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[Display omitted] Despite inherent comorbidities, obese cardiac surgical patients paradoxically had shown lower morbidity and mortality, although the nature of this association is still unclear. Thus, the authors intended in this large registry-based study to investigate the impact of obesity on short- and long-term postoperative outcomes, focusing on bleeding and transfusion requirements. Retrospective registry study. Three university hospitals. A cohort of 12,330 prospectively compiled data from coronary bypass grafting patients undergoing surgery between 2007 to 2020 were retrieved from the Western Denmark Heart Registry. The parameters were analyzed to assess the association between body mass index (BMI) and the selected outcome parameters. The crude data showed a clear statistically significant association in postoperative drainage from 637 (418-1108) mL in underweight patients with BMI <18.5 kg/m2 to 427 (295-620) mL in severely obese patients with BMI ≥40 kg/m2 (p < 0.0001, Kruskal-Wallis). Further, 50.0% of patients with BMI <18.5 received an average of 451 mL/m2 in red blood cell transfusions, compared to 16.7% of patients with BMI >40 receiving 84 mL/m2. The obese groups were less often submitted to reexploration due to bleeding, and fewer received perioperative hemostatics, inotropes, and vasoconstrictors. The crude data showed increasing 30-day and 6-month mortality with lower BMI, whereas the one-year mortality showed a V-shaped pattern, but BMI had no independent impact on mortality in logistic regression analysis. Patients with high BMI may carry protection against postoperative bleeding after cardiac surgery, probably secondary to an inherent hypercoagulable state, whereas underweight patients carry a higher risk of bleeding and worse outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The impact of positive pressure ventilation extends the effect on lungs and gas exchange because the altered intra-thoracic pressure conditions influence determinants of cardiovascular function. These mechanisms are called heart-lung interactions, which conceptually can be divided into two components (1) The effect of positive airway pressure on the cardiovascular system, which may be more or less pronounced under various pathologic cardiac conditions, and (2) The effect of cyclic airway pressure swing on the cardiovascular system, which can be useful in the interpretation of the individual patient's current haemodynamic state. It is imperative for the anaesthesiologist to understand the fundamental mechanisms of heart-lung interactions, as they are a foundation for the understanding of optimal, personalised cardiovascular treatment of patients undergoing surgery in general anaesthesia. The aim of this review is thus to describe what the anaesthesiologist needs to know about heart-lung interactions. [ABSTRACT FROM AUTHOR]

Objective Adjustment in the doses of opioids has been a focus of interest for achieving better fast-track conditions in cardiac anesthesia, but relatively sparse information exists on the potential effect of psychologic and behavioral factors, such as stress, anxiety, and type of personality, on anesthesia requirements and patient turnover in the cardiac recovery unit (CRU); to the authors’ knowledge, this particular focus has not been systematically investigated. In this randomized study, the authors tested the hypothesis that low-dose sufentanil, compared with a standard dose, can improve fast-track parameters and the overall quality of recovery. Opioid requirements related to personality type, pain sensitivity, and preoperative stress and anxiety also were assessed. Design A randomized, prospective study. Participants The study comprised 60 patients scheduled for elective coronary artery bypass grafting with or without aortic valve replacement. Setting A university hospital. Interventions Patients were randomly assigned to receive either a standard dose (bolus 0.5 µg/kg) or low dose (bolus 0.25 µg/kg) of sufentanil combined with propofol. Measurements and Main Results The primary outcome variables were ventilation time and eligible time to discharge from the CRU. The secondary objective was to evaluate the relationship between opioid requirements and personality type, pain sensitivity, and preoperative stress and anxiety. The groups were comparable in selected demographics and perioperative parameters. There was no difference between groups in ventilation time (low dose: 191 [163–257] v standard dose: 205 [139–279] min; p = 0.405); eligible CRU discharge time (10.3 ± 5.0 v 10.3 ± 4.2 h; p = 0.978); or administration of postoperative morphine (25 [11-34) v 27 [10–39] g; p = 0.790). There was no difference between groups in total sufentanil administration and various preoperative psychologic and behavioral test levels nor in the time to reach bispectral index <50 during induction, except that personality type A demonstrated a longer induction time of 10 (8-12) minutes versus 6 (4-8) minutes in low-score patients. Conclusion A lower dose of sufentanil, compared with a standard dose, does not enhance fast-track conditions significantly. [ABSTRACT FROM AUTHOR]

