Balanced forced‐diuresis as a renal protective approach in cardiac surgery: Secondary outcomes of electrolyte changes

Controlling Nutritional Status (CONUT) score predicts worse outcomes in Chinese cardiac surgery patients

10.21203/rs.2.22932/v1 ◽

2020 ◽

Author(s):

Yan Yang ◽

Pei Zhang ◽

Hua Zhou ◽

Min Yang

Keyword(s):

Cardiac Surgery ◽

Postoperative Complications ◽

Nutritional Status ◽

Cox Regression ◽

Characteristic Curve ◽

Laboratory Data ◽

Prognostic Impact ◽

All Cause Mortality ◽

Secondary Outcomes ◽

Conut Score

Abstract Background & Aims: Nutritional and immunological status was assessed by the Controlling Nutritional Status (CONUT) score calculated from serum albumin, total cholesterol and total peripheral lymphocyte count. The aim of this study was to determine the prognostic impact of the CONUT score on patients underwent cardiac surgery.Methods: This is a single-center retrospective observational study in cardiac surgery patients. Baseline characteristics, comorbidities, and laboratory data were collected. The primary outcome was all-cause mortality. The secondary outcomes were postoperative complications including acute kidney injury (AKI), transient ischemic attack or stroke, reoperation for bleeding. Univariate and multivariate Cox regression were performed to investigate the association between confounding factors and outcomes. The cut-off value of CONUT score was accessed by the receiving operating characteristic curve. We used the Kaplan-Meier curve to compare the outcomes according to the cut-off CONUT score. The area under the curve (AUC) was used to test discriminative power of CONUT score and relevant clinical parameters. Results: A total of 408 patients were enrolled in this study. During a median follow-up period of 72.12 months, 28 (6.9%) patients died and 43 (10.5%) patients occurred postoperative complications. The rate of all-cause mortality and postoperative complications was higher in the high CONUT score (>3) group than in the low CONUT score group (p=0.002, p=0.02). High CONUT score (hazard ratio [HR] =2.367, 95% confidence interval [CI]=1.072 to 5.266, P=0.033) was an independent predictor of all-cause mortality. The AUC of the joint probability of CONUT score, age, and hypertension in predicting all-cause mortality was 0.744 (95% CI: 0.687–0.775). The high CONUT score was still an independent risk factor of secondary outcomes (HR=2.316, 95%CI=1.122 to 4.780, P=0.023).Conclusion: The CONUT score was independently associated with all-cause mortality and postoperative complications in patients underwent cardiac surgery.

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Combining CHA2DS2-VASc score into RCRI for prediction perioperative cardiovascular outcomes in patients undergoing non-cardiac surgery: a retrospective pilot study

BMC Anesthesiology ◽

10.1186/s12871-021-01496-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Song-Yun Chu ◽

