Elective On-pump Cardiac Surgery Research Articles

Comparison of the effects of transversus thoracic muscle plane block and pecto-intercostal fascial block on postoperative opioid consumption in patients undergoing open cardiac surgery: a prospective randomized study

BackgroundThere is an association exists between cardiac surgery, performed through median sternotomy, and a considerable postoperative pain.ObjectivesThe aim of the current study is to compare the effects of transversus thoracic muscle plane block (TTMPB) and pecto-intercostal fascial plane block (PIFB) upon postoperative opioid consumption among the patients who underwent open cardiac surgery.MethodsThe present prospective, randomized, comparative study was conducted among 80 patients who underwent elective on-pump cardiac surgery with sternotomy. The subjects were randomly assigned to two groups with each group containing 40 individuals. For the TTMPB group, bilateral ultrasound-guided TTMPB was adopted in which 20 ml of 0.25% bupivacaine was used on each side. In case of PIFB group, bilateral ultrasound-guided PIFB was adopted with the application of 20 ml of 0.25% bupivacaine on each side. The researchers recorded the first time for rescue analgesia, the overall dosage of rescue analgesia administered in the first 24 h after the operation and the postoperative complications.ResultsThe PIFB group took significantly longer time to raise the first request for rescue analgesia (7.8 ± 1.7 h) than the TTMPB group (6.7 ± 1.4 h). Likewise, the PIFB group subjects had a remarkably lower ‘overall morphine usage’ in the first 24 h after the operation (4.8 ± 1.0 mg) than TTMPB group (7.8 ± 2.0 mg).ConclusionBilateral ultrasound-guided PIFB provided a longer time for the first analgesic demand than bilateral ultrasound-guided TTMPB in patients undergoing open cardiac surgery. In addition to this, the PIFB reported less postoperative morphine usage than the TTMPB and increases satisfaction in these patients.Trial registrationThis study was registered at Clinical Trials.gov on 28/11/2022 (registration number: NCT05627869).

Abnormal Iron Status and Adverse Outcome After Elective Cardiac Surgery: A Prospective, Observational Multicenter Study

ObjectivesTo investigate the incidence of preoperative abnormal iron status and its association with packed red blood cell (PRBC) transfusion, postoperative major complications, and new onset of clinically significant disability in patients undergoing elective cardiac surgery. DesignProspective, observational multicenter cohort study. SettingThree heart surgical centers in the Netherlands, between 2019 and 2021. Recruitment was on hold between March and May 2020, due to COVID-19. Patients427 patients aged 60 years and older who underwent elective on-pump cardiac surgery. Measurements and Main ResultsPrimary endpoint was 30-day packed red blood cell (PRBC) transfusion. Secondary endpoints were postoperative major complications within 30 days (e.g., acute kidney injury, sepsis), and new onset of clinically significant disability within 120 days within surgery. Iron status was evaluated prior to surgery. An abnormal iron status was present in 45.2% of patients (n=193), and most frequently the result of iron deficiency (27.4%, n = 117). An abnormal iron status was not associated with PRBC transfusion (adjusted relative risk (ARR) 1.2; 95% confidence interval (95% CI) 0.9 to 1.8: p = 0.227) or new onset of clinically significant disability (ARR 2.0; 95% CI 0.9 to 4.6: p = 0.098). However, the risk of postoperative major complications was increased in patients with an abnormal iron status (ARR 1.7; 95% CI 1.1 to 2.5: p = 0.012). ConclusionsAn abnormal iron status prior to elective cardiac surgery was associated with an increased risk of postoperative major complications, but not with PRBC-transfusion or new onset of clinically significant disability.

The effect of driving pressure-guided versus conventional mechanical ventilation strategy on pulmonary complications following on-pump cardiac surgery: A randomized clinical trial

Study objectivePostoperative pulmonary complications occur frequently and are associated with worse postoperative outcomes in cardiac surgical patients. The advantage of driving pressure-guided ventilation strategy in decreasing pulmonary complications remains to be definitively established. We aimed to investigate the effect of intraoperative driving pressure-guided ventilation strategy compared with conventional lung-protective ventilation on pulmonary complications following on-pump cardiac surgery. DesignProspective, two-arm, randomized controlled trial. SettingThe West China university hospital in Sichuan, China. PatientsAdult patients who were scheduled for elective on-pump cardiac surgery were enrolled in the study. InterventionsPatients undergoing on-pump cardiac surgery were randomized to receive driving pressure-guided ventilation strategy based on positive end-expiratory pressure (PEEP) titration or conventional lung-protective ventilation strategy with fixed 5 cmH2O of PEEP. MeasurementsThe primary outcome of pulmonary complications (including acute respiratory distress syndrome, atelectasis, pneumonia, pleural effusion, and pneumothorax) within the first 7 postoperative days were prospectively identified. Secondary outcomes included pulmonary complication severity, ICU length of stay, and in-hospital and 30-day mortality. Main resultsBetween August 2020 and July 2021, we enrolled 694 eligible patients who were included in the final analysis. Postoperative pulmonary complications occurred in 140 (40.3%) patients in the driving pressure group and 142 (40.9%) in the conventional group (relative risk, 0.99; 95% confidence interval, 0.82–1.18; P = 0.877). Intention-to-treat analysis showed no significant difference between study groups regarding the incidence of primary outcome. The driving pressure group had less atelectasis than the conventional group (11.5% vs 17.0%; relative risk, 0.68; 95% confidence interval, 0.47–0.98; P = 0.039). Secondary outcomes did not differ between groups. ConclusionAmong patients who underwent on-pump cardiac surgery, the use of driving pressure-guided ventilation strategy did not reduce the risk of postoperative pulmonary complications when compared with conventional lung-protective ventilation strategy.

