Giulia Maj

Fenoldopam Reduces the Need for Renal Replacement Therapy and In-Hospital Death in Cardiovascular Surgery: A Meta-Analysis

OBJECTIVE Acute renal failure is a common and threatening complication in patients undergoing cardiovascular surgery. To determine the efficacy of fenoldopam in the prevention of acute renal failure, the authors performed a systematic review of randomized, controlled trials and propensity-matched studies in patients undergoing cardiovascular surgery. DESIGN Meta-analysis. SETTING Hospitals. PARTICIPANTS A total of 1,059 patients from 13 randomized and case-matched studies were included in the analysis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Google Scholar, PubMed, and scientific sessions were searched (updated November 2006). Authors and external experts were contacted. Four unblinded reviewers selected controlled trials that used fenoldopam in the prevention or treatment of acute renal failure in cardiovascular surgery. Four reviewers independently abstracted patient data, treatment characteristics, and outcomes. Pooled estimates showed that fenoldopam consistently and significantly reduced the need for renal replacement therapy (odds ratio = 0.37 [0.23-0.59], p < 0.001) and in-hospital death (odds ratio = 0.46 [0.29-0.75], p = 0.01). These benefits were associated with shorter intensive care unit stay (weighted mean difference [WMD] = -0.93 days [-1.27; -0.58], p = 0.002). Sensitivity analyses, tests for small study bias, and heterogeneity assessment further confirmed the main analysis. CONCLUSIONS This meta-analysis provides evidence that fenoldopam may confer significant benefits in preventing renal replacement therapy and reducing mortality in patients undergoing cardiovascular surgery.

Desmopressin reduces transfusion needs after surgery: a meta-analysis of randomized clinical trials.

Background:Perioperative pathologic microvascular bleeding is associated with increased morbidity and mortality and could be reduced by hemostatic drugs. At the same time, safety concerns regarding existing hemostatic agents include excess mortality. Numerous trials investigating desmopressin have lacked power to detect a beneficial effect on transfusion of blood products. The authors performed a meta-analysis of 38 randomized, placebo-controlled trials (2,488 patients) investigating desmopressin in surgery and indicating at least perioperative blood loss or transfusion of blood products. Methods:Pertinent studies were searched in BioMed Central, CENTRAL, and PubMed (updated May 1, 2008). Further hand or computerized searches involved recent (2003–2008) conference proceedings. Results:In most of the included studies, 0.3 &mgr;g/kg desmopressin was used prophylactically over a 15- to 30-min period. In comparison with placebo, desmopressin was associated with reduced requirements of blood product transfusion (standardized mean difference = −0.29 [−0.52 to −0.06] units per patient; P = 0.01), which were more pronounced in the subgroup of noncardiac surgery and were without a statistically significant increase in thromboembolic adverse events (57/1,002 = 5.7% in the desmopressin group vs. 45/979 = 4.6% in the placebo group; P = 0.3). Conclusions:Desmopressin slightly reduced blood loss (almost 80 ml per patient) and transfusion requirements (almost 0.3 units per patient) in surgical patients, without reduction in the proportion of patients who received transfusions. This meta-analysis suggests the importance of further large, randomized controlled studies using desmopressin in patients with or at risk of perioperative pathologic microvascular bleeding.

Anesthetic Management of Percutaneous Aortic Valve Implantation: Focus on Challenges Encountered and Proposed Solutions

