Perioperative Period Of Cardiac Surgery Research Articles

Dexmedetomidine: a review of applications for cardiac surgery during perioperative period.

Cardiac surgery is associated with a high incidence of cardiovascular and other complications during the perioperative period that translate into increased mortality and prolonged hospital stays. Safe comprehensive perioperative management is required to eliminate these adverse events. Dexmedetomidine is a selective α2-adrenoreceptor agonist that has been described as an ideal medication in the perioperative period of cardiac surgery. The major clinical effects of dexmedetomidine in this perioperative period can be summarized as attenuating the hemodynamic response, cardioprotective effects, antiarrhythmic effects, sedation in the ICU setting, treatment of delirium, and procedural sedation. Although there are some side effects of dexmedetomidine, it is emerging as an effective therapeutic agent in the management of a wide range of clinical conditions with an efficacious, safe profile. The present review serves as an overview update in the diverse applications of dexmedetomidine for cardiac surgery during the perioperative period.

Goal-Directed Coagulation Management in the Perioperative Period of Cardiac Surgery

COAGULOPATHY IS A CONCERN in cardiac surgery that involves cardiopulmonary bypass as it leads to an increased risk of perioperative bleeding and transfusion. Recent advances in coagulation monitoring using point-of-care (POC) devices, and new hemostatic agents have increased interest in using a goal-directed approach to treat coagulopathy. The availability of POC devices in the perioperative setting allows coagulopathy to be assessed using rapid bedside tests. This allows physicians to adopt a goal-directed approach to targeted therapy according to the underlying hemostatic pathology.

Noninvasive Ventilation Practice in Cardiac Surgery Patients: Insights From a European Survey

Noninvasive Ventilation Practice in Cardiac Surgery Patients: Insights From a European Survey

Implantação de protocolo institucional para o uso racional de hemoderivados e seu impacto no pós-operatório de cirurgias de revascularização miocárdica

ABSTRACTObjective:Cardiac surgeries are sometimes followed by significant blood loss, and blood transfusions may be necessary. However, indiscriminant use of blood components can result in detrimental effects for the patient. We evaluated the short-term effects of implementation of a protocol for the rational use of blood products in the perioperative period of cardiac surgery.Methods:Between April and June 2011, an institutional protocol was implemented in a private hospital specializing in cardiology to encourage rational use of blood products, with the consent and collaboration of seven cardiac surgery teams. We collected clinical and demographic data on the patients. The use of blood products and clinical outcomes were analyzed during hospital stay before and after protocol implementation. The protocol consisted of an institutional campaign with an educational intervention to surgical and anesthesiology teams; the goal was to tailor blood transfusion practice according to clinical goals (anemia with hemodynamic changes and significant ventricular dysfunction) and to make routine the prescription of Ɛ-aminocaproic acid intraoperatively, which is recommended by international guidelines based on scientific evidence.Results:After three months of protocol implementation, the use of Ɛ-aminocaproic acid increased from 31% to 100%. A total of 67% of surgeries before protocol implementation required any blood transfusion, compared with 40% that required any blood transfusion after protocol implementation in subsequent months of the same year (p<0.001). There was no significant difference in clinical outcomes assessed before and after implementation of the protocol.Conclusion:The rational use of blood products associated with infusion of Ɛ-aminocaproic acid has the potential to reduce the number of blood transfusions in perioperative of cardiac surgeries, but it can affect the risk of complications.

The impact of systemic vascular resistance on the accuracy of the FloTrac/Vigileo™ system in the perioperative period of cardiac surgery: a prospective observational comparison study

FloTrac/Vigileo™ system is based on arterial pressure waveform analysis arterial pressure-based CO (APCO). Therefore, systemic vascular resistance (SVR) can influence the accuracy of APCO. The purpose of this study is to evaluate the relationship between SVR and the accuracy of APCO. We managed 50 consecutive patients in the perioperative period of cardiac surgery with FloTrac/Vigileo™ system (v. 3.02) and Swan-Ganz catheter/Vigilance™ system pulmonary artery catheter-based CO (PAC-CO) simultaneously. Continuous hemodynamic measurement using both methods was performed every 20s from the induction of anesthesia to PAC removal 4h after extubation. A total of 11,092 (intraoperative), 38,455 (postoperative, pre-extubation), and 44,235 (postoperative, post-extubation) data pairs were finally analyzed. Bland-Altman analysis revealed that in the intraoperative [postoperative pre-extubation, post-extubation] period, the bias was 0.5 [0.1, 0.0] L/min and the limits of agreement ranged from -2.4 to 3.3 [-2.2 to 2.4, -2.4 to 2.3] L/min. The percentage error was 60.3 [54.5, 48.5]%. Regression analysis of the systemic vascular resistance index (SVRI) and the bias between APCO and PAC-CO showed that the bias was positively correlated to the SVRI. Subanalysis based on SVR with Lin's concordance correlation coefficient revealed that relatively satisfactory concordance was found in the normal-SVR group (concordance correlation coefficient ρ c=0.51-0.56) regardless of vasoactive agent use. The accuracy of the FloTrac/Vigileo™ System (v. 3.02) is relatively satisfactory in the condition with normal SVR regardless of vasoactive agent use. Positive correlation between the bias and SVR can be the clue to the more effective use of FloTrac/Vigileo™ system.