Preoperative hypoalbuminemia and postoperative acute kidney injury in adult patients after elective on-pump cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background An earlier published prospective cohort study evaluating the impact of malnutrition on cardiac surgery outcomes showed serum albumin ≤42 g/dL to be associated with a poor prognosis [1]. However, the association with kidney outcomes was not studied. The adverse effect of preoperative hypoalbuminemia on postoperative kidney injury and its cut-off value in on-pump cardiac surgery patients is still controversial [2]. Methods A retrospective matched case-control study based on the secondary analysis of the open-access dataset [3] was conducted. The research hypothesis was that preoperative hypoalbuminemia is independently associated with a higher risk of acute kidney injury (AKI) requiring postoperative new-onset dialysis. We defined cases as patients treated with new-onset dialysis for AKI and controls as those who did not. Hypoalbuminemia was defined as serum albumin of ≤42 g/L based on findings from the original study. The dataset counted 1178 adults from multiple centers who underwent elective cardiopulmonary bypass (CPB) cardiac surgery in 2011. We excluded patients with missing data and compared key demographic and medical history characteristics. Following the hypothesis, subjects were matched on the type of surgery they received (coronary, valvular, or combined) in a multiple conditional logistic regression model that included the hypoalbuminemia status, diabetes history, CPB time, and logistic EuroScore. Additionally, univariate regression with and without conditional matching was performed. Results In total, 831 (39 cases and 792 controls) subjects were included. Subjects shared similar demographics and medical history. Expectedly, cases had prolonged CPB and aortic cross-clamp time. The median CPB time in cases and controls was 120 and 79 min, respectively (p=0.001). The median aortic cross-clamp time was 79 in cases and 54 in controls (p=0.001). Hypoalbuminemia was observed in 18 cases (46%) in cases compared to 241 (30%) in controls (p=0.038). Multiple conditional regression demonstrated that the risk of postoperative AKI requiring dialysis was not associated with preoperative hypoalbuminemia (OR 1.43, [0.70, 2.89]). Similarly, univariate conditional regression showed no association (OR 1.84 [0.95, 3.53]). Only univariate unmatched regression resulted in statistical significance(OR 1.96 [1.03, 3.74]). The higher logistic EuroScore (OR 1.11, [1.06, 1.15]) and the longer cardiopulmonary bypass time (OR 1.01, [1.01, 1.02]), but not the history of diabetes (OR 0.61, [0.19, 1.88]), increased the odds of renal replacement therapy requirement. Conclusion In our study, preoperative hypoalbuminemia was not independently associated with a higher risk of postoperative AKI requiring new-onset dialysis after elective on-pump cardiac surgery. Patients who required dialysis had lower preoperative albumin levels, but the association between hypoalbuminemia ≤ 42 g/L and kidney outcomes could be confounded.

Individualized flow-controlled versus conventional pressure-controlled ventilation in on-pump heart surgery (FLOWVENTIN HEARTSURG): study protocol for a randomized controlled trial

BackgroundIn on-pump cardiac surgery, lungs are at high risk of periprocedural organ impairment because of atelectasis formation, ventilator-induced lung injury, and hyperinflammation due to the cardiopulmonary bypass which results in postoperative pulmonary complications in half of this patient population. The new ventilation mode flow-controlled ventilation (FCV) uniquely allows full control of ins- and expiratory airway flows. This approach reduces the mechanical power of invasive ventilation as a possible cause of ventilator-induced lung injury. The scope of FLOWVENTIN HEARTSURG is to compare perioperative individualized FCV with best clinical practice pressure-controlled ventilation (PVC) modes in patients with elective on-pump cardiac surgery procedures. We hypothesize that the postoperative inflammatory response can be reduced by the perioperative application of FCV compared to PCV.MethodsFLOWVENTIN HEARTSURG is a single-center, randomized, parallel-group trial with two intervention arms: perioperative PCV modes (n = 70, PCV group) with an individualized positive end-expiratory pressure (PEEP) and a tidal volume of 6–8 ml/kg predicted bodyweight compared to perioperative FCV (n = 70, FCV group) with an individualized PEEP and driving pressure, resulting in a liberal tidal volume. As the primary study endpoint interleukin 8 plasma level is assessed 6 h after cardiopulmonary bypass as a surrogate biomarker of systemic and pulmonary inflammation. As secondary aims clinically relevant patient outcomes are analyzed, e.g., perioperative lung function regarding oxygenation indices, postoperative pulmonary and extra-pulmonary complications, SIRS-free days as well as ICU and total inpatient stays. As additional sub-studies with an exploratory approach perioperative right ventricular function parameters are assessed by echocardiography and perioperative lung aeration by electrical impedance tomography.DiscussionCurrent paradigms regarding protective low tidal volume ventilation are consciously left in the FCV intervention group in order to reduce mechanical power as a determinant of ventilator-induced lung injury in this high-risk patient population and procedures. This approach will be compared in a randomized controlled trial with current best clinical practice PCV in FLOWVENTIN HEARTSURG.Trial registrationGerman Clinical Trials Register DRKS00018956. Registered on 12 June 2020 (Version 1), last update on 22 August 2022 (Version 4).

Perioperative Tracking of Intravenous Iron in Patients Undergoing On-Pump Cardiac Surgery: A Prospective, Single-Center Pilot Trial.

Preoperative intravenous iron administration is a frequently used patient blood management procedure. If the timeframe of intravenous iron administration before surgery is short, (1) the concentration of the intravenous iron compound might still be high in patients' plasma when undergoing surgery and (2) this iron in patients' plasma is at risk to be lost due to blood loss. The aim of the current study was, therefore, to track the iron compound ferric carboxymaltose (FCM) before, during, and after cardiac surgery requiring cardiopulmonary bypass, with an emphasis on intraoperative iron losses in shed blood and potential recovery through autologous cell salvage. Concentrations of FCM were analyzed in patients' blood using a hyphenation of liquid chromatography and inductively coupled plasma-mass spectrometry to distinguish between pharmaceutical compound FCM and serum iron. In this prospective, single-center pilot trial, 13 anemic and 10 control patients were included. Anemic patients with hemoglobin levels ≤12/13 g/dL in women and men were treated with 500 milligrams (mg) intravenous FCM 12 to 96 hours before elective on-pump cardiac surgery. Patients' blood samples were collected before surgery and at days 0, 1, 3, and 7 after surgery. One sample each was taken of the cardiopulmonary bypass, the autologous red blood cell concentrate generated by cell salvage, and the cell salvage disposal bag. Patients who had received FCM <48 hours before surgery had higher FCM serum levels (median [Q1-Q3], 52.9 [13.0-91.6]) compared to ≥48 hours (2.1 [0.7-5.1] µg/mL, P = .008). Of 500-mg FCM administered <48 hours, 327.37 (257.96-402.48) mg were incorporated compared to administration ≥48 hours with 493.60 (487.78-496.70) mg. After surgery, patients' plasma FCM concentration in the FCM <48 hours group was decreased (-27.1 [-30 to -5.9] µg/mL). Little FCM was found in the cell salvage disposal bag (<48 hours, 4.2 [3.0-25.8] µg/mL, equivalent to 29.0 [19.0-40.7] mg total; equivalent to 5.8% or 1/17th of the 500 mg FCM initially administered), almost none in the autologous red blood cell concentrate (<48 hours, 0.1 [0.0-0.43] µg/mL). The data generate the hypotheses that nearly all FCM is incorporated into iron stores with administration ≥48 hours before surgery. When FCM is given <48 hours of surgery, the majority is incorporated into iron stores by the time of surgery, although a small amount may be lost during surgical bleeding with limited recovery by cell salvage.

Comparison of Nebulized Versus Intravenous Milrinone on Reducing Pulmonary Arterial Pressure in Patients with Pulmonary Hypertension Candidate for Open-cardiac Surgery: A Double-Blind Randomized Clinical Trial.

Regardless of the cause, pulmonary hypertension can increase patient complications and mortality. This study compared the effect of nebulized versus intravenous (IV) milrinone on reducing pulmonary arterial pressure in patients with pulmonary hypertension candidates for open-cardiac surgery. This double-blind, randomized clinical trial was performed on 32 patients undergoing elective on-pump cardiac surgery during January 2021-January 2022 in the Cardiac Operating Room of Golestan Hospital, Ahvaz, Iran. Patients were randomly divided into test groups nebulize milrinone (N = 16) and IV milrinone (N = 16). The medication was administered after the cross-clamp of the aorta opening. The outcome variables included hemodynamic data, cardiac output, cardiac index, stroke volume, mean arterial pressure (MAP), central venous pressure, mean pulmonary artery pressure (mPAP), systemic vascular resistance, pulmonary vascular resistance, MAP/mPAP ratio, time until extubation, duration of hospitalization in the Intensive Care Unit (ICU), and duration of hospital stay. In the nebulized group, MAP and MAP/mPAP were significantly higher than in the IV milrinone group (P = 0.09 and P < 0.0001, respectively). The time of extubation (P = 0.001), duration of hospitalization in the ICU (P = 0.009), and duration of hospital stay (P = 0.026) in the nebulized milrinone group were significantly shorter than in the IV milrinone group. Nebulized milrinone administration before weaning off cardiopulmonary bypass (CPB) can be accelerated and facilitate weaning off CPB. Moreover, despite maintaining MAP, nebulized milrinone significantly reduces mPAP. According to the results of this study, nebulized milrinone is recommended in patients undergoing cardiac surgery with pulmonary hypertension.

A comparison of postoperative blood lactate concentrations and kinetics in cardiac surgical patients being and not being administered metformin

Aim. Early discontinuation of metformin before cardiac surgery is advised by several national societies but no hard evidence exist supporting this practice. This precaution is mostly extrapolated by data on different clinical settings. The aim of this study is to investigate the impact of preoperative metformin use on lactate concentrations and lactate clearance during the first postoperative day after cardiac surgery.Methods. Among 367 consecutive patients who underwent elective on-pump cardiac surgery from January 2019 to October 2019, 109 were diabetics, 74 of which were treated with metformin. Data on lactate concentrations and clearance during the first postoperative day were prospectively collected on arrival, H6, H12 and H24 in the ICU and compared. A subgroup analysis focusing only on diabetic patients was also performed. Repeated measures multivariate analysis of variance (MANOVA) was used to investigate the data based on group, time and their interaction effects.Results. Lactate concentrations were the same for both groups upon arrival in the ICU. Interestingly, metformin users had lower lactate concentrations than non-users on the following measurements (p = 0.003 at 6 h and p = 0.01 at 24 h). No significant interaction was found between the two groups (p = 0.76). No difference was found between the two groups in terms of lactate clearance (p = 0.53). In the subgroup analysis no difference was found between metformin users and non-users neither on lactate concentrations (p = 0.61) nor on lactate clearance (p = 0.86).Conclusions. In a post cardiac surgery ICU setting, using metformin up until the night before surgery was not associated with increased postoperative lactate concentrations or impaired lactate clearance.

The incidence of early neurological complications after on-pump cardiac surgery: a retrospective study

Background: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a significant risk for neurological complications. Reported incidence and risk factors for these complications vary significantly. Identifying risk factors could lead to preventive strategies to reduce complications and improve patient’s outcome. Objective: The study aims to assess the overall incidence and risk factors for severe early postoperative neurological complications after elective on-pump cardiac surgery. We specifically analyzed the incidence of stroke, global cerebral ischemia (GCI) and epilepsy in these patients. Methods: After getting approval from the Ethics Committee Research UZ/KU Leuven, on 14/12/2021 (s65871), we retrospectively evaluated data of 1080 adult patients after cardiac surgery with CPB between 06/2019 and 06/2021 at the University Hospitals Leuven. After exclusion of emergency procedures and patients who died before neurological evaluation, 977 patients remained for primary analysis. All data were collected from the electronic patient’s file. Primary objective was to identify the incidence of stroke, GCI and epilepsy. We defined stroke and GCI according to the American Stroke Association. Secondary endpoints were identifying independent risk-factors and assessing the impact of early neurological complications on mortality. Statistical analysis was performed using econometric and statistical modeling with python. We performed univariate logistic regression with Bonferonni correction and multivariable logistic regression with backwards elimination approach and p-value set to be &lt;0.05. Results: The overall incidence of defined neurological complications after elective on-pump cardiac surgery at our institution was 3.17% (n=31) (stroke 2.35% (n=23), epilepsy 0.61% (n=6) and GCI 0.31% (n=3)). No statistically significant risk factors for these complications were found. In secondary analysis, patients with stroke and GCI had a higher risk of in-hospital mortality (Fisher’s exact test resulted in odds ratio 7.23 with p=0.005 and odds ratio 65.17 with p=0.003 respectively) Diabetes mellitus, preoperative atrial fibrillation, and endocarditis were also significantly related to in-hospital mortality. Conclusions: The incidence of early neurological complications after elective on-pump cardiac surgery at our institution was comparable to that reported in earlier studies. No independent risk factors for these neurological complications were found. The occurrence of stroke and GCI significantly increased in-hospital mortality which emphasizes the importance of these complications, with possible mortality benefit of early recognition and management of stroke.

A S tudy of the Effectiveness of Lidocaine to Treat S evere P ulmonary Vascular Constriction induced by Protamine