OBJECTIVE To describe 6 months of experience in the anesthetic management of percutaneous aortic valve implantation. DESIGN An observational, cohort study. SETTING A university hospital. PARTICIPANTS Eighteen high-risk patients with relative contraindications to surgical valve replacement (78 +/- 8.7 years, logistic EuroSCORE 26 +/- 19.1). INTERVENTION An Edwards/Sapien Aortic Bioprosthesis (Edwards Lifesciences LLC, Irvine, CA) was implanted in patients with severe symptomatic aortic stenosis who underwent percutaneous retrograde aortic valve implantation without cardiopulmonary bypass. The procedure was performed using general anesthesia (15 patients) or sedation (3 patients). MEASUREMENTS AND MAIN RESULTS The valve was successfully implanted in all patients. One patient had prolonged ventricular fibrillation that required advanced cardiopulmonary resuscitation, endotracheal intubation, and placement of an intra-aortic balloon pump. Six patients had vascular access site complications managed either percutaneously or surgically. Five patients were extubated in the catheterization laboratory. All patients were transferred to the intensive care unit for monitoring, and all but one were discharged to an intermediate care unit within 24 hours. Early postoperative complications included acute renal failure (1 patient), arrhythmias (1 atrial fibrillation and 1 transient heart block), and stroke (1 patient). One patient died 58 days after the procedure for noncardiac reasons. CONCLUSIONS Transcatheter aortic valve implantation is possible in selected high-risk patients. Anesthesiologists must be aware of current technology in order to have an active role in patient selection, to develop monitoring and standards of care in the cardiac catheterization laboratory, and to plan postoperative management.

Impact of impedance threshold devices on cardiopulmonary resuscitation: A systematic review and meta-analysis of randomized controlled studies

Objectives:Vital organ hypoperfusion significantly contributes to the dismal survival rates observed with manual cardiopulmonary resuscitation after cardiac arrest. The impedance threshold device is a valve which reduces air entry into lungs during chest recoil between chest compressions, producing a potentially beneficial decrease in intrathoracic pressure and thus increasing venous return to the heart. This review provides an update on the impedance threshold device and underlines its effect on short-term survival. Data Source:MedCentral, CENTRAL, PubMed, and conference proceedings were searched (updated March 27, 2007). Authors and external experts were contacted. Study Selections:Three unblinded reviewers selected randomized trials using an impedance threshold device in cardiopulmonary resuscitation of nontraumatic out-of-hospital cardiac arrests. Four reviewers independently abstracted patient, treatment and outcome data. Data Extraction:A total of 833 patients from five high quality randomized studies were included in the analysis. Data Synthesis:Pooled estimates showed that the impedance threshold device consistently and significantly improved return to spontaneous circulation (202/438 [46%] for impedance threshold device group vs. 159/445 [36%] for control, relative risk [RR] = 1.29 [1.10–1.51], p = .002), early survival (139/428 [32%] vs. 97/433 [22%], RR = 1.45 [1.16–1.80], p = .0009) and favorable neurologic outcome (39/307 [13%] vs. 18/293 [6%], RR = 2.35 [1.30–4.24], p = .004) with no effect on favorable neurologic outcome in survivors (39/60 [65%] vs. 18/44 [41%]) nor an improved survival at the longest available follow up (35/428 [8.2%] vs. 24/433 [5.5%]). Conclusions:This meta-analysis of randomized controlled studies suggests that the impedance threshold device improves early outcome in patients with out-of-hospital cardiac arrest undergoing cardiopulmonary resuscitation.

Cardiac Index Validation Using the Pressure Recording Analytic Method in Unstable Patients

