. The cognitive function was similar between the treatment and control groups at 6 weeks postoperatively with a Mini Mental State Examination (MMSE) of 27 (26,29) in the intervention group and an MMSE of 29 (27,29) in the control group, median (interquartile range), with p = 0.12. The authors observed a reduction in the incidence of delirium, occurring in 2.4% (n = 1) of patients in the intervention group and in 20% (n = 8) in the control group (p = 0.01).
This pilot trial demonstrates that noninvasive target-controlled depth of anesthesia monitoring is feasible. Cognitive function at 6 weeks showed no difference between the treatment and control groups; however, postoperative delirium was reduced in the intervention group.
Acute kidney injury (AKI) is common after cardiac surgery. To date, there are no specific pharmacological therapies. In this review, we summarise the existing evidence for prevention and management ...of cardiac surgery-associated AKI and outline areas for future research. Preoperatively, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be withheld and nephrotoxins should be avoided to reduce the risk. Intraoperative strategies include goal-directed therapy with individualised blood pressure management and administration of balanced fluids, the use of circuits with biocompatible coatings, application of minimally invasive extracorporeal circulation, and lung protective ventilation. Postoperative management should be in accordance with current KDIGO AKI recommendations.
Perioperative myocardial ischemia contributes to postoperative morbidity and mortality. Remote intermittent ischemia (RI) has been shown to benefit patients undergoing coronary artery bypass graft ...(CABG) surgery by decreasing postoperative cardiac troponin levels. In addition, there is evidence that volatile anesthetics may provide myocardial protection. In this prospective randomized controlled trial we tested the hypothesis that RI is cardioprotective under a strict anesthetic regime with volatile anesthesia until cardiopulmonary bypass (CPB). We also assessed whether RI modulates postoperative cytokine and growth factor concentrations. Fifty-four patients referred for elective CABG surgery without concomitant valve or aortic surgery were randomized to three 5-min cycles of left upper limb ischemia by cuff inflation (RI) or placebo without cuff inflation (Plac). All patients received the volatile anesthetic isoflurane (1.15–1.5 vol%) before CPB and the intravenous anesthetic propofol (3–4 mg/kg/h) thereafter until the end of surgery. Cardiac arrest during CPB was induced by intermittent cross-clamp fibrillation, or by blood cardioplegia. We excluded patients older than 85 years, with unstable angina, significant renal disease, and those taking sulfonylureas. Troponin I (cTnI) was measured preoperatively and after 6, 12, 24 and 48 h. In addition, brain natriuretic peptide (BNP), creatine kinase (CKMB) and a panel of cytokines and growth factors were analyzed perioperatively. Although cTnI, BNP and CKMB all increased post-CABG, there were no significant differences between RI and Plac groups; area under the curve for cTnI 189.4 (183.6) ng/mL/48 h and 183.0 (155.2) ng/mL/48 h mean (SD),
p
= 0.90, respectively, despite a tendency to a shorter (
p
< 0.07) cross-clamp time in the treatment group. Similarly, there were no differences between groups in the central venous concentrations of numerous cytokines and growth factors. In patients undergoing CABG surgery RI does not provide myocardial protection under a strict anesthetic regime with volatile anesthesia until CPB, and RI was not associated with changes in cytokines.
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