High Central Venous Pressure after Cardiac Surgery Might Depict Hemodynamic Deterioration Associated with Increased Morbidity and Mortality.

Fridtjof Schiefenhövel,Christian Berger,Michael Sander,Ralf F Trauzeddel,Jochen Kruppa,Sascha Treskatsch,Heinrich V Groesdonk,Felix Balzer,Herko Grubitzsch,Matthias Heringlake

doi:10.3390/jcm10173945

Abstract

Background: Cardiac surgery patients represent a high-risk cohort in intensive care units (ICUs). Central venous pressure (CVP) measurement seems to remain an integral part in hemodynamic monitoring, especially in cardio-surgical ICUs. However, its value as a prognostic marker for organ failure is still unclear. Therefore, we analyzed postoperative CVP values after adult cardiac surgery in a large cohort with regard to its prognostic value for morbidity and mortality. Methods: All adult patients admitted to our ICUs between 2006 and 2019 after cardiac surgery were eligible for inclusion in the study (n = 11,198). We calculated the median initial CVP (miCVP) after admission to the ICU, which returned valid values for 9802 patients. An ROC curve analysis for optimal cut-off miCVP to predict ICU mortality was conducted with consecutive patient allocation into a (a) low miCVP (LCVP) group (≤11 mmHg) and (b) high miCVP (HCVP) group (>11 mmHg). We analyzed the impact of high miCVP on morbidity and mortality by propensity score matching (PSM) and logistic regression. Results: ICU mortality was increased in HCVP patients. In addition, patients in the HCVP group required longer mechanical ventilation, had a higher incidence of acute kidney injury, were more frequently treated with renal replacement therapy, and showed a higher risk for postoperative liver dysfunction, parametrized by a postoperative rise of ≥ 10 in MELD Score. Multiple regression analysis confirmed HCVP has an effect on postoperative ICU-mortality and intrahospital mortality, which seems to be independent. Conclusions: A high initial CVP in the early postoperative ICU course after cardiac surgery is associated with worse patient outcome. Whether or not CVP, as a readily and constantly available hemodynamic parameter, should promote clinical efforts regarding diagnostics and/or treatment, warrants further investigations.

Highlights

Surgical and perioperative management has been improved over previous decades [1], cardiac surgery patients still represent a high-risk cohort in intensive care units (ICUs) [2], and strategies to further improve outcome have to be implemented into clinical routine [3]
Primary end-point was in-hospitalmortality; secondary outcome parameters included the following: length of stay in the ICU (LOS-ICU) and the hospital (LOS-Hospital), duration of mechanical ventilation, acute kidney injury defined by a rise of 0.3 mg/dL or more within 48 h [20], need for continuous renal replacement therapy excluding cases with pre-existing chronic renal insufficiency and postoperative rise in MELD (Model of End-Stage Liver Disease) score of more than
35 mmHg, including only values taken within six hours of ICU admission and including only patients with at least three Central venous pressure (CVP) measurements in this timeframe, 9802 patients with

Summary

Introduction

Surgical and perioperative management has been improved over previous decades [1], cardiac surgery patients still represent a high-risk cohort in intensive care units (ICUs) [2], and strategies to further improve outcome have to be implemented into clinical routine [3]. Goal-directed therapy (GDT) has been shown to reduce morbidity and mortality in cardiac surgery [4,5]. GDT is recommended by the ERACS group [8] Such extended hemodynamic monitoring is available in most ICUs in so-called western countries [9]. Cardiac surgery patients represent a high-risk cohort in intensive care units (ICUs). We analyzed postoperative CVP values after adult cardiac surgery in a large cohort with regard to its prognostic value for morbidity and mortality. Patients in the HCVP group required longer mechanical ventilation, had a higher incidence of acute kidney injury, were more frequently treated with renal replacement therapy, and showed a higher risk for postoperative liver dysfunction, parametrized by a postoperative rise of ≥ 10 in MELD Score

Methods

Results

Conclusion