OBJECTIVE The authors investigated the accuracy and precision of the pressure recording analytic method (PRAM) in cardiac index measurement compared with thermodilution in unstable patients, a setting in which minimally invasive monitoring devices often fail. DESIGN Criterion standard. SETTING Intensive care unit. PATIENTS Thirty-two consecutive patients with low cardiac output syndrome treated with an intra-aortic balloon pump and/or high doses of inotropic drugs but without atrial fibrillation were studied after cardiac surgery. INTERVENTIONS None. Pulmonary and radial artery catheters were already in situ for clinical reasons. MEASUREMENTS AND MAIN RESULTS Four patients (12.5%) were excluded from the study because of artifacts caused by under- or overdamping of the arterial pressure monitoring system. The authors performed 3 injections of the thermal indicator in 5 minutes through the pulmonary artery catheter. Mean cardiac index values of 12 consecutive beats were considered for the PRAM. A significant correlation was found between the cardiac index assessed by thermodilution and PRAM (r = 0.72, p < 0.001). The mean bias between the 2 techniques was 0.072 +/- 0.41 L/min/m(2) with lower and upper 95% limits of confidence of -0.089 and 0.233 L/min/m(2), respectively. The percentage error was 30%. Sufficient agreement between the two techniques was evidenced by the Bland-Altman plot with only two points above the limits of agreement. CONCLUSIONS This study showed that PRAM, a minimally invasive method for cardiac index assessment, is clinically useful even in unstable patients such as those receiving intra-aortic balloon pump and/or ongoing high doses of a inotropic drugs because of a low cardiac output syndrome but without atrial fibrillation.

Bioline® heparin-coated ECMO with bivalirudin anticoagulation in a patient with acute heparin-induced thrombocytopenia: the immune reaction appeared to continue unabated

Heparin-induced thrombocytopenia (HIT) is a serious, antibody-mediated complication of heparin which significantly confers risks of thrombosis and devastating outcomes. Once diagnosed, it requires immediate cessation of heparin and therapy with an alternative anticoagulant. No data are available in the literature on the pathophysiology and clinical implications of performing prolonged extracorporeal membrane oxygenation with a heparin-coated system in a patient with acute HIT treated with bivalirudin.

Cardiac Protection With Volatile Anesthetics in Stenting Procedures

OBJECTIVE Myocardial ischemic damage is reduced by volatile anesthetics in patients undergoing coronary artery bypass graft surgery. The authors tested the hypothesis that low-dose sevoflurane could decrease perioperative myocardial damage, as measured by cTnI release, when compared with placebo, in patients undergoing interventional cardiology procedures. DESIGN A single-blind, randomized controlled trial. SETTING A university hospital. PARTICIPANTS Thirty patients undergoing stenting procedures (May 2005) were included in the present study. INTERVENTIONS The authors randomly assigned 16 patients to breathe sevoflurane (expired end-tidal concentration 1%) and 14 patients to breathe a placebo oxygen/air mix before stenting procedures. MEASUREMENTS AND MAIN RESULTS Postprocedural cardiac troponin I release was measured as a marker of myocardial necrosis. Sixteen patients had detectable cardiac troponin I levels after stenting procedures, with no difference between groups: 10 in the sevoflurane group (16 patients) versus 6 in the placebo group (14 patients) (p = 0.3). No difference in the amount of postprocedural median (interquartile range) cardiac troponin I release was noted between the sevoflurane group, 0.15 (0-4.73) ng/mL, and the placebo group, 0.14 (0-0.87) ng/mL (p = 0.4). CONCLUSIONS Myocardial damage measured by cardiac troponin release was not reduced by the volatile anesthetic sevoflurane during interventional cardiology procedures in this study.

Treatment of heparin-induced thrombocytopenia after cardiac surgery: Preliminary experience with fondaparinux

Heparin-induced thrombocytopenia (HIT) is an immunemediated prothrombotic disorder that is often encountered after cardiac surgery. The appropriate alternative anticoagulant to be used in this setting is not univocal, especially for the coexistence of renal failure and high bleeding risk. Fondaparinux is a factor Xa inhibitor via the action of antithrombin but devoid of antifactor II (thrombin) activity. It is modeled after a critical heparin pentasaccharide sequence; although the drug is identical in structure to the pentasaccharide domain found in heparin, it is too small to be recognized by the majority of heparin-reactive antibodies. We describe our early experience with fondaparinux in the management of HIT in critically ill patients after cardiac surgery.