Pei-Wen Li ◽

Fang-Fang Fan ◽

Xiao-Ning Han ◽

Lin Liu ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Cardiac Surgery ◽

Clinical Decision Making ◽

Characteristic Curve ◽

Risk Index ◽

Cardiac Complications ◽

Discriminative Ability ◽

Net Reclassification Improvement ◽

Secondary Outcomes

Abstract Background Treatment decisions in patients undergoing non-cardiac surgery are based on clinical assessment. The Revised Cardiac Risk Index (RCRI) is pragmatic and widely used but has only moderate discrimination. We aimed to test the efficacy of the CHA2DS2-VASc score and the combination of CHA2DS2-VASc and RCRI to predict perioperative risks for non-cardiac surgery. Methods This pre-specified analysis was performed in a retrospective cohort undergoing intra-abdominal surgery in our center from July 1st, 2007 to June 30th, 2008. The possible association between the baseline characteristics (as defined by CHA2DS2-VASc and RCRI) and the primary outcome of composite perioperative cardiac complications (myocardial infarction, cardiac ischemia, heart failure, arrhythmia, stroke, and/or death) and secondary outcomes of individual endpoints were explored using multivariate Logistic regression. The area under the receiver operating characteristic curve (C-statistic) was used for RCRI, CHA2DS2-VASc, and the combined models, and the net reclassification improvement (NRI) was calculated to assess the additional discriminative ability. Results Of the 1079 patients (age 57.5 ± 17.0 years), 460 (42.6%) were women. A total of 83 patients (7.7%) reached the primary endpoint. Secondary outcomes included 52 cardiac ischemic events, 40 myocardial infarction, 20 atrial fibrillation, 18 heart failure, four strokes, and 30 deaths. The endpoint events increased with the RCRI and CHA2DS2-VASc grade elevated (P < 0.05 for trend). The RCRI showed a moderate predictive ability with a C-statistics of 0.668 (95%CI 0.610–0.725) for the composite cardiac outcome. The C-statistics for the CHA2DS2-VASc was 0.765 (95% CI 0.709–0.820), indicating better performance than the RCRI (p = 0.011). Adding the CHA2DS2-VASc to the RCRI further increased the C-statistic to 0.774(95%CI 0.719–0.829), improved sensitivity, negative predictive value, and enhanced reclassification in reference to RCRI. Similar performance of the combined scores was demonstrated in the analysis of individual secondary endpoints. The best cut-off of a total of 4 scores was suggested for the combined CHA2DS2-VASc and RCRI in the prediction of the perioperative cardiac outcomes. Conclusions The CHA2DS2-VASc score significantly enhanced risk assessment for the composite perioperative cardiovascular outcome in comparison to traditional RCRI risk stratification. Incorporation of CHA2DS2-VASc scores into clinical-decision making to improve perioperative management in patients undergoing non-cardiac surgery warrants consideration.

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Safety of gelatin solutions for the priming of cardiopulmonary bypass in cardiac surgery: a systematic review and meta-analysis

Perfusion ◽

10.1177/0267659116685418 ◽

2017 ◽

Vol 32 (5) ◽

pp. 350-362 ◽

Cited By ~ 6

Author(s):

Idris Ghijselings ◽

Dirk Himpe ◽

Steffen Rex

Keyword(s):

Systematic Review ◽

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Blood Loss ◽

Meta Analysis ◽

Postoperative Bleeding ◽

Postoperative Blood Loss ◽

Transfusion Requirements ◽

Significant Difference ◽

Secondary Outcomes

This systematic review and meta-analysis was conducted to evaluate the safety of gelatin versus hydroxyethyl starches (HES) and crystalloids when used for cardiopulmonary bypass (CPB)-priming in cardiac surgery. MEDLINE (Pubmed), Embase and CENTRAL were searched. We included only randomized, controlled trials comparing CPB-priming with gelatin with either crystalloids or HES-solutions of the newest generation. The primary endpoint was the blood loss during the first 24 hours. Secondary outcomes included perioperative transfusion requirements, postoperative kidney function, postoperative ventilation times and length of stay on the intensive care unit. Sixteen studies were identified, of which only ten met the inclusion criteria, representing a total of 824 adult patients: 4 studies compared gelatin with crystalloid, and 6 studies gelatin with HES priming. Only 2 of the studies comparing HES and gelatin reported postoperative blood loss after 24 hours. No significant difference in postoperative blood loss was found when results of both studies were pooled (SMD -0.12; 95% CI: -0.49, 0.25; P=0.52). Likewise, the pooled results of 3 studies comparing gelatin and crystalloids as a priming solution could not demonstrate significant differences in postoperative bleeding after 24 hours (SMD -0.07; 95% CI: -0.40, 0.26; P=0.68). No differences regarding any of the secondary outcomes could be identified. This systematic review suggests gelatins to have a safety profile which is non-inferior to modern-generation tetrastarches or crystalloids. However, the grade of evidence is rated low owing to the poor methodological quality of the included studies, due to inconsistent outcome reporting and lack of uniform endpoint definitions.

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Reduction in acute kidney injury post cardiac surgery using balanced forced diuresis: a randomized, controlled trial

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa395 ◽

2020 ◽

Author(s):

Heyman Luckraz ◽

Ramesh Giri ◽

Benjamin Wrigley ◽

Kumaresan Nagarajan ◽

Eshan Senanayake ◽

...

