Anesthesia For Cardiac Surgery Research Articles

Evaluation of the effectiveness of phenylephrine in hypotension management in anesthesia for cardiac surgery using extracorporeal circulation

Background: Phenylephrine is a vasoconstrictor often chosen to raise blood pressure during induction of anesthesia. The study aimed to evaluate the effectiveness of phenylephrine in hypotension treatment in anesthesia for cardiac surgery using extracorporeal circulation. Methods: Descriptive study and evaluation of phenylephrine response in 40 cardiac surgery patients using extracorporeal circulation. Results: During the induction phase, phenylephrine increased mean arterial blood pressure the most at time T2 (mean mean ∆BP was 26.2 ± 6.9), then the trend gradually decreased and remained within normal limits (p<0.05). The mean number of intravenous injections of phenylephrine during the induction period was 1.1 ± 0.3 times, the mean dose of phenylephrine used was 0.9 ± 0.3 µg/kg. During the extracorporeal circulation phase, phenylephrine increased mean blood pressure early, and persistently, peaking at T5 (mean ∆HATB of 17.4 ± 3.6 mmHg). The mean number of intravenous injections of phenylephrine during the extracorporeal circulation phase was 1 time, the mean dose of phenylephrine used was 0.8 ± 0.3 µg/kg. Conclusion: Phenylephrine is used effectively with a small number of injections and a moderate dose when treating hypotension in anesthesia for cardiac surgery using extracorporeal circulation.

E.N. Meshalkin scientific school of cardiac surgery in Siberia (To the 300th anniversary of the Russian Academy of Sciences)

This article presents historical milestones for E.N. Meshalkin scientific school of cardiac surgery. E.N. Meshalkin was corresponding member of the USSR Academy of Sciences and first director of Meshalkin National Medical Research Center. Publications by E.N. Meshalkin and his followers reflect the study of circulatory organ pathology, physiology, and regeneration, as well as the diagnosis and surgical treatment of heart defects and diseases, including hypothermia and cardiopulmonary bypass. Additionally, they cover methods of anesthesia in cardiac surgery, organ transplantation, and the creation of new equipment, as well as improvements in methods of hemodynamics research. Successors of E.N. Meshalkin scientific school combine high-tech medical care with fundamental research, development, and implementation of innovative diagnostic and treatment methods in cardiac surgery, oncology, neurosurgery, and related fields of medicine. Received 12 December 2023. Accepted 18 December 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Remimazolam attenuates myocardial ischemia-reperfusion injury by inhibiting the NF-ĸB pathway of macrophage inflammation

BackgroundInflammation is a major contributing factor in myocardial ischemia/reperfusion (I/R) injury, and targeting macrophage inflammation is an effective strategy for myocardial I/R therapy. Though remimazolam is approved for sedation, induction, and the maintenance of general anesthesia in cardiac surgery, its effect on cardiac function during the perioperative period has not been reported. Therefore, this research aimed to explore the impact of remimazolam on inflammation during myocardial ischemia/reperfusion (I/R) injury. MethodsAn in vivo myocardial I/R mice model and an in vitro macrophage inflammation model were used to confirm remimazolam's cardiac protective effect. In vivo, we used echocardiography, hematoxylin and eosin (HE), and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining to determine remimazolam's therapeutic effects on myocardial I/R injury and inflammation. In vitro, we employed enzyme-linked immunosorbent assay (ELISA), Western blot, Real-time Quantitative PCR (qPCR), flow cytometry, and immunofluorescence staining to assess inflammatory responses, especially remimazolam's effects on macrophage polarization after I/R. Furthermore, molecular docking was used to identify its potential binding targets on the inflammatory pathway to explore the mechanism of remimazolam. ResultsRemimazolam exhibited significant anti-myocardial I/R injury activity by inhibiting macrophage-mediated inflammation to reduce myocardial infarction, enhancing cardiac function. In addition, macrophage depletion counteracted improved cardiac function by remimazolam treatment. Mechanistically, the activated NF-ĸB signaling pathway and phosphorylation of p50 and p65 were repressed for anti-inflammatory effect. Consistently, two binding sites on p50 and p65 were identified by molecular docking to affect their phosphorylation of the Ser, Arg, Asp, and His residues, thus regulating NF-κB pathway activity. ConclusionOur results unveil the therapeutic potential of remimazolam against myocardial I/R injury by inhibiting macrophages polarizing into the M1 type, alleviating inflammation.