Red blood cells storage duration does not influence morbidity and mortality in children transfused during the perioperative period of cardiac surgery

Red blood cells storage duration does not influence morbidity and mortality in children transfused during the perioperative period of cardiac surgery

Routine use of Corticosteroids to Prevent Inflammation Response in Cardiac Surgery

Cardiac surgery, especially if it involves cardiopulmonary bypass, is associated with a severe systemic inflammatory response. It is characterized by complement activation and initiation of coagulation, fibrinolysis and kallikrein cascades. Consecutive activation of immunoregulatory cells results in an extensive release of pro- and anti-inflammatory cytokines. This inflammatory storm is related to organ dysfunction or failure and correlates with postoperative morbidity. In order to attenuate this deleterious inflammatory response in the perioperative period alternative surgical techniques, novel extracorporeal circulation devices and immunomodulatory pharmacological strategies are in focus of contemporary research. Since decades corticosteroids have been used and studied in patients undergoing cardiac surgery. Although it could be shown that glucocorticoids seem to change the pro-inflammatory cytokine profile in a favourable manner, it still remains controversial if this effect translates into a better clinical outcome. Several clinical trials have proclaimed an association between this inflammatory response and the incidence of major complications i.e, myocardial infarction and pulmonary complications, but until now they have failed to show conclusive results. This article describes the different types and recommended dose schemes of corticosteroids in the perioperative period of cardiac surgery along with the discussion of few patents. It will comment on potential side effects and review the effect on the postoperative outcome.

心臓外科周術期におけるリハビリテーションプログラム遅延因子の検討

心臓外科周術期におけるリハビリテーションプログラム遅延因子の検討

The clinical application of dexmedetomidine in the perioperative period of cardiac surgery

Background Dexmedetomidine (DEX),a highly potent selective alpha-2 adrenergic agonist,has not only sedative,analgesic and anxiolytic effects,but also anti-sympathetic and autorhythmicity-blockade properties which might be beneficial to high-risk cardiac situations.Therefore,its application has been increasing in the perioperative period of cardiac surgery.Objective To assess the efficacy and safety of DEX application in the perioperative period of cardiac surgery and provide evidence for its clinical application.Content This review introduced the pharmacological properties of DEX on cardiovascular system,and summarized the specific proposal and safety of DEX when used in different periods of cardiac surgery.Trend DEX has been proved to possess the unique advantages through the application in the perioperative period of cardiac surgery,and will be widely used in the future. Key words: Dexmedetomidine; Cardiac surgery; Perioperative period

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet-based process with a final meeting on 28 June 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic β-blockade, early aspirin therapy, the use of pre-operative intra-aortic balloon counterpulsation, and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic β-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Prescribing Amiodarone