Objective The right choice of fluid replacement still is a matter of debate. Recently, two large-scale studies on the use of hydroxyethyl starches (HES) in the intensive care setting have been published, which have caused a huge shift in the daily practice of volume therapy. These results have been applied to patients outside intensive care. The aim of this study was to evaluate the impact this change has had on the outcomes in a large population of cardiac surgery patients, with a focus on the type of colloid infusion. Design A prospective, registered, observational study, using propensity score matching. Setting Cohort study from 3 university hospitals using a common registry. Participants The study comprised 17,742 patients who were referred for cardiac surgery from 2007 to 2014. Interventions Patients were divided in groups according to perioperative fluid replacement with either crystalloids or colloids. The colloid group was further divided into HES or human albumin (HA). Analyses were based on the following 3 subsections: HES versus crystalloids, HA versus crystalloids, and HES versus HA, with use of propensity score matching or direct matching of cases. Primary outcome parameters were 30-day and 6-month mortality, new postoperative renal replacement therapy, and new cardiac ischemic events. Measurements and Main Results The groups were fully comparable in individual analyses. The use of HES had no impact on new dialysis and 30-day mortality. A Cox proportional regression analysis showed that HES had no impact on 6-month mortality and new postoperative ischemic events. When comparing HA with crystalloid use, a significantly increased risk in crude analysis was demonstrated on all outcome parameters; and when comparing HA with HES, a significantly higher risk was observed in HA patients in mortality parameters and new postoperative, but after adjustment, only the risk of new postoperative dialysis persisted. Conclusion This study underlined the difficulties in establishing hardcore outcome data, even in large cohort studies. The findings seemed to diminish the magnitude of risk when using HES in cardiac surgery patients and seriously questioned the choice of HA when a plasma expander is needed. [ABSTRACT FROM AUTHOR]

Objective Progressive cost containment has resulted in a growing interest for fast-track cardiac surgery. Ventilation time and length of stay (LOS) in the intensive care unit (ICU) are important factors in patient turnover, a more efficient use of resources, and early patient mobilization. However, LOS in ICU is not an objective measure because, in addition to medical factors, patient discharge may be guided by logistics and policy, and thus more objective measures are warranted. The authors hypothesized that remifentanil compared with sufentanil would reduce ventilation time and LOS in the ICU and that remifentanil would have beneficial effects on the overall quality of recovery. Design A randomized, prospective study. Participants Sixty patients scheduled for elective coronary artery bypass grafting with or without aortic valve replacement. Setting A university hospital. Interventions Patients were assigned randomly to receive either remifentanil or sufentanil combined with propofol. Measurements and Main Results Patients with ejection fraction<0.3, myocardial infarction within the last 4 weeks, diabetes, and severe pulmonary or arterial hypertension were excluded. The primary outcome variables were ventilation time and time to eligibility of discharge from the cardiac recovery unit. Secondary outcomes were actual LOS in the cardiac recovery unit and quality of recovery. The groups were comparable in selected demographics and perioperative parameters. There were no differences in ventilation time or eligible ICU discharge time between the groups. Remifentanil patients received more morphine than did the sufentanil patients during recovery (20 mg v 10 mg; p = 0.040). No difference was found in pharmacologic support or use of a pacemaker. Conclusion In a fast-track protocol, remifentanil did not seem to be superior to a standard moderate- to high-dose sufentanil regimen. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the addition of high thoracic epidural analgesia (HTEA) to general anesthesia in cardiac surgery patients to enhance the fast-track and improvement in outcome. Design: Retrospective cohort study of prospectively registered data using population-based healthcare databases. Participants: One thousand seven hundred thirteen consecutive patients scheduled for elective coronary artery bypass grafting, aortic valve replacement, mitral valve surgery, and combinations eligible for supplementation with epidural analgesia. One thousand sixteen patients were matched and analyzed. Setting: University hospital, single center. Intervention: To minimize bias and confounding, epidural patients were matched using EuroSCORE criteria to nonepidural in a 1:1 ratio requiring exact match on sex, age, patient factors, cardiac factors, and procedure type together with normal/moderate/poor left ventricular function, insulin-dependent diabetes, and on-pump/off-pump surgery. All together, 1,016 patients (508 each group) were identified with matching criteria. Measurements and Main Results: Outcome parameters were 30-day and 6-month mortality, postoperative dialysis, stroke, and myocardial infarction. Univariate analysis showed that epidural analgesia was associated with lower 6-month mortality (p = 0.021), lower frequency of postoperative dialysis (p = 0.029), and lower frequency of myocardial infarction (p = 0.049). No difference was seen in stroke (p = 0.341). However, adjusted odds ratio of selected perioperative variables showed that HTEA only had a positive impact on the frequency of postoperative dialysis (0.22 [0.06-0.74]). Conclusion: This large, uniquely matched single-center cohort was generated, and, subject to the listed limitations the authors concluded that supplemental HTEA to general anesthesia had a better outcome in low-risk cardiac surgery patients, with a significantly lower 6-month mortality rate compared with the control group. However, regression analysis revealed that HTEA only had an independently positive effect on the frequency of postoperative dialysis. [Copyright &y& Elsevier]