Regional anesthesia in cardiac surgery and electrophysiology procedures

Regional anesthesia in cardiac surgery and electrophysiology procedures

Regional anesthesia in coronary artery bypass grafting: a narrative review

Coronary artery bypass grafting (CABG) is one of the most frequently performed procedures in modern cardiac surgery because it is indicated in most patients with coronary artery disease. Currently, there are no standard methods for regional anesthesia in cardiac surgery. The purpose of this review was to describe the available techniques for regional anesthesia in post-CABG. Studies published in the databases PubMed, The Cochrane Library, Google Scholar, Russian science citation index were included. Techniques reported in the literature were local blockade of the postoperative wound with local anesthetics in the anteromedial chest wall (parasternal-intercostal plane blocks), anterolateral chest wall (interpectoral plane blocks, serratus anterior plane block), and posterolateral chest wall (erector spinae plane block, thoracic paravertebral block, retrolaminar block, rhomboid intercostal block). Numerous studies demonstrate that the use of regional anesthesia as a component of multimodal anesthesia after coronary artery bypass grafting significantly improves pain relief. Blockade of the peripheral nerves of the chest wall under ultrasound guidance can be considered not only as an alternative to epidural anesthesia when not indicated or not feasible. It also contributes to early tracheal extubation, reduced duration of mechanical ventilation, adequate pain control, and a decrease in the need for narcotic analgesics, reduced postoperative nausea and vomiting, and reduced length of stay in the intensive care unit. Further research is needed to determine the optimal technique for performing interfascial blockades of the chest wall post-CABG, which would require data on the effectiveness, safety, and dosing regimen for each specific blockade.

EXPLORING THE HEMODYNAMIC AND POST-OPERATIVE IMPLICATIONS: A COMPARATIVE ANALYSIS OF INTRAVENOUS SEDATION WITH DEXMEDETOMIDINE VERSUS PROPOFOL IN CARDIAC SURGICAL PROCEDURES

A comparative study was conducted to examine the impact of dexmedetomidine and propofol on hemodynamic stability and post-operative outcomes in cardiac surgery patients. The study included 100 patients aged 15-60 who were ASA physical Status I-III and scheduled for elective open-heart surgery. Patients were divided into the dexmedetomidine group (n=50) and the propofol group (n=50). The study meticulously detailed hemodynamic assessments, induction protocols, and anesthesia management. The study found that dexmedetomidine exhibited consistently lower heart rates at critical intervals. In the post-operative phase, dexmedetomidine showed favorable outcomes, including significantly shorter ventilation duration (6.43 ± 8.86 vs. 8.86 ± 5.60 hours, P = 0.014) and ICU stay (92.34 ± 56.71 vs. 118.56 ± 41.89 hours, P = 0.01). The incidence of delirium was also significantly lower in the dexmedetomidine group (8% vs. 24%, P = 0.029), suggesting potential neuroprotective effects. It is important to note that the study's sample size was moderate and focused on short-term outcomes. Therefore, further research is needed to explore diverse patient subgroups and the long-term implications of dexmedetomidine and propofol in cardiac surgery anesthesia. Nonetheless, the study concluded that dexmedetomidine demonstrated favorable hemodynamic stability and beneficial post-operative outcomes, making it a promising option for cardiac surgery patients

Protocol Study for the Evaluation of Non-Opioid Balanced General Anaesthesia in Cardiac Surgery with Cardiopulmonary Bypass: A Randomised, Controlled, Multicentric Superiority Trial (OFACAR Study).

