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Volatile anesthetics reduce mortality in cardiac surgery.

OBJECTIVES A recent meta-analysis suggested that volatile anesthetics reduce postoperative mortality after cardiac surgery. Nonetheless, whether volatile anesthetics improve the outcome of cardiac surgical patients is still a matter of debate. The authors investigated whether the use of volatile anesthetics reduces mortality in cardiac surgery. DESIGN, SETTING, AND INTERVENTIONS: A longitudinal study of 34,310 coronary artery bypass graft interventions performed in Italy estimated the risk-adjusted mortality ratio for each center. A survey was conducted among these centers to investigate whether the use of volatile anesthetics showed a correlation with mortality. MEASUREMENTS AND MAIN RESULTS All 64 eligible centers provided the required data. The median unadjusted 30-day mortality among participating centers was 2.2% (0.3-8.8), whereas the median risk-adjusted 30-day mortality was 1.8% (0.1-7.2). Risk-adjusted analysis showed that the use of volatile anesthetics was associated with a significantly lower rate of risk-adjusted 30-day mortality (beta = -1.172 [-2.259, -0.085], R(2) = 0.070, p = 0.035). Dichotomization into centers using volatile anesthetics in at least 25% of their cases or in less than 25% yielded even more statistically significant results (p = 0.003). Furthermore, a longer use of volatile anesthetics was associated with a significantly lower death rate (p = 0.022); and exploring the impact of the specific volatile anesthetic agent, the use of isoflurane was associated with significant reductions in risk-adjusted mortality rates (p = 0.039). CONCLUSIONS This survey among 64 Italian centers shows that risk-adjusted mortality may be reduced by the use of volatile agents in patients undergoing coronary artery bypass graft surgery.

Esmolol reduces perioperative ischemia in noncardiac surgery: a meta-analysis of randomized controlled studies.

OBJECTIVE Literature increasingly has suggested how beta-blockers could be associated with reductions of mortality and morbidity in noncardiac surgery. Recently, the POISE trial showed that beta-blockers could be harmful in the perioperative period. The authors performed a meta-analysis to evaluate the clinical effects of esmolol in noncardiac surgery. DESIGN Meta-analysis. SETTING Hospitals. PARTICIPANTS A total of 1765 patients from 32 randomized trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three investigators independently searched BioMedCentral and PubMed. Inclusion criteria were random allocation to treatment and comparison of esmolol versus placebo, other drugs, or standard of care in noncardiac surgery. Exclusion criteria were duplicate publications, nonhuman experimental studies, and no data on clinical outcomes. The use of esmolol was associated with a significant reduction of myocardial ischemia episodes (5/283 [1.76%] in the esmolol group v 16/265 [6.03%] in the control arm, odds ratio [OR] = 0.16 [0.05-0.54], p = 0.003). The authors did not observe significant differences regarding episodes of arrhythmias (8/236 [3.38%] v 22/309 [7.11%], OR = 0.52 [0.23-1.18], p = 0.12) and in the incidence of myocardial infarction (0/148 [0%] v 1/169 [0.59%], OR = 0.23 [0.01-6.09], p = 0.38). Esmolol-treated patients did not experience more episodes of hypotension (17/384 [4.42%] v 38/439 [8.65%], OR = 0.41 [0.22-0.79], p = 0.17) and bradycardia (25/342 [7.30%] v 17/406 [4.18%], OR = 1.42 [0.74-2.74], p = 0.42). CONCLUSIONS Esmolol seemed to reduce the incidence of myocardial ischemia in noncardiac surgery without increasing the episodes of hypotension and bradycardia. Large randomized trials are necessary to confirm these promising results.