Although amiodarone is approved by the US Food and Drug Administration only for refractory ventricular arrhythmias, it is one of the most frequently prescribed antiarrhythmic medications in the United States. To evaluate and synthesize evidence regarding optimal use of amiodarone for various arrhythmias. Systematic search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other studies with clinical pertinence. The search was limited to human-participant, English-language reports published between 1970 and 2007. Amiodarone was searched using the terms adverse effects, atrial fibrillation, atrial flutter, congestive heart failure, electrical storm, hypertrophic cardiomyopathy, implantable cardioverter-defibrillator, surgery, ventricular arrhythmia, ventricular fibrillation, and Wolff-Parkinson-White. Bibliographies of identified articles and guidelines from official societies were reviewed for additional references. Ninety-two identified studies met inclusion criteria and were included in the review. Amiodarone may have clinical value in patients with left ventricular dysfunction and heart failure as first-line treatment for atrial fibrillation, though other agents are available. Amiodarone is useful in acute management of sustained ventricular tachyarrythmias, regardless of hemodynamic stability. The only role for prophylactic amiodarone is in the perioperative period of cardiac surgery. Amiodarone may be effective as an adjunct to implantable cardioverter-defibrillator therapy to reduce number of shocks. However, amiodarone has a number of serious adverse effects, including corneal microdeposits (>90%), optic neuropathy/neuritis (< or =1%-2%), blue-gray skin discoloration (4%-9%), photosensitivity (25%-75%), hypothyroidism (6%), hyperthyroidism (0.9%-2%), pulmonary toxicity (1%-17%), peripheral neuropathy (0.3% annually), and hepatotoxicity (elevated enzyme levels, 15%-30%; hepatitis and cirrhosis, <3% [0.6% annually]). Amiodarone should be used with close follow-up in patients who are likely to derive the most benefit, namely those with atrial fibrillation and left ventricular dysfunction, those with acute sustained ventricular arrhythmias, those about to undergo cardiac surgery, and those with implantable cardioverter-defibrillators and symptomatic shocks.

Stress doses of hydrocortisone reduce chronic stress symptoms and improve health-related quality of life in high-risk patients after cardiac surgery: A randomized study

Improvement in health-related quality of life is a major object of cardiac surgery. However, high stress exposure during the perioperative period of cardiac surgery can result in the formation of traumatic memories and symptoms of chronic stress or even posttraumatic stress disorder, which can have negative effects on health-related quality-of-life outcome. In this controlled study we examined whether exogenously administered stress doses of hydrocortisone during cardiac surgery reduce perioperative stress exposure and the long-term incidence of chronic stress symptoms and improve health-related quality of life after cardiac surgery. Thirty-six high-risk patients undergoing cardiac surgery were prospectively randomized to receive either stress doses of hydrocortisone or placebo. Of 28 available patients at 6 months after cardiac surgery, 14 had received hydrocortisone, and 14 had received placebo. Traumatic memories, chronic stress symptoms (posttraumatic stress disorder scores), and health-related quality of life were measured by using validated questionnaires. Compared with patients from the placebo group, patients from the hydrocortisone group had a significantly shorter duration of intensive care unit treatment, required lower doses of the stress hormone norepinephrine during cardiac surgery, and had significantly fewer stress symptoms and a better health-related quality of life regarding physical function, chronic pain, general health, vitality, and mental health during follow-up. The groups did not differ with regard to the number or type of intensive care unit-related traumatic memories. The use of stress doses of hydrocortisone in high-risk cardiac surgical patients reduces perioperative stress exposure, decreases chronic stress symptoms, and improves health-related quality of life at 6 months after cardiac surgery.

A peeled off and entrapped intraaortic balloon catheter in the femoral artery: an unusual complication

The intraaortic balloon is the most commonly used support device during perioperative period of cardiac surgery. A rare complication after its use is entrapment. In this case-report we present a 70-year-old man who had undergone coronary bypass and needed intraaortic balloon support early in the postoperative period with an extraordinary complication.

Behavior of inflammatory markers of myocardial injury in cardiac surgery: laboratory correlation with the clinical picture of postpericardiotomy syndrome

To verify the association of serum markers of myocardial injury, such as troponin I, creatinine kinase, and creatinine kinase isoenzyme MB, and inflammatory markers, such as tumor necrosis factor alpha (TNF-alpha), C-reactive protein, and the erythrocyte sedimentation rate in the perioperative period of cardiac surgery, with the occurrence of possible postpericardiotomy syndrome. This was a cohort study with 96 patients undergoing cardiac surgery assessed at the following 4 different time periods: the day before surgery (D0); the 3rd postoperative day (D3); between the 7th and 10th postoperative days (D7-10); and the 30th postoperative day (D30). During each period, we evaluated demographic variables (sex and age), surgical variables (type and duration, extracorporeal circulation), and serum dosages of the markers of myocardial injury and inflammatory response. Of all patients, 12 (12.5%) met the clinical criteria for a diagnosis of postpericardiotomy syndrome, and their mean age was 10.3 years lower than the age of the others (P=0.02). The results of the serum markers for tissue injury and inflammatory response were not significantly different between the 2 assessed groups. No significant difference existed regarding either surgery duration or extracorporeal circulation. The patients who met the clinical criteria for postpericardiotomy syndrome were significantly younger than the others were. Serum markers for tissue injury and inflammatory response were not different in the clinically affected group, and did not correlate with the different types and duration of surgery or with extracorporeal circulation.