Objective: To evaluate the postoperative effect of high thoracic epidural analgesia on the time in the intensive care unit (ICU) and the quality of cardiac recovery in patients undergoing cardiac surgery. Design: A randomized prospective study. Participants: Sixty low-risk patients 65 to 80 years of age scheduled for elective coronary artery bypass graft surgery with or without aortic valve replacement. Setting: A university hospital. Interventions: Patients randomized to receive high thoracic epidural analgesia (HTEA) as a supplement to general anesthesia. Measurements and Main Results: The eligible time to discharge from the ICU and the quality of recovery were evaluated by an objective ICU scoring system. The time to eligible discharge from the ICU, the ventilation time, and the actual time in the ICU were not shorter in the HTEA group compared with patients receiving conventional general anesthesia. Patients receiving HTEA in addition to general anesthesia received less morphine postoperatively but with no consequent beneficial effect on respiration, nausea, sedation, or motor function. Conclusions: HTEA does not reduce the time in the ICU or improve the quality of recovery in the ICU. [Copyright &y& Elsevier]

Objective: The purpose of this study was to evaluate the perioperative cardioprotective effect of high thoracic epidural analgesia (HTEA), primarily expressed as an effect on cardiac performance and hemodynamics in patients undergoing cardiac surgery. Design: A randomized, prospective study. Participants: Sixty low-to-moderate risk patients between the ages of 65 and 80 years scheduled for elective coronary artery bypass graft surgery with or without aortic valve replacement. Setting: A university hospital. Intervention: Patients randomized to receive HTEA as a supplement to general anesthesia. Measurements and Main Results: Perioperative hemodynamic measurements, perioperative fluid balance, and postoperative release of cardiac enzymes were collected. The end-diastolic volume index (EDVI), the stroke volume index (overall 38 v 32 mL), the cardiac index (overall 2.35 v. 2.18 L/minute/m2), the central venous pressure, and central venous oxygenation were higher in the HTEA group. The mean arterial blood pressure was marginally lower in the HTEA group, whereas no difference was noted in the heart rate or peripheral saturation between the groups. No differences were found in the postoperative levels of troponin T and CK-MB between groups. NT-proBNP changed over time (p < 0.001) and was lower in the HTEA group (p = 0.013), with maximal values of 291 ± 265 versus 326 ± 274. Conclusions: The findings of a higher stroke volume index and central venous oxygenation without an increase in heart rate or mean arterial pressure suggest that HTEA improves cardiac performance in elderly cardiac surgery patients. [Copyright &y& Elsevier]

Abstract: Objectives: Growth hormone (GH) reduces the catabolic side effects of steroid treatment via effects on the amino-nitrogen metabolism. Ipamorelin is a synthetic peptide with GH releasing properties. We wished to study the metabolic effects of Ipamorelin and GH on selected hepatic measures of α-amino-nitrogen conversion during steroid-induced catabolism. Design: Five groups of rats were included: (1) free-fed controls (2) pair-fed controls (3) prednisolone (delcortol, 4mg×kg−1 ×day−1) (4) prednisolone and GH (1mg×kg−1 ×day−1) (5) prednisolone and Ipamorelin (0.5mg×kg−1 ×day−1). After seven days the hepatic capacity of urea-N synthesis (CUNS) was determined in parallel with measurements of liver mRNA levels of urea cycle enzymes, whole-body N-balance, and N-contents of various organs. Results: Compared to pair-fed controls, prednisolone increased CUNS (p <0.01) as well as the expression of urea cycle genes (p <0.01), and decreased N-balance (p <0.01) as well as organ N-contents (p <0.05). Compared to prednisolone treated animals, co-administration of GH reduced CUNS by 33% (p <0.01), normalized urea cycle gene expression, improved N-balance 2.5-fold, and normalized or improved organ N-contents. In prednisolone treated rats Ipamorelin reduced CUNS by 20% (p <0.05), decreased the expression of urea cycle enzymes, neutralised N-balance, and normalized or improved organ N-contents. Conclusion: Accelerated nitrogen wasting in the liver and other organs caused by prednisolone treatment was counteracted by treatment with either GH or its secretagogue Ipamorelin, though at the doses given less efficiently by the latter. This functional study of animals confirms that the GH secretagogue exerts GH related metabolic effects and may be useful in the treatment of steroid-induced catabolism. [Copyright &y& Elsevier]