Keyword(s):

At Risk ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Confidence Interval ◽

Kidney Injury ◽

Control Group ◽

Binary Logistic Regression Analysis ◽

Number Needed To Treat ◽

Forced Diuresis ◽

Patients At Risk

Abstract OBJECTIVES Our goal was to investigate the efficacy of balanced forced diuresis in reducing the rate of acute kidney injury (AKI) in cardiac surgical patients requiring cardiopulmonary bypass (CPB), using the RenalGuard® (RG) system. METHODS Patients at risk of developing AKI (history of diabetes and/or anaemia; estimated glomerular filtration rate 20–60 ml/min/1.73 m2; anticipated CPB time >120 min; log EuroSCORE > 5) were randomized to the RG system group (n = 110) or managed according to current practice (control = 110). The primary end point was the development of AKI within the first 3 postoperative days as defined by the RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease) criteria. RESULTS There were no significant differences in preoperative and intraoperative characteristics between the 2 groups. Postoperative AKI rates were significantly lower in the RG system group compared to the control group [10% (11/110) vs 20.9% (23/110); P = 0.025]. This effect persisted even after controlling for a number of potential confounders (odds ratio 2.82, 95% confidence interval 1.20–6.60; P = 0.017) when assessed by binary logistic regression analysis. The mean volumes of urine produced during surgery and within the first 24 h postoperatively were significantly higher in the RG system group (P < 0.001). There were no significant differences in the incidence of blood transfusions, atrial fibrillation and infections and in the median duration of intensive care unit stays between the groups. The number needed to treat with the RG system to prevent AKI was 9 patients (95% confidence interval 6.0–19.2). CONCLUSIONS In patients at risk for AKI who had cardiac surgery with CPB, the RS RG system significantly reduced the incidence of AKI and can be used safely and reproducibly. Larger studies are required to confirm cost benefits. Clinical trial registration number: NCT02974946

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Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery: An Update Meta-Analysis and Trial Sequential Analysis

BioMed Research International ◽

10.1155/2018/7563083 ◽

2018 ◽

Vol 2018 ◽

pp. 1-10 ◽

Cited By ~ 2

Author(s):

Benji Wang ◽

Xiaojie He ◽

Yuqiang Gong ◽

Bihuan Cheng

Keyword(s):

Atrial Fibrillation ◽

Clinical Trials ◽

Cardiac Surgery ◽

Renal Replacement Therapy ◽

Sequential Analysis ◽

Randomized Clinical Trials ◽

Postoperative Mortality ◽

Left Ventricular ◽

Trial Sequential Analysis ◽

Secondary Outcomes

Background. Recent studies suggest that levosimendan does not provide mortality benefit in patients with low cardiac output syndrome undergoing cardiac surgery. These results conflict with previous findings. The aim of the current study is to assess whether levosimendan reduces postoperative mortality in patients with impaired left ventricular function (mean EF ≤ 40%) undergoing cardiac surgery. Methods. We conducted a comprehensive search of PubMed, EMBASE, and Cochrane Library Database through November 20, 2017. Inclusion criteria were random allocation to treatment with at least one group receiving levosimendan and another group receiving placebo or other treatments and cardiac surgery patients with a left ventricular ejection fraction of 40% or less. The primary endpoint was postoperative mortality. Secondary outcomes were cardiac index, pulmonary capillary wedge pressure (PCWP), length of intensive care unit (ICU) stay, postoperative atrial fibrillation, and postoperative renal replacement therapy. We performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint. Results. Data from 2,152 patients in 15 randomized clinical trials were analyzed. Pooled results demonstrated a reduction in postoperative mortality in the levosimendan group [RR = 0.53, 95% CI (0.38–0.73), I2=0]. However, the result of TSA showed that the conclusion may be a false positive. Secondary outcomes demonstrated that PCWP, postoperative renal replacement therapy, and length of ICU stay were significantly reduced. Cardiac index was greater in the levosimendan group. No difference was found in the rate of postoperative atrial fibrillation. Conclusions. Levosimendan reduces the rate of death and other adverse outcomes in patients with low ejection fraction who were undergoing cardiac surgery, but results remain inconclusive. More large-volume randomized clinical trials (RCTs) are warranted.

