D. van Dijk

Association between early and three month cognitive outcome after off-pump and on-pump coronary bypass surgery

Objective: To describe the association between cognitive outcome in the first postoperative week and that at three months after both off-pump and on-pump coronary bypass surgery, and to make a direct comparison of early cognitive outcome after off-pump versus on-pump surgery. Design: Randomised trial with an additional prediction study within the two randomised groups. Setting: Three centres for heart surgery in the Netherlands. Patients: 281 patients, mean age 61 years. Interventions: Participants were randomly assigned to off-pump or on-pump coronary bypass surgery. Main outcome measures: Cognitive outcome, assessed by psychologists who administered neuropsychological tests one day before and four days and three months after surgery. A logistic regression model was used to study the predictive association between early cognitive outcome, together with eight clinical variables, and cognitive outcome after three months. Results: Cognitive outcome in the first week after surgery was determined for 219 patients and was a predictor of cognitive decline after three months. This association was stronger in on-pump patients (odds ratio (OR) 5.24, p < 0.01) than in off-pump patients (OR 1.80, p  =  0.23). Early decline was present in 54 patients (49%) after off-pump surgery and 61 patients (57%) after on-pump surgery (OR 0.73, p  =  0.25). Conclusions: In patients undergoing first time coronary bypass surgery, early cognitive decline predicts cognitive outcome after three months. Early cognitive decline is not significantly influenced by the use of cardiopulmonary bypass.

Intraoperative hypotension and delirium after on-pump cardiac surgery

BACKGROUND Delirium is a common complication after cardiac surgery and may be as a result of inadequate cerebral perfusion. We studied delirium after cardiac surgery in relation to intraoperative hypotension (IOH). METHODS This observational single-centre, cohort study was nested in a randomized trial, on a single intraoperative dose of dexamethasone vs placebo during cardiac surgery. During the first four postoperative days, patients were screened for delirium based on the Confusion Assessment Method (CAM) for Intensive Care Unit on the intensive care unit, CAM on the ward, and by inspection of medical records. To combine depth and duration of IOH, we computed the area under the curve for four blood pressure thresholds. Logistic regression analyses were performed to investigate the association between IOH and the occurrence of postoperative delirium, adjusting for confounding and using a 99% confidence interval to correct for multiple testing. RESULTS Of the 734 included patients, 99 patients (13%) developed postoperative delirium. The adjusted Odds Ratio for the Mean Arterial Pressure <60 mm Hg threshold was 1.04 (99% confidence interval: 0.99-1.10) for each 1000 mm Hg(2) min(2) AUC(2) increase. IOH, as defined according to the other three definitions, was not associated with postoperative delirium either. Deep and prolonged IOH seemed to increase the risk of delirium, but this was not statistically significant. CONCLUSIONS Independent of the applied definition, IOH was not associated with the occurrence of delirium after cardiac surgery.

Association between delirium and cognitive change after cardiac surgery

Background Previous studies provide inconsistent data on whether postoperative delirium (POD) is a risk factor for postoperative cognitive decline (POCD). We thus investigated the relationship between POD and cognitive change after cardiac surgery and assessed the relationship between preoperative cognitive domain scores and POD. Methods Postoperative delirium was assessed with the Confusion Assessment Method (CAM) adapted for the intensive care unit and the conventional CAM accompanied by chart review. Cognitive function was assessed with a neuropsychological test battery before elective cardiac surgery and 1 month and 1 yr afterwards. Cognitive change was calculated using the Reliable Change Index (RCI). Multiple linear regression was used to adjust for confounding. Results Of the 184 patients who completed baseline assessment, 23 (12.5%) developed POD. At 1 month, the decline in cognitive performance was worse in patients with POD [median composite RCI -1.00, interquartile range (IQR) -1.67 to 0.28] than in patients without POD (RCI -0.04, IQR -0.70 to 0.63, P =0.02). At 1 yr, both groups showed cognitive improvement on average compared with baseline (POD patients median composite RCI 0.25, IQR -0.42 to 1.31, vs non-POD patients RCI 0.92, IQR 0.18-1.53; P =0.08). Correction for differences in age and level of education did not change the results. Patients with POD performed less well than patients without POD on the preoperative Trailmaking test part A ( P =0.03). Conclusions Postoperative delirium is independently associated with cognitive decline 1 month after surgery, but cognitive performance generally recovers in 1 yr. Patients with a predisposition to POD can be identified before surgery by worse performance in an attention task. Clinical trial registration NCT00293592.

Systemic Corticosteroids And Transition To Delirium in Critically Ill Patients

Delirium is frequent in the critically ill and is associated with long-term morbidity [1]. Currently, the key approach for delirium in the ICU is avoidance of risk factors. Systemic corticosteroids are often used in the ICU, and regularly administered in high dosages, as increasing evidence suggests potential benefits of these medications in critically ill patients [2, 3]. However, corticosteroids are proposed to be a risk factor delirium in patients with acute lung injury [4].