Study Objective: Postoperative cognitive dysfunction (POCD) is a well-known complication after cardiac surgery and may cause permanent disabilities with severe consequences for quality of life. The objectives of this study were, first, to estimate the frequency of POCD after on-pump cardiac surgery in patients randomized to remifentanil- or sufentanil-based anesthesia and, second, to evaluate the association between POCD and quality of recovery and perioperative hemodynamics, respectively.Design: Randomized study.Setting: Postoperative cardiac recovery unit, University Hospital.Patients: Sixty patients with ischemic heart disease scheduled for elective coronary artery bypass grafting ± aortic valve replacement.Interventions and Handling: Randomized to either remifentanil or sufentanil anesthesia as basis opioid. Postoperative pain management consisted of morphine in both groups.Measurements: Cognitive functioning evaluated preoperatively and on the 1st, 4th, and 30th postoperative day using the cognitive test from the Palo Alto Veterans Affairs Hospital. Perioperative invasive hemodynamics and the quality of recovery was evaluated by means of invasive measurements and an intensive care unit discharge score.Main Results: No difference between opioids in POCD at any time. A negative correlation was found between preoperative cognitive function and POCD on the first postoperative day (r=-0.47; P=.0002). The fraction of patients with POCD on the first postoperative day was statistically greater in patients with more than 15minutes of Svo2 <60 (P=.037; χ(2) test). Among patients with postoperative ventilation time exceeding 300minutes, more patients had POCD on postoperative day 4 (P=.002).Conclusions: We could not demonstrate differences in POCD between remifentanil and sufentanil based anaesthesia, but in general, the fraction of patients with POCD seemed smaller than previously reported. We found an association between POCD and both perioperative low Svo2 and postoperative ventilation time, underlining the importance of perioperative stable hemodynamics and possible fast-track protocols with short ventilation times to attenuate POCD. [ABSTRACT FROM AUTHOR]

Background Cardiac surgery may cause a serious coagulopathy leading to increased risk of bleeding and transfusion demands. Blood bank products are commonly first line haemostatic intervention, but has been associated with hazardous side effect. Coagulation factor concentrates may be a more efficient, predictable, and potentially a safer treatment, although prospective clinical trials are needed to further explore these hypotheses. This study investigated the haemostatic potential of ex vivo supplementation of coagulation factor concentrates versus blood bank products on blood samples drawn from patients undergoing cardiac surgery. Methods 30 adults were prospectively enrolled (mean age = 63.9, females = 27%). Ex vivo haemostatic interventions (monotherapy or combinations) were performed in whole blood taken immediately after surgery and two hours postoperatively. Fresh-frozen plasma, platelets, cryoprecipitate, fibrinogen concentrate, prothrombin complex concentrate (PCC), and recombinant FVIIa (rFVIIa) were investigated. The haemostatic effect was evaluated using whole blood thromboelastometry parameters, as well as by thrombin generation. Results Immediately after surgery the compromised maximum clot firmness was corrected by monotherapy with fibrinogen or platelets or combination therapy with fibrinogen. At two hours postoperatively the coagulation profile was further deranged as illustrated by a prolonged clotting time, a reduced maximum velocity and further diminished maximum clot firmness. The thrombin lagtime was progressively prolonged and both peak thrombin and endogenous thrombin potential were compromised. No monotherapy effectively corrected all haemostatic abnormalities. The most effective combinations were: fibrinogen + rFVIIa or fibrinogen + PCC. Blood bank products were not as effective in the correction of the coagulopathy. Conclusion Coagulation factor concentrates appear to provide a more optimal haemostasis profile following cardiac surgery compared to blood bank products. [ABSTRACT FROM AUTHOR]