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Balanced forced-diuresis compared to control as a reno-protective approach in cardiac surgery: secondary outcome of a randomized controlled trial, assessment of neutrophil gelatinase-associated lipocalin levels

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-021-01620-w ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Heyman Luckraz ◽

Ramesh Giri ◽

Benjamin Wrigley ◽

Kumaresan Nagarajan ◽

Eshan Senanayake ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Injury ◽

Secondary Outcome ◽

Control Group ◽

Neutrophil Gelatinase Associated Lipocalin ◽

Forced Diuresis ◽

Increased Risk ◽

Neutrophil Gelatinase ◽

The Impact

Abstract Background Neutrophil gelatinase-associated lipocalin (NGAL) is a recognised biomarker for acute kidney injury (AKI).This study investigated the impact of balanced forced-diuresis using RenalGuard® system (RG), in reducing acute kidney injury (AKI) rates and the associated NGAL levels (6-h post-CPB plasma level) post adult cardiac surgery with cardiopulmonary bypass (CPB). Methods Patients included in the study were at high-risk for AKI post cardiac surgery, namely history of diabetes and/or anaemia, e-GFR 20–60 ml/min/1.73 m2, Logistic EuroScore > 5, anticipated CPB time > 120 min. Patients were randomized to either RG (n = 110) or managed as per current practice (control = 110). RIFLE-defined AKI rate (based on serum creatinine level increase) within first 3 days of surgery and 6-h post CPB NGAL levels were the primary and secondary end-points. Results Pre and intra-operative characteristics between the two groups were similar (p > 0.05) including the pre-op NGAL levels, the oxygen delivery (ecDO2i) and the carbon dioxide production (ecVCO2i) during CPB. Patients in the RG group had a significantly lower post-operative RIFLE-defined AKI rate compared to control (10% (11/110) v/s 20.9% (23/110), p = 0.03). Overall, median 6-h post CPB NGAL levels in patients with AKI were significantly higher than those who did not develop AKI (211 vs 150 ng/ml, p < 0.001). Patients managed by balanced forced-diuresis had lower post-operative NGAL levels (146 vs 178 ng/ml, p = 0.09). Using previously reported NGAL cut-off level for AKI (142 ng/ml), binary logistic regression analysis confirmed a beneficial effect of the RG system, with an increased risk of AKI of 2.2 times in the control group (OR 2.2, 95% CI 1.14–4.27, p = 0.02). Conclusions Overall, the 6-h post-CPB plasma NGAL levels were significantly higher in patients who developed AKI. Patients managed with the novel approach of balanced forced-diuresis, provided by the RenalGuard® system, had a lower AKI rate and lower NGAL levels indicating a lesser degree of renal tissue injury. Trial registration ClinicalTrials.gov website, NCT02974946, https://clinicaltrials.gov/ct2/show/NCT02974946.

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Balanced forced-diuresis compared to control as a reno-protective approach in cardiac surgery: Secondary outcome of a randomized controlled trial, assessment of neutrophil gelatinase-associated lipocalin levels

10.21203/rs.3.rs-277522/v1 ◽

2021 ◽

Author(s):

Heyman Luckraz ◽

Ramesh Giri ◽

Benjamin Wrigley ◽

Kumaresan Nagarajan ◽

Eshan Senanayake ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Controlled Trial ◽