Diagnosis of infection in patients undergoing extracorporeal membrane oxygenation: A case-control study

OBJECTIVE Diagnosis of infection in patients receiving extracorporeal membrane oxygenation is challenging in clinical practice but represents a crucial aspect of the upgrading of therapeutic options. The aim of this study was to analyze the role of C-reactive protein and procalcitonin in the diagnosis of infection in patients requiring extracorporeal membrane oxygenation and to assess the difference between venovenous and venoarterial extracorporeal membrane oxygenation settings. METHODS A case-control study was performed on 27 patients. Serum values of procalcitonin and C-reactive protein were analyzed according to the presence of infection. RESULTS Forty-eight percent of patients had infection. Gram-negative bacteria were the predominant pathogens, and Candida albicans was the most frequent isolated microorganism. Procalcitonin had an area under the curve of 0.681 (P = .0062) for the diagnosis of infection in the venoarterial extracorporeal membrane oxygenation group but failed to discriminate infection in the venovenous extracorporeal membrane oxygenation group (P = .14). The area under the curve of C-reactive protein was 0.707 (P < .001) in all patients receiving extracorporeal membrane oxygenation. In patients receiving venoarterial extracorporeal membrane oxygenation, procalcitonin had good accuracy with 1.89 ng/mL as the cutoff (sensitivity = 87.8%, specificity = 50%) and C-reactive protein with 97.70 mg/L as the cutoff (sensitivity = 85.3%, specificity = 41.6%). The procalcitonin and C-reactive protein combined assay had a sensitivity of 87.2% and specificity of 25.9%. Four variables were identified as statistically significant predictors of infection: procalcitonin and C-reactive protein combined assay (odds ratio, 1.184; P < .001), age (odds ratio, 0.980; P < .001), presence of infection before extracorporeal membrane oxygenation implantation (odds ratio, 1.782; P < .001), and duration of extracorporeal membrane oxygenation support (odds ratio, 1.056; P < .001). CONCLUSIONS Traditional and emerging inflammatory biomarkers, especially if compounded in the procalcitonin and C-reactive protein combined assay, can aid in the diagnosis of infection in patients undergoing venoarterial extracorporeal membrane oxygenation.

Cardiac index assessment by the pressure recording analytic method in unstable patients with atrial fibrillation.

OBJECTIVE Most-Care (powered by the pressure-recording analytic method [PRAM]; Vytech HealthTM, Padova, Italy) is a minimally invasive cardiac output monitoring. This system already has been studied and validated in cardiac surgery and in children. It already showed a correlation with thermodilution methods in hemodynamically unstable patients. The purpose of this study was to confirm the reliability of cardiac index determinations by Most-Care in unstable patients with atrial fibrillation. DESIGN A prospective study. SETTING A teaching hospital. PARTICIPANTS Forty-nine patients. INTERVENTIONS Simultaneous cardiac index measurements by bolus thermodilution and by PRAM from a standard arterial access (radial and femoral) were obtained. The thermodilution cardiac index was calculated as the mean of 3 separate measurements. Because PRAM is a beat-to-beat monitoring system, the mean cardiac index of 12 consecutive beats was considered for the analysis. Correlations were calculated and differences compared by Bland-Altman analysis. MEASUREMENTS Eight patients were excluded because the signal was altered by the arterial catheter resonance so that the study described the remaining 41 patients. The overall estimates of cardiac index measured by PRAM did not show agreement with the reference cardiac index by thermodilution (mean difference = 0.136 L/min/m(2) [0,43 L/min/m(2)-0.15 L/min/m(2)], with an upper limit of agreement of 1.94 L/min/m(2) and a lower limit of agreement of -1.665 L/min/m(2), respectively). The median (interquartile) value of cardiac index assessed by thermodilution was 2.42 L/min/m(2) (2.21-2.98 L/min/m(2)), and by PRAM it was 2.48 L/min/m(2) (1.80-3.00 L/min/m(2), p = 0.6). CONCLUSIONS The authors concluded that PRAM did not compare well with thermodilution in unstable patients with atrial fibrillation.