Opioid-free anaesthesia (OFA) is general anaesthesia based on the use of several non-opioid molecules that aim to have an analgesic effect, decrease the sympathetic response, decrease hormonal stress, and decrease the inflammatory response during surgery. Although this approach to anaesthesia is regularly used in clinical practice, it remains a novel approach. The literature on this anaesthesia modality finds a number of positive effects on cardiac, respiratory, and cognitive function but no randomised study evaluated these effects during cardiac surgery where there is a high incidence of postoperative complications. The main aim of the study is to compare OFA vs. standard balanced opioid general anaesthesia on the incidence of postoperative complications and the length of stay in intensive care and hospital. OFACAR is a multicentric, randomised, controlled, superiority, single-blind, two parallel-arm clinical trial in patients undergoing cardiac surgery with cardiopulmonary bypass. We compared a balanced general anaesthesia without opioids (OFA group) vs. a balanced opioid general anaesthesia with sufentanil (control group). One hundred and sixty patients will be enrolled in each treatment group. The primary endpoint is a composite one which corresponds to the occurrence of at least one of the postoperative complications, defined according to European standards within 30 days after surgery. Recruitment started in September 2019, and data collection is expected to end in November 2024.

Cardioprotective effect of propofol in cardioplegia compared to systemic propofol in heart valves surgery; a randomized controlled trial

BackgroundMyocardial protection is still a focus of ongoing research. Propofol is used widely during the induction of anaesthesia in cardiac surgery. So, this triggers us to investigate the cardioprotective effect of the propofol when added to the cardioplegia compared to systemic propofol by measuring the troponin T level.MethodsThis clinical randomized controlled trial was carried out on 150 patients operated for elective valvular heart surgery. Patients were assigned into three equal groups: Group 1: received propofol in the cardioplegia, Group 2: received propofol injection in the aortic line before and after the aortic cross-clamp, and Group 3 (control group): patients without propofol in the cardioplegia or aortic line. All patients were subjected to full medical histories, physical examinations, routine tests, and echocardiography. Cardiac troponin T was measured before surgery and 4 times postoperatively.ResultsIn group 1, there was a significant improvement in troponin T level at the last reading compared with the control group (mean ± SD. of group 1 was 246.4 ± 131.4, mean ± SD. of group 3 was 317.0 ± 117.9, p = 0.031), denoting propofol's cardioprotective effect when added as a cardioplegia additive. In group 2, there was a significant improvement of troponin T level at the last reading compared with the group 1 and control group (mean ± SD. of group 2 was 202.54 ± 156.03, mean ± SD. of group 3 was 317.0 ± 117.9, p < 0.001), denoting propofol's more cardioprotective effect when used systemically during cardiopulmonary bypass than when added as a cardioplegia additive.ConclusionsIn valvular cardiac surgery, propofol has an additional cardioprotective effect and a superior cardiac outcome when administered systematically during cardiopulmonary bypass rather than added to cardioplegia.Trial registrationPan African Clinical Trials Register PACTR201907764652028. Registered on 01 July 2019, retrospectively registered, https://pactr.samrc.ac.za/ TrialDisplay.aspx?TrialID = 5726.

Parasternal intercostal plane block catheters for cardiac surgery: a retrospective, propensity weighted, cohort study.

Aim: Anesthesia for cardiac surgery has evolved toward fast-track recovery strategies incorporating nonopioid analgesics and regional anesthesia. Materials & methods: This retrospective cohort study compared opioid consumption, pain scoresand length of stay in patients who underwent cardiac surgery via median sternotomy and did or did not receive preoperative parasternal intercostal plane block catheters with postoperative ropivacaine infusions. Results: Postoperative opioid consumption and postoperative pain scores did not differ. Blocks were associated with decreased intraoperative opioids and reduced length of stay in the intensive care unit and hospital. Conclusion: Parasternal intercostal plane block catheters were not associated with decreased postoperative opioid consumption or pain scores, but were associated with reduced intraoperative opioids and length of stay.