Kidney Injury ◽

Secondary Outcome ◽

Control Group ◽

Binary Logistic Regression Analysis ◽

Forced Diuresis ◽

Increased Risk ◽

The Impact

Abstract BackgroundNeutrophil gelatinase-associated lipocalin (NGAL) is a recognised biomarker for acute kidney injury (AKI).This study investigated the impact of balanced forced-diuresis using RenalGuard® system (RG), in reducing acute kidney injury (AKI) rates and the associated NGAL levels (6-hour post-CPB plasma level) post adult cardiac surgery with cardiopulmonary bypass (CPB).MethodsPatients included in the study were at high-risk for AKI post cardiac surgery, namely history of diabetes and/or anaemia, e-GFR 20–60 ml/min/1.73m2, Logistic EuroScore > 5, anticipated CPB time > 120 minutes. Patients were randomized to either RG (n = 110) or managed as per current practice (control = 110). RIFLE-defined AKI rate (based on serum creatinine level increase) within first 3 days of surgery and 6-hour post CPB NGAL levels were the primary and secondary end-points.ResultsPre & intra-operative characteristics between the two groups were similar (p > 0.05) including the pre-op NGAL levels, the oxygen delivery (ecDO2i) and the carbon dioxide production (ecVCO2i) during CPB. Patients in the RG group had a significantly lower post-operative RIFLE-defined AKI rate compared to control (10% (11/110) v/s 20.9% (23/110), p = 0.03). Overall, median 6-hour post CPB NGAL levels in patients with AKI were significantly higher than those who did not develop AKI (211 vs 150 ng/ml, p < 0.001). Patients managed by balanced forced-diuresis had lower post-operative NGAL levels (146 vs 178 ng/ml, p = 0.09). Using previously reported NGAL cut-off level for AKI (142 ng/ml), binary logistic regression analysis confirmed a beneficial effect of the RG system, with an increased risk of AKI of 2.2 times in the control group (OR 2.2, 95% CI 1.14–4.27, p = 0.02).ConclusionsOverall, the 6-hour post-CPB plasma NGAL levels were significantly higher in patients who developed AKI.Patients managed with the novel approach of balanced forced-diuresis, provided by the RenalGuard® system, had a lower AKI rate and lower NGAL levels indicating a lesser degree of renal tissue injury.Clinical Registration NumberClinicalTrials.gov website, NCT02974946, https://clinicaltrials.gov/ct2/show/NCT02974946

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Intraoperative Oxygen Concentration and Neurocognition after Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000003650 ◽

2020 ◽

Author(s):

Shahzad Shaefi ◽

Puja Shankar ◽

Ariel L. Mueller ◽

Brian P. O’Gara ◽

Kyle Spear ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Cognitive Dysfunction ◽

Cognitive Assessment ◽

Older Patients ◽

Postoperative Cognitive Dysfunction ◽

Neurocognitive Function ◽

Secondary Outcomes ◽

Fraction Of Inspired Oxygen ◽

Inspired Oxygen

Background Despite evidence suggesting detrimental effects of perioperative hyperoxia, hyperoxygenation remains commonplace in cardiac surgery. Hyperoxygenation may increase oxidative damage and neuronal injury leading to potential differences in postoperative neurocognition. Therefore, this study tested the primary hypothesis that intraoperative normoxia, as compared to hyperoxia, reduces postoperative cognitive dysfunction in older patients having cardiac surgery. Methods A randomized double-blind trial was conducted in patients aged 65 yr or older having coronary artery bypass graft surgery with cardiopulmonary bypass. A total of 100 patients were randomized to one of two intraoperative oxygen delivery strategies. Normoxic patients (n = 50) received a minimum fraction of inspired oxygen of 0.35 to maintain a Pao2 above 70 mmHg before and after cardiopulmonary bypass and between 100 and 150 mmHg during cardiopulmonary bypass. Hyperoxic patients (n = 50) received a fraction of inspired oxygen of 1.0 throughout surgery, irrespective of Pao2 levels. The primary outcome was neurocognitive function measured on postoperative day 2 using the Telephonic Montreal Cognitive Assessment. Secondary outcomes included neurocognitive function at 1, 3, and 6 months, as well as postoperative delirium, mortality, and durations of mechanical ventilation, intensive care unit stay, and hospital stay. Results The median age was 71 yr (interquartile range, 68 to 75), and the median baseline neurocognitive score was 17 (16 to 19). The median intraoperative Pao2 was 309 (285 to 352) mmHg in the hyperoxia group and 153 (133 to 168) mmHg in the normoxia group (P < 0.001). The median Telephonic Montreal Cognitive Assessment score on postoperative day 2 was 18 (16 to 20) in the hyperoxia group and 18 (14 to 20) in the normoxia group (P = 0.42). Neurocognitive function at 1, 3, and 6 months, as well as secondary outcomes, were not statistically different between groups. Conclusions In this randomized controlled trial, intraoperative normoxia did not reduce postoperative cognitive dysfunction when compared to intraoperative hyperoxia in older patients having cardiac surgery. Although the optimal intraoperative oxygenation strategy remains uncertain, the results indicate that intraoperative hyperoxia does not worsen postoperative cognition after cardiac surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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