Abstract Background: Protamine neutralises heparin after separation from cardiopulmonary bypass. This study aimed to evaluate the effects of lidocaine on protamine induced pulmonary vascular constriction in paediatric cardiothoracic surgery. Methods: This was a single-centre, prospective, double-blind and randomised study conducted among eighty pediatric patients with acyanotic congenital cardiac disease, scheduled for elective on-pump cardiac surgery under general anaesthesia. In the study, the participants were divided into four groups: Group NPHL- nonpulmonary hypertension with lidocaine preconditioning, group NPHS- nonpulmonary hypertension with normal saline (as placebo), group PHL- pulmonary hypertension with lidocaine preconditioning, and group PHS- pulmonary hypertension with normal saline (as placebo). Results: Pulmonary vasoconstriction occurred in 11.25% of cases after protamine administration. Both the NPHS and PHS groups exhibited an increase in mean airway pressure (Paw), Respiratory index (RI), alveolar-arterial oxygen difference (A-aDO2), pulmonary artery pressure (PAP) and decreased dynamic pulmonary compliance (Cydn) and oxygen index (OI) after protamine administration. However, these changes were not observed in the NPHL and PHL groups with lidocaine preconditioning. Plasma levels of TXB2 in the NPHS and PHS groups were higher than the NPHL and PHL groups, but 6-keto-PGF1 alpha levels were lower in the NPHS and PHS groups than in the NPHL and PHL groups. Conclusion: In congenital heart disease, repair without cardiopulmonary bypass is not possible in most cases. Prior to reversing heparin with protamine, preconditioning lidocaine reverses protamine-induced pulmonary vasoconstriction and improves lung function.

Prognostic value of suPAR and hsCRP on acute kidney injury after cardiac surgery

BackgroundAcute kidney injury (AKI) represents a serious complication following cardiac surgery. Adverse outcome after cardiac surgery has been observed in the presence of elevated levels of soluble urokinase-type plasminogen activator receptor (suPAR) and high-sensitivity C-Reactive Protein (hsCRP). The aim of study was (i) to investigate the relationship between preoperative elevated levels of suPAR and hsCRP and postoperative AKI in unselected cardiac surgery patients and (ii) to assess whether the concentration of the biomarkers reflected severity of AKI.MethodsIn a retrospective observational study, biobank blood plasma samples (n = 924) from patients admitted for elective on-pump cardiac surgery were analysed for suPAR and hsCRP levels. The relation between suPAR and hsCRP-values and AKI (any stage), defined by the KDIGO (Kidney Disease: Improving Global Outcomes) criteria, was assessed using adjusted logistic regression. Further, the association between biomarkers and severity (KDIGO 1, KDIGO 2–3 and renal replacement therapy (RRT)) was assessed using adjusted logistic regression.ResultsPostoperative AKI (any stage) was observed in 327 patients (35.4 %). A doubling of preoperative suPAR corresponded to an adjusted odds ratio (OR) for postoperative AKI (any stage) of 1.62 (95 % CI 1.26–2.09, p < 0.001). Furthermore, a doubling of suPAR had an adjusted OR of 1.50 (95 % CI 1.16–1.93, p = 0.002), 2.44 (95 % CI 1.56–3.82, p < 0.001) and 1.92 (95 % CI 1.15–3.23, p = 0.002), for KDIGO 1, KDIGO 2–3 and need for RRT, respectively. No significant association was found between elevated levels of hsCRP and any degree of AKI.ConclusionsIncreasing levels of suPAR, but not hsCRP, were associated with development and severity of AKI following on-pump cardiac surgery.

A Descriptive Study of Perioperative Hemodynamics in Open Cardiac Surgery Patients

The purpose of the present study was to describe how the perioperative hemodynamic profile before and after cardiopulmonary bypass during cardiac surgery is influenced by age and to describe the association between postoperative hemodynamics and one-year mortality. A retrospective registry-based study. University Hospital of Aarhus, Denmark. The study comprised 6,595 patients undergoing elective on-pump cardiac surgery from 2006 to 2016. Perioperative hemodynamic values were derived from computerized anesthesia and intensive care reports, including mean arterial pressure, cardiac index, and oxygenation saturation from mixed venous blood in the pulmonary artery, during the perioperative period. Perioperative hemodynamic values were stratified according to age. Logistic regression was applied to predict the crude probability of death within one year from surgery according to hemodynamic values at six hours after surgery, stratified by age and use of inotropic agents, respectively. Lower values for cardiac index and mixed venous blood in the pulmonary artery with increasing age, across all points in time in the perioperative course, were observed. Higher probability of death was associated with lower hemodynamic values in the postoperative phase, and the probability of death was modified by age and the need for inotropic agents. This is a large registry based study describing the perioperative hemodynamic profile of patients undergoing cardiac surgery and the results enhance our understanding of age-differentiated values of CI and SvO2 in this specific population.

Is Lignocaine Preconditioning Effective to Treat Severe Pulmonary Vasoconstriction Induced by Protamine During Cardiac Surgery