A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications

Background: There is a need for robust, clearly defined, patient‐relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research. Methods: A systematic literature search was conducted using MEDLINE, Web of Science, SciELO, and the Korean Journal Database. Definitions were extracted from included manuscripts. We then conducted a three‐stage Delphi consensus process to select the optimal outcome measures in terms of methodological quality and overall suitability for perioperative trials. Results: From 2358 records, the full texts of 81 manuscripts were retrieved, of which 45 met the inclusion criteria. We identified three main categories of outcome measure specific to perioperative pulmonary outcomes: (i) composite outcome measures of multiple pulmonary outcomes (27 definitions); (ii) pneumonia (12 definitions); and (iii) respiratory failure (six definitions). These were rated by the group according to suitability for routine use. The majority of definitions were given a low score, and many were imprecise, difficult to apply consistently, or both, in large patient populations. A small number of highly rated definitions were identified as appropriate for widespread use. The group then recommended four outcome measures for future use, including one new definition. Conclusions: A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.

Long-term outcomes and cost effectiveness of high-dose dexamethasone for cardiac surgery: a randomised trial

Prophylactic intra‐operative administration of dexamethasone may improve short‐term clinical outcomes in cardiac surgical patients. The purpose of this study was to evaluate long‐term clinical outcomes and cost effectiveness of dexamethasone versus placebo. Patients included in the multicentre, randomised, double‐blind, placebo‐controlled DExamethasone for Cardiac Surgery (DECS) trial were followed up for 12 months after their cardiac surgical procedure. In the DECS trial, patients received a single intra‐operative dose of dexamethasone 1 mg.kg−1 (n = 2239) or placebo (n = 2255). The effects on the incidence of major postoperative events were evaluated. Also, overall costs for the 12‐month postoperative period, and cost effectiveness, were compared between groups. Of 4494 randomised patients, 4457 patients (99%) were followed up until 12 months after surgery. There was no difference in the incidence of major postoperative events, the relative risk (95%CI) being 0.86 (0.72‐1.03); p = 0.1. Treatment with dexamethasone reduced costs per patient by £921 [€1084] (95%CI £−1672 to −137; p = 0.02), mainly through reduction of postoperative respiratory failure and duration of postoperative hospital stay. The probability of dexamethasone being cost effective compared with placebo was 97% at a threshold value of £17,000 [€20,000] per quality‐adjusted life year. We conclude that intra‐operative high‐dose dexamethasone did not have an effect on major adverse events at 12 months after cardiac surgery, but was associated with a reduction in costs. Routine dexamethasone administration is expected to be cost effective at commonly accepted threshold levels for cost effectiveness.

Non-intubated recovery from refractory cardiogenic shock on percutaneous VA-extracorporeal membrane oxygenation

We report on the use of percutaneous femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a fully awake, non-intubated and spontaneously breathing patient suffering from acute, severe and refractory cardiogenic shock due to a (sub)acute anterior myocardial infarction. Intensified heart failure therapy was closely monitored with a pulmonary artery catheter and allowed gradual weaning off the ECMO support without additional invasive measures, notably without mechanical ventilation. Neurological assessment was possible at all times and complete physical mobilisation was straightforward directly after weaning from ECMO. This limited invasive approach may encourage a more widespread use of percutaneous VA-ECMO.

Systematic review and consensus definitions for standardised endpoints in perioperative medicine: postoperative cancer outcomes

Background The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco‐anaesthesia based on a current evidence base, international consensus and expert guidance. Methods We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician–researchers was then used to refine a recommended list of endpoints. Results We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by ≥70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease‐free survival, cancer‐specific survival, and overall survival (and 5‐yr overall survival). Conclusion Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta‐analysis) of trials. It is therefore recommended that one or more of these consensus‐derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia–analgesia technique on oncological outcomes.

Awake' Extracorporeal Membrane Oxygenation Requires Adequate Lower Body Muscle Training and Mobilisation As Successful Bridge to Lung Transplant

‘Awake’ extracorporeal membrane oxygenation (ECMO) is being used increasingly as a bridge to lung transplant (LuTx) to support refractory respiratory failure as an alternative to invasive mechanical ventilation and associated immobilisation and deconditioning which are associated with poor outcome. the ideal combination of ECMO cannulation and muscle training has yet to be determined and depends largely on patient-specific needs and procedural limitations.

Intensive care unit length of stay beyond the first week and 1-year mortality - dutch single centre study in unselected critically ill patients describing long-term survival according to length of stay in conjunction with age

Increasing age and prolonged intensive care unit (ICU) length of stay (LoS) are both associated with in-hospital mortality. Especially older patients with a prolonged ICU stay are often considered to be at high risk for mortality.[1] However the effect of a prolonged ICU LoS in conjunction with age on long-term survival remained to be specified.