Journal of cardiothoracic and vascular anesthesia最新文献

Objective: Postoperative delirium remains a common complication after cardiac surgery in high-risk patients and has been associated with prolonged intensive care unit length of stay, overall morbidity, and mortality. It has been proposed that cerebral hypoperfusion is an important etiological component. In the present study, we retrospectively queried intraoperative near-infrared spectroscopy measurements of regional cerebral oxygen saturations (rSO₂) during adult cardiac surgical procedures to examine the association between rSO₂ desaturations and postoperative delirium.

Design: Retrospective observational cross-sectional study.

Setting: Single tertiary care institution.

Participants: Patients aged 18 and older undergoing cardiac or open ascending thoracic aortic surgery from January 2016 through April 2023 were eligible; 3,696 patients were included in the analysis.

Measurements and main results: As per departmental protocol, bilateral rSO₂ probes were applied to the patients' forehead before induction of anesthesia. The first 5 minutes of rSO₂ measurements were averaged and used as their baseline measurements. The total intraoperative duration of rSO₂ measurements that were either 20% below baseline or below an absolute value of 50% and the total time in either category were determined. Postoperative delirium was assessed using the Confusion Assessment Method for Intensive Care Unit during the postoperative period. Age, cerebral vascular disease, preoperative cognitive impairment, dexmedetomidine use, and durations of cardiopulmonary bypass and bispectral index values less than 40 were associated with delirium. Neither baseline rSO₂ nor any of the perioperative rSO₂ desaturation incidences or durations were associated with postoperative delirium.

Conclusions: Neither baseline nor intraoperative near-infrared spectroscopy-measured cerebral rSO₂ parameters were associated with postoperative delirium. Additional future studies are necessary to further define the value of perioperative cerebral rSO₂ monitoring for the prevention of delirium after cardiac surgery.

Objectives: To demonstrate for the first time the performance of the novel biomarker pancreatic stone protein (PSP) in predicting the occurrence of sepsis in cardiogenic shock patients requiring mechanical circulatory support. Many patients with cardiogenic shock develop sepsis and the timely identification and treatment of sepsis remains a key factor to improve outcome and avoid unnecessary antibiotics treatment.

Design: Observational study recording PSP values for 5 days or until intensive care unit discharge (whichever came first) to analyze its kinetic and evaluate a potential correlation with sepsis development.

Setting: Cardiac intensive care unit.

Participants: 32 adult patients with cardiogenic shock requiring mechanical circulatory support, 28% women with a median age of 68 years (range, 60-72 years).

Interventions: None.

Measurements and main results: The main causes of cardiogenic shock were postcardiotomy (50%) and acute myocardial infarction (25%). Patients were supported with and intra-aortic balloon pump (62.5%), Impella (6.3%), or venoarterial extracorporeal membrane oxygenation (3.1%); 28% of patients had more than 1 support device. Forty percent of patients developed sepsis during their intensive care unit stay. The overall median peak PSP reached was 389.5 ng/mL (interquartile range, 222-601 ng/mL), with a peak on day 2. The peak was higher in patients who developed sepsis (601 ng/mL [interquartile range, 556-601 ng/mL] in patients with sepsis v 257 ng/mL [interquartile range, 207-576 ng/mL] in patients without ). In these patients also daily PSP values from day 2 to 5 were higher.

Conclusions: Patients supported with mechanical circulatory support who develop sepsis present with significantly higher PSP values than those who do not develop sepsis. PSP values are generally high in this population, even in patients not developing sepsis.

Background: Enhanced recovery after surgery (ERAS) programs emerged as a strategy to reduce perioperative morbidity; however, there is currently limited evidence of their clinical efficacy. The objective of this study was to assess the impact of ERAS programs in cardiac surgery on hospital length of stay, mortality, atrial fibrillation, and quality of life.

Methods: A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, encompassing studies on ERAS programs in adult patients undergoing elective cardiac surgery. The effect size and 95% confidence interval (CI) were estimated with a random-effects model. The protocol was preregistered on Open Science Framework.

Results: Eighteen studies (published between 2016 and 2023) comprising 4,469 patients were included in the analysis, of which only one was a randomized controlled trial. The implementation of ERAS was associated with a reduction in hospital stay of 1.24 days (95% CI: -1.67, -0.82, p < 0.001, I² = 83%). No differences were observed between the groups in mortality (odds ratio: 0.65, 95% CI: 0.28, 1.48, p = 0.3, I² = 0%), nor in the incidence of atrial fibrillation (odds ratio: 0.77, 95% CI: 0.57, 1.03, p = 0.08, I² = 17%). A meta-analysis of quality of life was not feasible due to a lack of sufficient data.

Conclusions: Although ERAS programs were associated with a reduction in hospital stay and no differences in mortality or atrial fibrillation, the quality of the evidence was very low. To recommend the implementation of ERAS programs in cardiac surgery, it is necessary to have randomized studies providing evidence of its efficacy, and studies including quality of life and other patient-centered recovery criteria outcomes.

Left ventricular (LV) unloading has demonstrated favorable outcomes in patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, the optimal timing for LV unloading during VA-ECMO remains controversial. PubMed, Embase, and Cochrane were searched for studies comparing early versus bail-out LV unloading in patients undergoing VA-ECMO. We computed mean differences (MD) for continuous outcomes and risk ratios (RR) for binary outcomes, with 95% confidence intervals (95%CIs). Heterogeneity was assessed using I² statistics. Statistical analyses were performed using R version 4.2.3. Six studies comprising 1,556 participants were included in the meta-analysis, of whom 936 (60%) were referred to early LV unloading. There were no significant differences between groups in weaning from VA-ECMO (MD 1.07; 95% CI 0.86 - 1.33; p = 0.55; I² = 26%), in-hospital mortality (RR 0.95; 95% CI 0.86 - 1.05; p = 0.28; I² = 0%), 30-day mortality (RR 0.75; 95% CI 0.52 - 1.10; p = 0.14; I² = 64%), or duration of VA-ECMO (MD 0.37; 95% CI -1.57 - 2.32; p = 0.71; I² = 20%). Sepsis (RR 0.84; 95% CI 0.63 - 1.11; p = 0.22; I² = 0%), stroke (RR 0.90; 95% CI 0.52 - 1.56; p = 0.70; I² = 48%), and bridge to heart transplantation or left ventricular assist device (RR 1.20; 95% CI 0.90 - 1.62; p = 0.22; I² = 0%) also did not differ significantly between the groups. In patients undergoing VA-ECMO, early LV unloading was not associated with improved efficacy and safety outcomes when compared to the bail-out strategy for LV unloading.