Protamine is a low molecular weight protein fraction (5.5-13.0 kDa) that is rich in basic arginine (67%) and lysine amino acids. They are basic polypeptides that neutralize the strongly negatively charged heparin. This study was aimed to explore the effect of lignocaine preconditioning on protamine-induced pulmonary vasoconstriction, which is used to reverse the effect of heparin during cardiac surgery. This was a prospective, single-centre, double-blind and randomised study performed among eighty paediatric patients of either sex in the age group between 1 to 12 years with acyanotic congenital heart disease, scheduled for elective on-pump cardiac surgery under general anaesthesia. The study participants were divided into four groups: Group A non-pulmonary hypertension+lignocaine preconditioning, group B- non-pulmonary hypertension+normal saline preconditioning, group C-pulmonary hypertension+lignocaine preconditioning and group D-pulmonary hypertension +normal saline preconditioning. Haemodynamic parametres, pulmonary inflammatory compounds, and pulmonary function were assessed intraoperatively at 6, 2, and 3-time points, respectively. Routine perioperative data were collected and analysed. Shapiro-Wilk test was used to test if the data were normally distributed. Continuous variables are expressed as mean ± standard deviation (SD) and compared across groups using one-way Analysis of Variance (ANOVA). Categorical variables were expressed as the number of patients together with the corresponding percentage of the total group and analyzed using chi-square tests or Fisher’s Exact test. Spearman’s correlation analysis was performed to evaluate the relationship between pulmonary haemodynamic indicators and inflammatory factors. A P-value<0.05 was considered statistically significant. Group B exhibited increased pulmonary artery pressure (PAP), Mean airway pressure (Paw), Respiratory index (RI), and alveolar-arterial oxygen difference (A-aDO ). Group D exhibited increased Paw, RI, and A-aDO and decreased dynamic pulmonary compliance (Cydn) and oxygen index (OI) after protamine administration. These changes were not observed in groups A and C. Compared with groups A and C groups, plasma thromboxane B2 (TXB2) level in groups B and D were higher, but 6-keto-prostaglandin F1a (6-keto-PGF1a) in groups B and D groups was lower. The incidence of protamine adverse reactions in groups A and C were lower than that in B and D groups respectively. The precondition of lignocaine before neutralization of heparin effectively reverses protamine-induced pulmonary vasoconstriction during cardiac surgery.

Is preoperative anxiety associated with postoperative delirium in older persons undergoing cardiac surgery? Secondary data analysis of a randomized controlled trial

BackgroundAlthough many studies have reported numerous risk factors for postoperative delirium, data are scarce about preoperative anxiety as a risk factor. The study aimed to investigate the association between preoperative anxiety and postoperative delirium in older patients undergoing cardiac surgery.MethodsSecondary data analysis of a randomized, observer-blind, controlled trial. A total of 190 patients 65 years or older and admitted to the intensive care unit and cardiac surgery unit of a university hospital scheduled for elective on-pump cardiac surgery were included. State anxiety was measured preoperatively using the Amsterdam Preoperative Anxiety and Information Scale and the Visual Analogue Scale for anxiety. Incidence of delirium was measured during the first 5 postoperative days using the Confusion Assessment Method for Intensive Care Unit (when ventilated), or the 3 Minute Diagnostic Interview for Confusion Assessment Method (when extubated) and by daily chart review.ResultsPreoperative state anxiety was reported by 31% of the patients and 41% had postoperative delirium. A multiple step logistic regression analyses revealed no association between preoperative anxiety and postoperative delirium. Significant risk factors for postoperative delirium were age (OR = 1.10, 95% CI (1.03–1.18)), activities of daily living (0.69, 95% CI (0.50–0.96)), diabetes mellitus (OR = 3.15, 95% CI (1.42–7.00)) and time on cardiopulmonary bypass (OR = 1.01, 95% CI (1.00 to 1.02)).ConclusionsNo relationship could be found between preoperative anxiety and postoperative delirium.

Prognostic Value of Soluble Urokinase-Type Plasminogen Activator Receptor and High-Sensitivity C-Reactive Protein on Postoperative Mortality in Patients Undergoing Elective On-Pump Cardiac Surgery

Elevated soluble urokinase-type plasminogen activator receptor (suPAR) and high-sensitivity C-reactive protein (hsCRP) have been associated with increased mortality in patients with cardiovascular disease. The aim of the present study was to explore the relationship between suPAR and hsCRP values and associated mortality after elective cardiac surgery. A secondary aim was to assess whether a combined risk model of European System for Cardiac Operative Risk Evaluation (EuroSCORE II), suPAR, and/or hsCRP would improve the prognostic accuracy compared with EuroSCORE II alone. Retrospective observational study. Single-center, university hospital. Adult patients admitted for elective on-pump cardiac surgery were included. Biobank blood samples were obtained from previous research projects at a tertiary heart center from 2012 to 2018. None. A total of 931 patients were included. Kaplan-Meier and Cox proportional hazard analyses were used to explore a potential association between preoperative suPAR and hsCRP values and all-cause mortality up to one year after surgery. Thirty-day mortality was predicted from suPAR, hsCRP, and EuroSCORE II by logistic regression and compared using area under the receiver operating characteristics curve and Brier scores. After adjustment for known confounders, a doubling of suPAR and hsCRP corresponded to a hazard ratio for all-cause mortality of 2.27 (95% confidence interval 1.65-3.11; p < 0.001) and 1.26 (95% confidence interval 1.07-1.49; p = 0.005), respectively. However, adding the biomarkers to EuroSCORE II did not improve prediction/discrimination with respect to 30-day mortality. Elevated preoperative levels of suPAR and hsCRP were associated with all-cause mortality in elective cardiac surgery patients. However, inclusion of biomarkers did not improve the prognostic accuracy of EuroSCORE II.