Extracorporeal circulation in the elderly: anesthesia in patients undergoing myocardial revascularization in the intensive care unit (ICU)

To describe cardiopulmonary bypass in the elderly under anesthesia of patients undergoing myocardial revascularization in the Intensive Care Unit. Cardiopulmonary bypass (CPB) can alter plasma concentrations of drugs used during anesthesia for cardiac surgery and cause effects on the central nervous system, leading patients to a greater degree of sedation, which alters the time of patient awakening. Method: This is a descriptive-qualitative-exploratory study, of a comprehensive nature, of the systematic type. Results: The three groups were compared in terms of weight, height, age and body mass index (BMI). Regarding intubation time and wake-up time, it was observed that the CPB group had higher values ​​for these variables, with a significant difference. Conclusion: The short duration of action of propofol of approximately 6 to 9 minutes can be explained by the high clearance and rapid distribution of the drug. Propofol concentration at the site of action also increases rapidly due to the rapid equilibrium between plasma and brain concentrations (&lt; 4 minutes).

Con: Regional Anesthesia With Thoracic Fascial Plane Blocks Should Not Be Routinely Used for Cardiac Surgery

REGIONAL ANESTHESIA in the form of thoracic fascial plane blocks is a relatively new phenomena within the world of cardiac surgery. Historically, high-dose opioids were used to allow for a controlled hemodynamic response during induction and times of extreme stimulation such as incision and sternotomy. In present day trends of Enhanced Recovery after Surgery, fast-track extubation, and opioid reduction, regional anesthesia for cardiac surgery has received a lot of attention. 1 Kelava M Alfirevic A Bustamante S et al. Regional anesthesia in cardiac surgery: An overview of fascial plane chest wall blocks. Anesthesia & Analgesia. 2020; 131: 127-135 Crossref PubMed Scopus (67) Google Scholar Despite the initial allure, the evidence in support of regional anesthesia over multimodal adjuncts is inconsistent and less than compelling. Furthermore, safety and efficiency concerns regarding regional anesthesia are not uncommon and need to be considered. Despite the current trend, the authors feel the current body of evidence does not support routine use of regional anesthesia for cardiac surgery.

High Thoracic Epidural Anesthesia and Dexmedetomidine for Awake Off-Pump Coronary Artery Bypass Grafting: A Feasible Option for Patients with Severe Pulmonary Disease.

High thoracic epidural anesthesia in cardiac surgery as the sole anesthetic technique is used in a select groups of patients having severe pulmonary co morbidities. We describe a case series of three patients at high risk for post operative pulmonary complications where this technique was used along with dexmedetomidine infusion for conscious sedation in off pump coronary artery bypass grafting. Proper selection of patients, proper placement of the epidural catheter at the appropriate level and timing of catheter insertion and removal are of paramount importance.

Effects of ultrasound-guided regional anesthesia in cardiac surgery: a systematic review and network meta-analysis

BackgroundThe objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery.MethodsThis systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.ResultsThe primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]).ConclusionsIn this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.Trial registrationPROSPERO; CRD42022315497.

Regional anesthesia in cardiac surgery: is it necessary to refuse?

<h3></h3> В стратегии ускоренной активизации пациента после операций на сердце помимо минимизации хирургической агрессии важную роль играет эффективный контроль болевого синдрома. Для его купирования могут быть использованы различные методы, в том числе методы регионарной анестезии. Однако все инвазивные манипуляции сопровождаются риском развития различных осложнений. В кардиохирургии на фоне широкого периоперационного применения антикоагулянтов и дезагрегантов использование регионарной анестезии может сопровождаться геморрагическими осложнениями. Кроме этого, применение регионарных методик в клинической практике ограничено риском несостоятельности анестезии. В данном обзоре рассмотрены современные представления о клинической эффективности, риске и осложнениях регионарных блокад при кардиохирургических вмешательствах.

Regional Anesthesia in Cardiac Surgery: A Review of the Literature.

With our population getting older and sicker, we are witnessing a steady increase in the volume of cardiothoracic procedures performed. As the role of anesthesiologists continues to shift towards being perioperative physicians, it is crucial to tailor the anesthetic to manage the surgical pain in both intraoperative and postoperative periods. In cardiac surgery, poorly controlled surgical pain can lead to opioid-induced hyperalgesia as well as chronic pain syndrome. As current practice encourages early extubation and decreased length of stay, clinicians have increasingly steered away from heavy intraop narcotic therapy over the past two decades. To blunt the sympathetic response and postoperative pain control, some have been using various fascial plane nerve blocks to reduce opioid use during surgery. These blocks are considered very safe to perform and do not lead to hemodynamic changes seen in neuraxial blockades. In this review article, we provide a brief overview of each of the commonly used blocks and summarize and discuss the latest clinical data for each of the common blocks and their efficacy in the setting of cardiothoracic surgery.

THE INFLUENCE OF CLINICAL AND LABORATORY FACTORS ON THE DEVELOPMENT OF HEMODYNAMIC COMPLICATIONS DURING ANESTHESIA IN CARDIAC SURGERY

Background. Currently, cardioanesthesiology is one of the most actively developing areas of modern medicine. Thanks to new methods of treatment, the contingent of patients for whom it became possible to undergo cardiac surgery has significantly expanded. The main problems that lead to hemodynamic complications are endothelial dysfunction and cellular hypoxia. Purpose. To present data on the influence of clinical and laboratory factors of endothelial dysfunction and cellular hypoxia on the development of hemodynamic complications during anesthesia in cardiac surgery. Material and methods. The review and analysis of literature data from 49 sources is presented. Results. The laboratory markers of endothelial dysfunction leading to the development of major hemodynamic complications in cardiovascular diseases are MPC-1, CRP, NO, TNF-α, IL-6, homocysteine. Conclusion. The data obtained indicate a significant effect of cell markers (MPC-1, CRP, NO, TNF-A, IL-6, homocysteine) as well as clinical and laboratory factors of endothelial dysfunction not only on the development of major diseases of the cardiovascular system, but also on their complications. An early study of these markers can improve anesthesia during cardiac surgery as well as reduce complications in the postoperative period.

ВЛИЯНИЕ КЛИНИКО-ЛАБОРАТОРНЫХ ФАКТОРОВ НА РАЗВИТИЕ ГЕМОДИНАМИЧЕСКИХ ОСЛОЖНЕНИЙ ВО ВРЕМЯ АНЕСТЕЗИИ ПРИ КАРДИОХИРУРГИЧЕСКИХ ВМЕШАТЕЛЬСТВАХ

Background. Currently, cardioanesthesiology is one of the most actively developing areas of modern medicine. Thanks to new methods of treatment, the contingent of patients for whom it became possible to undergo cardiac surgery has significantly expanded. The main problems that lead to hemodynamic complications are endothelial dysfunction and cellular hypoxia. Purpose. To present data on the influence of clinical and laboratory factors of endothelial dysfunction and cellular hypoxia on the development of hemodynamic complications during anesthesia in cardiac surgery. Material and methods. The review and analysis of literature data from 49 sources is presented. Results. The laboratory markers of endothelial dysfunction leading to the development of major hemodynamic complications in cardiovascular diseases are MPC-1, CRP, NO, TNF-α, IL-6, homocysteine. Conclusion. The data obtained indicate a significant effect of cell markers (MPC-1, CRP, NO, TNF-A, IL-6, homocysteine) as well as clinical and laboratory factors of endothelial dysfunction not only on the development of major diseases of the cardiovascular system, but also on their complications. An early study of these markers can improve anesthesia during cardiac surgery as well as reduce complications in the postoperative period.