Additive Effect on Survival of Anaesthetic Cardiac Protection and Remote Ischemic Preconditioning in Cardiac Surgery: A Bayesian Network Meta-Analysis of Randomized Trials

Introduction Cardioprotective properties of volatile agents and of remote ischemic preconditioning have survival effects in patients undergoing cardiac surgery. We performed a Bayesian network meta-analysis to confirm the beneficial effects of these strategies on survival in cardiac surgery, to evaluate which is the best strategy and if these strategies have additive or competitive effects. Methods Pertinent studies were independently searched in BioMedCentral, MEDLINE/PubMed, Embase, and the Cochrane Central Register (updated November 2013). A Bayesian network meta-analysis was performed. Four groups of patients were compared: total intravenous anesthesia (with or without remote ischemic preconditioning) and an anesthesia plan including volatile agents (with or without remote ischemic preconditioning). Mortality was the main investigated outcome. Results We identified 55 randomized trials published between 1991 and 2013 and including 6,921 patients undergoing cardiac surgery. The use of volatile agents (posterior mean of odds ratio = 0.50, 95% CrI 0.28–0.91) and the combination of volatile agents with remote preconditioning (posterior mean of odds ratio = 0.15, 95% CrI 0.04–0.55) were associated with a reduction in mortality when compared to total intravenous anesthesia. Posterior distribution of the probability of each treatment to be the best one, showed that the association of volatile anesthetic and remote ischemic preconditioning is the best treatment to improve short- and long-term survival after cardiac surgery, suggesting an additive effect of these two strategies. Conclusions In patients undergoing cardiac surgery, the use of volatile anesthetics and the combination of volatile agents with remote preconditioning reduce mortality when compared to TIVA and have additive effects. It is necessary to confirm these results with large, multicenter, randomized, double-blinded trials comparing these different strategies in cardiac and non-cardiac surgery, to establish which volatile agent is more protective than the others and how to best apply remote ischemic preconditioning.

Dexmedetomidine vs midazolam as preanesthetic medication in children: a meta‐analysis of randomized controlled trials

The preoperative period is a stressing occurrence for most people undergoing surgery, in particular children. Approximately 50–75% of children undergoing surgery develop anxiety which is associated with distress on emergence from anesthesia and with later postoperative behavioral problems. Premedication, commonly performed with benzodiazepines, reduces preoperative anxiety, facilitates separation from parents, and promotes acceptance of mask induction. Dexmedetomidine is a highly selective α2‐agonist with sedative and analgesic properties. A meta‐analysis of all randomized controlled trials (RCTs) on dexmedetomidine versus midazolam was performed to evaluate its efficacy in improving perioperative sedation and analgesia, and in reducing postoperative agitation when used as a preanesthetic medication in children.

Sevoflurane vs. propofol in patients with coronary disease undergoing mitral surgery: a randomised study

Myocardial ischemic damage is reduced by volatile anaesthetics in patients undergoing low‐risk coronary artery bypass graft surgery; few and discordant results exist in other settings. We therefore performed a randomised controlled trial (sevoflurane vs. propofol) to compare cardiac troponin release in patients with coronary disease undergoing mitral surgery.

A survey on the use of intra-aortic balloon pump in cardiac surgery

Intra-aortic balloon pump (IABP) is an established tool in the management of cardiac dysfunction in cardiac surgery. The best timing for IABP weaning is unknown and varies greatly among cardiac centers. The authors investigated the differences in IABP management among 66 cardiac surgery centers performing 40,675 cardiac surgery procedures in the 12-month study period. The centers were contacted through email, telephone, or in person interview. IABP management was very heterogeneous in this survey: In 43% centers it was routinely removed on the first postoperative day, and in 34% on the second postoperative day. In 50% centers, it was routinely removed after extubation of the patients whereas in 15% centers it was removed while the patients were sedated and mechanically ventilated. In 66% centers, patients were routinely receiving pharmacological inotropic support at the time of removal of IABP. The practice of decreasing IABP support was also heterogeneous: 57% centers weaned by reducing the ratio of beat assistance whereas 34% centers weaned by reducing balloon volume. We conclude that the management of IABP is heterogeneous and there is a need for large prospective studies on the management of IABP in cardiac surgery.