Magnesium metabolism after cardiac surgery in children.

OBJECTIVE: To analyze magnesium metabolism in children after cardiac surgery. DESIGN: Prospective observational study. SETTING: Pediatric intensive care unit (PICU) of a university hospital. PATIENTS: A total of 42 children in the perioperative period of cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Determinations of serum magnesium (MgS), ultrafiltrable magnesium (MgU), intraerythrocytic magnesium, urinary magnesium, blood and urinary calcium, phosphorus, sodium, and blood and urinary creatinine were made in the operating room before surgery, at admission to the PICU, at 24 hrs, and at 3 and 5 days after surgery. The relationship with age, sex, diagnosis, type of surgery, arrhythmias, complications, length of stay in the PICU, and mortality was analyzed. MgS and MgU levels decreased after cardiac surgery (MgS before surgery, 0.74 +/- 0.09 mmol/L; MgS at admission to the PICU, 0.66 +/- 0.11 mmol/L; MgU before surgery, 0.56 +/- 0.06 mmol/L; MgU at admission to the PICU, 0.50 +/- 0.07 mmol/L; p <.0001 for both values). At admission to the PICU, 61.5% of the patients had MgS of <0.63 mmol/L, and 47.2% of the patients had an MgU of <0.46 mmol/L. MgS and MgU had increased by 24 hrs and showed further increases over the first 5 days after surgery. There were no significant changes in the intraerythrocytic magnesium levels in the postoperative period. Changes of MgS and MgU were greater after extracorporeal circulation than after closed surgery (p <.001). There was no correlation between MgS, MgU, or intraerythrocytic magnesium and other analytic and clinical parameters. No patient presented arrhythmias and none died. CONCLUSIONS: After cardiac surgery, and particularly after extracorporeal circulation surgery, children present with low MgS and MgU levels at admission to the PICU. MgS and MgU levels increase over the first 5 days after cardiac surgery. No relationship was found between magnesium levels and the postoperative course.

Autotransfusion in cardiac surgery.

There are a number of problems with allogeneic blood transfusion. Some of these problems are defined and can be quantified, such as the problem of rising cost or the risk of viral infection, but some of the problems are not well defined and it is only outcome data that point to allogeneic blood transfusion contributing to patient mortality and morbidity. Autotransfusion includes any technique in which the patient's own blood is collected, processed and stored, followed by reinfusion when circumstances dictate. In the perioperative period of cardiac surgery, a number of techniques are recognized as useful in this context. Preoperative autologous donation, with or without erythropoietin supplementation, intraoperative acute normovolaemic haemodilution, intraoperative cell salvage, postoperative cell salvage (reinfusion of shed mediastinal blood) and platelet rich plasmapheresis are all techniques which are used with more or less enthusiasm to reduce the need for an allogeneic blood transfusion. Modification of the priming technique of the cardiopulmonary bypass circuit using an autologous blood prime is included in this review even though it does not fall strictly within the definition of autotransfusion. Although autotransfusion is not the answer to every problem, there is no doubt that it should play a significant part in the strategy of blood conservation.

Changes in plasma free and sulfoconjugated catecholamines during the perioperative period of cardiac surgery: effect of continuous infusion of dopamine.

In order to elucidate the pharmacological properties of the formation of sulfoconjugated catecholamines (CAs) in human plasma, we investigated the changes in the plasma levels of free and sulfoconjugated CA during the continuous infusion of dopamine (DA; 4-6 microg/kg/min for 24 h, followed by 3-4 microg/kg/min for 48 h) in patients who had undergone cardiac surgery. The plasma level of free DA increased immediately after the start of the infusion and reached a plateau within 1 h at a level of about 2000 times the basal value. In the control patients who had received non-cardiac surgery without DA infusion, plasma-free DA increased only 5-fold after their operation. The plasma level of DA sulfate increased linearly for 24 h, to 48-fold of the basal value by DA infusion, whereas it showed only a 2-fold increase in the control patients. After 24 h, due to reduction of the infused DA dose, the level of free DA gradually decreased, whereas the level of DA sulfate remained elevated. The plasma levels of free adrenaline (Ad) and noradrenaline (NA) also increased during the DA infusion, but their levels reached a plateau within 1-2 h. Sulfoconjugated Ad and NA increased progressively until the tapering off of DA infusion. In the control patients, both free and conjugated Ad and NA showed transient increases over 12 h after surgery. These results suggest that sulfoconjugation plays a role in regulating the plasma levels of excess free CA, thereby modifying the cardiovascular effects of circulating CA. Measurement of the increase in plasma conjugated CA may be useful as an index of the increase in free CA in plasma due to the administration of an exogenous form or release of endogenous CA from the tissues.