Infectious Complications after Etomidate vs. Propofol for Induction of General Anesthesia in Cardiac Surgery-Results of a Retrospective, before-after Study.

Background: Etomidate is typically used as an induction agent in cardiac surgery because it has little impact on hemodynamics. It is a known suppressor of adrenocortical function and may increase the risk for post-operative infections, sepsis, and mortality. The aim of this study was to evaluate whether etomidate increases the risk of postoperative sepsis (primary outcome) and infections (secondary outcome) compared to propofol. Methods: This was a retrospective before–after trial (IRB EA1/143/20) performed at a tertiary medical center in Berlin, Germany, between 10/2012 and 01/2015. Patients undergoing cardiac surgery were investigated within two observation intervals, during which etomidate and propofol were the sole induction agents. Results: One-thousand, four-hundred, and sixty-two patients, and 622 matched pairs, after caliper propensity-score matching, were included in the final analysis. Sepsis rates did not differ in the matched cohort (etomidate: 11.5% vs. propofol: 8.2%, p = 0.052). Patients in the etomidate interval were more likely to develop hospital-acquired pneumonia (etomidate: 18.6% vs. propofol: 14.0%, p = 0.031). Conclusion: Our study showed that a single-dose of etomidate is not statistically associated with higher postoperative sepsis rates after cardiac surgery, but is associated with a higher incidence of hospital-acquired pneumonia. However, there is a notable trend towards a higher sepsis rate.

Analysis of Failure Modes in Anesthesia for Cardiac Surgery Using the Healthcare Failure Mode and Effects Analysis (HFMEA) Technique

Background: Healthcare statistics, issued by various international organizations, show that medical errors in health centers impose high costs on patients and hospitals and increase the rates of morbidity and mortality around the world. Due to the potential risks of cardiovascular diseases, the occurrence of any errors can potentially endanger the patients’ lives and incur costs on them, as well as hospitals. On the other hand, anesthesia is one of the priorities for risk management in clinical care. Objectives: This study aimed to identify, classify, and evaluate anesthesia failures in open heart surgeries, using the healthcare failure mode and effects analysis (HFMEA) technique. Methods: The anesthesia process in open heart surgery was reviewed using the HFMEA technique, and four processes, 25 sub-processes, 95 activities, and 204 risks were extracted. The causes of failure were also identified, and four failure modes were determined as the most important failures, based on the qualitative and quantitative methods; finally, some solutions were proposed. Changes in the level of healthcare workers’ knowledge and competence, computer use and timing, and the amount of administered medications were identified as the potential risk factors and errors. Results: The inadequate awareness and knowledge of healthcare workers, non-use of computers, prescription errors, technique errors, and timing and amount of medication administration were identified as the errors and risk factors. Based on the present findings, another expert needs to evaluate the design, feasibility, and prioritization of techniques, including continuing medical education for anesthesia professionals and experts, statutory documentation, and control of the individuals’ activities. Conclusions: Based on the present findings, establishing a risk management committee seems essential to identify errors and improve the design and plan of different techniques so as to execute, monitor, control, and review errors in a cycle of continuous improvement.

Ultrasound-Guided Regional Anesthesia-Current Strategies for Enhanced Recovery after Cardiac Surgery.

With the advent of fast-track pathways after cardiac surgery, there has been a renewed interest in regional anesthesia due to its opioid-sparing effect. This paradigm shift, looking to improve resource allocation efficiency and hasten postoperative extubation and mobilization, has been pursued by nearly every specialty area in surgery. Safety concerns regarding the use of classical neuraxial techniques in anticoagulated patients have tempered the application of regional anesthesia in cardiac surgery. Recently described ultrasound-guided thoracic wall blocks have emerged as valuable alternatives to epidurals and landmark-driven paravertebral and intercostal blocks. These novel procedures enable safe, effective, opioid-free pain control. Although experience within this field is still at an early stage, available evidence indicates that their use is poised to grow and may become integral to enhanced recovery pathways for cardiac surgery patients.