Perioperative use of renin-angiotensin system inhibitors and short-term outcomes in patients undergoing cardiac surgery

Abstract Background Controversy exists about whether preoperative angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) therapy is associated with adverse outcomes after cardiac surgery. Current guidelines stated that it is uncertain about the safety of the preoperative administration of this medications because of the potential deleterious consequences of perioperative hypotension Purpose To determine the effect of preoperative therapy with ACEi or ARB on short-term outcome after cardiac surgery. Methods Single-center prospective cohort between January 2018 and December 2019. Patients were eligible if they were submitted to elective on-pump cardiac surgery and aged ≥18 years. Patients were divided into two groups according to previous use of ACEi or ARB. All preoperative demographic, clinical, and intraoperative surgical variables were collected prospectively. Outcomes of interests were intensive care unit (ICU) mortality, incidence and duration (hours) of postoperative shock (defined as the need for intravenous vasopressors or inopressors), postoperative acute kidney injury (AKI), defined as a doubling of serum creatinine, duration of mechanical ventilation (hours) and length of stay in the ICU (days). A multivariate regression was performed for categorical outcomes and Kruskal-Wallis test for non-parametric continuous variables. Results 353 patients were evaluated in the period, 182 (51.6%) of male sex, with a mean age of 54.5 (±14.7) and STS mortality and EURO scores of 1.93 (±1.81) and 1.89 (±1.9), respectively. Coronary artery bypass grafting was the common procedure, 168 (47.6%). After multivariate regression, use of ACEi or ARB preoperatively was associated with postoperative shock: RR: 2.03, CI 1.25–3.30, p=0.004; incidence of AKI: RR: 2.84, CI 1.01–7.98, increased length of ICU stay: 4 (3–6) vs 3 (2–5), p=0.03; and increased duration of shock: 10 (0–39) vs 0 (0–24), p&amp;lt;0.01. There was no association with the duration of mechanical ventilation: 10.5 (6–20) vs 11.0 (5–18), p=0.31 or ICU mortality: 14 (7.3%) vs 16 (10.0%), p=0,44. Conclusions The use of preoperative ACEi or ARBs was associated with increased incidence and duration of postoperative shock, incidence of acute kidney injury, and durations of mechanical ventilation and ICU stay. Funding Acknowledgement Type of funding source: None

Prognostic value of supar and hs-crp on acute kidney injury following on-pump cardiac surgery

Introduction Acute kidney injury (AKI) is a serious complication after cardio-pulmonary bypass (CPB) surgery, occurring in approximately 20-30% of all patients1. Elevated preoperative levels of the proinflammatory biomarkers soluble urokinase-type plasminogen activating receptor (suPAR) and high-sensitivity C-Reactive Protein (hs-CRP) have previously been associated with occurrence of AKI in selected cardiac surgery populations. Aim of this study was to investigate the relation between suPAR and hs-CRP-concentrations and occurrence of AKI in unselected cardiac surgery patients. Methods Adult patients admitted for elective on-pump cardiac surgery, from August 2012 to June 2018, were included (n=924). Preoperative biobank blood samples were retrospectively analysed for suPAR and hs-CRP levels. We assessed the relationship between suPAR/hs-CRP-values and AKI (any stage), defined by the KDIGO (Kidney Disease: Improving Global Outcomes) criteria, using adjusted logistic regression with both biomarkers evaluated either as a continuous variables (log2-transformed) or as quartiles, with the lowest quartile serving as reference. Further, we performed adjusted logistic regression with the biomarkers as continuous variables (log2-transformed), to assess the following secondary outcomes: KDIGO 1, KDIGO 2-3, and need for renal replacement therapy (RRT). Results AKI (any stage) within 7 days was observed in 327 patients (35.4%) and 26 patients (2.8%) required RRT during hospitalisation. Severity of AKI was 265 (28.7%), 33 (3.6%) and 29 patients (3.1%), for KDIGO stage 1, 2 and 3, respectively. A doubling of suPAR and hs-CRP corresponded to an odds ratio (OR) for AKI of 1.62 (95% CI 1.26-2.09, p 3.42 ng/mL) and 29% in the lowest quartile ( Discussion Elevated preoperative levels of suPAR were associated with increased risk for AKI development evaluated by multiple AKI outcomes. Conversely, increasing hs-CRP-levels were not associated with AKI development. Preoperative assessment of suPAR-concentration may provide prognostic information for AKI development in patients undergoing elective on pump cardiac surgery.

Prognostic value of supar and hs-crp on postoperative mortality following on-pump cardiac surgery

Introduction Elevated levels of soluble urokinase-type plasminogen activating receptor (suPAR) and high-sensitivity C-Reactive Protein (hs-CRP) have in previous studies been associated with increased mortality in selected cardiac surgery populations1 2. Aim of this study was to explore the relationship between suPAR and hsCRP-values and mortality in 30 days and during 1st year from surgery in patients admitted for elective cardiac surgery. Further, to assess whether a combined risk model of EuroSCORE II, suPAR and/or hs-CRP would improve the prognostic accuracy compared to EuroSCORE II alone. Methods Adult patients admitted for elective on-pump cardiac surgery, from August 2012 to June 2018, were included (n=931). Biobank blood samples were analysed for suPAR and hs-CRP levels. Biomarkers and clinical data were explored in relation to quartiles of the two biomarkers. Kaplan-Meier and Cox proportional hazard analysis were used to explore any association between preoperative suPAR and hs-CRP-values and all-cause mortality up to 1-year after surgery. Thirty-day mortality was predicted from suPAR, hsCRP and EuroSCORE II by logistic regression and compared using area under the ROC curve and Brier scores. Results A doubling of suPAR and hsCRP corresponded to a hazard ratio (HR) for all-cause mortality of 2.27 (95% CI 1.65-3.11, p Discussion In conclusion, elevated levels of the proinflammatory biomarkers, suPAR and hs-CRP, can be used as preoperative risk assessment for all-cause mortality in a population of all-comers to elective on-pump cardiac surgery. However, combination of either or both biomarkers to EuroSCORE II did not improve the prognostic accuracy compared to EuroSCORE II alone. In future studies, preoperative assessment of proinflammatory biomarkers may be used to establish personalised rehabilitation programs and follow-up on high-risk patients.

Perioperative Open-lung Approach, Regional Ventilation, and Lung Injury in Cardiac Surgery

In the Protective Ventilation in Cardiac Surgery (PROVECS) randomized, controlled trial, an open-lung ventilation strategy did not improve postoperative respiratory outcomes after on-pump cardiac surgery. In this prespecified subanalysis, the authors aimed to assess the regional distribution of ventilation and plasma biomarkers of lung epithelial and endothelial injury produced by that strategy. Perioperative open-lung ventilation consisted of recruitment maneuvers, positive end-expiratory pressure (PEEP) = 8 cm H2O, and low-tidal volume ventilation including during cardiopulmonary bypass. Control ventilation strategy was a low-PEEP (2 cm H2O) low-tidal volume approach. Electrical impedance tomography was used serially throughout the perioperative period (n = 56) to compute the dorsal fraction of ventilation (defined as the ratio of dorsal tidal impedance variation to global tidal impedance variation). Lung injury was assessed serially using biomarkers of epithelial (soluble form of the receptor for advanced glycation end-products, sRAGE) and endothelial (angiopoietin-2) lung injury (n = 30). Eighty-six patients (age = 64 ± 12 yr; EuroSCORE II = 1.65 ± 1.57%) undergoing elective on-pump cardiac surgery were studied. Induction of general anesthesia was associated with ventral redistribution of tidal volumes and higher dorsal fraction of ventilation in the open-lung than the control strategy (0.38 ± 0.07 vs. 0.30 ± 0.10; P = 0.004). No effect of the open-lung strategy on the dorsal fraction of ventilation was noted at the end of surgery after median sternotomy closure (open-lung = 0.37 ± 0.09 vs. control = 0.34 ± 0.11; P = 0.743) or in extubated patients at postoperative day 2 (open-lung = 0.63 ± 0.18 vs. control = 0.59 ± 0.11; P > 0.999). Open-lung ventilation was associated with increased intraoperative plasma sRAGE (7,677 ± 3,097 pg/ml vs. 6,125 ± 1,400 pg/ml; P = 0.037) and had no effect on angiopoietin-2 (P > 0.999). In cardiac surgery patients, open-lung ventilation provided larger dorsal lung ventilation early during surgery without a maintained benefit as compared with controls at the end of surgery and postoperative day 2 and was associated with higher intraoperative plasma concentration of sRAGE suggesting lung overdistension.

Association between transfusion of blood products and acute kidney injury following cardiac surgery.

Acute kidney injury (AKI) is a serious complication following cardiac surgery associated with increased mortality. Red blood cell transfusion enhances the risk of developing AKI. However, the impact of other blood products on AKI is virtually unexplored. The aim of this study was to explore if transfusion of red blood cells, fresh frozen plasma and platelets alone or in combination were associated with postoperative AKI. Patients undergoing elective on-pump cardiac surgery were included (n=1960) between 2012 to 2014. Transfusion data were collected intraoperatively and until the first postoperative day. AKI was classified according to the KDIGO criteria. Data were analysed using univariate and stepwise multiple logistic regression with adjustment for clinical risk factors and complementary blood products. AKI was observed in 542 patients (27.7%). In univariate analysis and following adjustment for clinical risk factors, administration of red blood cells, freshfrozen plasma and platelets were all independently associated with KDIGO stage 2-3. Following additional adjustment for complementary blood products, only red blood cell transfusion remained significantly associated with AKI. A dose-dependent association between volume of red blood cells and degree of AKI severity was observed. Transfusion of all blood products in a dose-dependent manner increased the risk for AKI. However, in multivariate analysis combining all blood products, only red blood cell transfusion remained significantly associated with AKI development.