Thoracic intravascular and extravascular fluid volumes in cardiac surgical patients.

One possible mechanism of impaired oxygenation in cardiac surgery with extracorporeal circulation (ECC) is the accumulation of extravascular lung water (EVLW). Intrathoracic blood volume (ITBV) and pulmonary blood volume (PBV) also may increase after separation from ECC, which can influence both cardiac performance and pulmonary capillary fluid filtration. This study tested whether there were any relationships between lung fluid accumulation and pulmonary gas exchange during the perioperative period of cardiac surgery and ECC. Ten patients undergoing myocardial revascularization were studied. ITBV, PBV, and EVLW were determined from the mean transit times and decay times of the dye and thermal indicator curves obtained simultaneously in the descending aorta. Gas exchange was assessed by arterial and mixed venous partial pressure of oxygen (PO2) and carbon dioxide (PCO2), and calculation of alveolo-arterial PO2 gradient (PA-aO2) and venous admixture (QVA/QT). Recordings were made after induction of anesthesia, after sternotomy, 15 min after separation from ECC, and 4 and 20 h postoperatively. After induction of anesthesia, EVLW (6.0 +/- 1.0 ml/kg, mean +/- SD), PBV (3.6 +/- 1.3 ml/kg), and ITBV (18.4 +/- 2.7 ml/kg) were within normal ranges. Oxygenation was moderately impaired, as indicated by an increased PA-aO2 (144 +/- 46 mmHg) and QVA/QT (11 +/- 4%). After separation from ECC, EVLW had increased to 9.1 +/- 2.6 ml/kg, which was accompanied by an increase of ITBV (26.0 +/- 4.4 ml/kg) and PBV (5.6 +/- 1.9 ml/kg). PAa-O2 (396 +/- 116 mmHg) and QVA/QT (29 +/- 7%) also were increased. ITBV and PBV remained increased 4 and 20 h postoperatively, but EVLW decreased to presurgery values. No correlations were found between thoracic intravascular and extravascular fluid volumes and gas exchange. Cardiac surgery with the use of ECC induces alterations of thoracic intravascular and extravascular fluid volumes. Postoperatively, increased ITBV and PBV need not be associated with higher EVLW. Thus, sufficient mechanisms protecting against lung edema formation or providing resolution of EVLW probably are maintained after ECC. Since oxygenation is impaired during and after cardiac surgery, it is concluded that mechanisms other than or in addition to changes of ITBV, PBV, and EVLW predominantly influence gas exchange.

Changes in plasma dopamine-beta-hydroxylase activity during the perioperative period of cardiac surgery: an index of sympathetic nerve activity.

To evaluate the usefulness of plasma dopamine-beta-hydroxylase (DBH) activity as an index of sympathetic nerve activity during cardiac operations, we examined the serial changes in plasma DBH activity, in relation to the plasma noradrenaline (NA) level and hemodynamic parameters, in patients who underwent cardiac surgery. The plasma DBH activity decreased significantly after cardiopulmonary bypass, and remained low during dopamine (DA) infusion until 72 h after the operation. However, recovery of the hemodynamic parameters, being the mean arterial pressure, heart rate and cardiac index, was seen as early as 1-3 h postoperatively. It was therefore assumed that the plasma DBH activity takes a long time to recover after an operation. The time-course changes in the plasma NA level were quite different from the changes in DBH activity, with an apparent negative correlation being observed between them. Thus, there is a possibility that exogenously administered DA, as well as increased plasma NA, might inhibit DBH activity during cardiac surgery. Moreover, since catecholamines are often administered upon completion of cardiac surgery, measurement of the plasma catecholamine level would be inappropriate for evaluating real sympathetic nerve activity. From the results of this study, it is surmised that measurement of the plasma DBH activity could be useful for estimating the intrinsic sympathetic nerve activity of patients who have undergone cardiac surgery.

Changes in plasma dopamine-&beta;-hydroxylase activity during the perioperative period of cardiac surgery:

Changes in plasma dopamine-&beta;-hydroxylase activity during the perioperative period of cardiac surgery: