Erector spinae plane block for minimally invasive mitral valve surgery: a double-blind, prospective, randomised placebo-controlled trial—a study protocol

Introduction In the context of enhanced recovery after cardiac surgery, surgical techniques for mitral valve surgery have witnessed substantial modifications, from approaching the heart using open approaches with traditional sternotomy to thoracoscopic access via minithoracotomy. After cardiac surgery, acute postoperative pain is frequent and caused by surgical incision and retraction. Perioperative analgesia in cardiac surgery still relies mainly on opioids. Although neuraxial techniques could be a valuable non-opioid-based analgesia regimen, they can be associated with devastating complications in situations with (iatrogenic) coagulation abnormalities. Only two randomised clinical trials describe the erector spinae plane (ESP) block to provide sufficient postoperative analgesia following cardiac surgery with median sternotomy. Regarding postoperative analgesia after cardiac surgery with a minithoracotomy approach, adequately designed trials are still lacking. We, therefore, designed a double-blind, placebo-controlled trial to prove the hypothesis that the ESP block reduces opioid consumption in patients undergoing minimally invasive mitral valve surgery (MIMVS).Methods and analysis Sixty-four patients undergoing MIMVS will be included in this double-blind, prospective, placebo-controlled trial. Patients will be randomised to receive an ESP block with a catheter with either intermittent ropivacaine 0.5% (ropi group) or normal saline 0.9% (placebo group). Both groups will receive patient-controlled intravenous analgesia with morphine following extubation. Primary endpoint is the 24-hour cumulative morphine consumption after extubation. Multiple secondary endpoints will be evaluated.Ethics and dissemination The study is approved by the ethics committee of the University Hospitals Leuven, the Clinical Trials Centre of the University Hospitals Leuven and the ‘Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten’. Dissemination of the study results will be via scientific papers.Trial registration number EudraCT identifier: 2019-001125-27

The role of intravenous lidocaine in modern anesthesia

status: publishe

PECTORAL NERVE BLOCK FOR MASTECTOMIES: WORTH THE EFFORT?

status: publishe

Is preoperative anxiety associated with postoperative delirium in older persons undergoing cardiac surgery? Secondary data analysis of a randomized controlled trial

BACKGROUND: Although many studies have reported numerous risk factors for postoperative delirium, data are scarce about preoperative anxiety as a risk factor. The study aimed to investigate the association between preoperative anxiety and postoperative delirium in older patients undergoing cardiac surgery. METHODS: Secondary data analysis of a randomized, observer-blind, controlled trial. A total of 190 patients 65 years or older and admitted to the intensive care unit and cardiac surgery unit of a university hospital scheduled for elective on-pump cardiac surgery were included. State anxiety was measured preoperatively using the Amsterdam Preoperative Anxiety and Information Scale and the Visual Analogue Scale for anxiety. Incidence of delirium was measured during the first 5 postoperative days using the Confusion Assessment Method for Intensive Care Unit (when ventilated), or the 3 Minute Diagnostic Interview for Confusion Assessment Method (when extubated) and by daily chart review. RESULTS: Preoperative state anxiety was reported by 31% of the patients and 41% had postoperative delirium. A multiple step logistic regression analyses revealed no association between preoperative anxiety and postoperative delirium. Significant risk factors for postoperative delirium were age (OR = 1.10, 95% CI (1.03-1.18)), activities of daily living (0.69, 95% CI (0.50-0.96)), diabetes mellitus (OR = 3.15, 95% CI (1.42-7.00)) and time on cardiopulmonary bypass (OR = 1.01, 95% CI (1.00 to 1.02)). CONCLUSIONS: No relationship could be found between preoperative anxiety and postoperative delirium.status: publishe

S100-beta as a prognostic marker for post-operative delirium

status: publishe

Serum protein S100β for the prediction of postoperative delirium after off-pump coronary artery bypass surgery: a prospective observational trial

Introduction. Patients undergoing cardiac surgery are vulner- able for the development of postoperative neuropsychiatric complications. Early recognition of these complications is of great clinical importance. Serum protein S100β is a biomarker that reflects blood brain barrier dysfunction. Serum S100β-levels are significantly increased after cardiac surgery with the use of cardiopulmonary bypass (1). We hypothesized that S100β is also released during off-pump coronary artery bypass (OPCAB)- surgery and that S100β is an accurate neurobiochemical marker for the prediction of postoperative delirium (POD). Methods. From January 2012 to June 2013, 91 patients older than 18 years, scheduled for elective OPCAB-surgery were included in this prospective observational trial. All patients underwent baseline neuropsychiatric examination with the confusion assessment score (CAM). Anaesthesia was titrated to achieve bispectral index values between 40-60. Serum S100β-levels were determined in arterial blood at baseline, the end of surgery and at postoperative day (PD) one using batch analysis with the Elecsyss S100-assay (Roche Diagnostics, Mannheim, Germany). Patients were daily evaluated, until discharge, for the presence of POD, using the CAM or the intensive care unit version of the CAM (CAM-ICU). Results. Serum levels of S100β showed a significant increase at end of surgery and on PD1 (Fig.1). The occurrence of POD was 21% (95% confidence interval (CI): 13%-31%). In the receiver-operating- characteristic plot, S100β predicted the development of POD with an area under the curve of 0.719. The cut-off level of S100β measured at PD1 to predict POD was 160.5pg∙mL-1, with a sensitivity of 68% and a specificity of 58%. The positive predictive value of S100β was 30%, while the negative predictive value was 88%. Positive likelihood ratios for different test result intervals were 0.0 (95%-CI: 0.000-3.942) when the serum value of S100β at admission to the ICU was o180pg∙mL- 1, 0.271 (95%-CI: 0.0379-1.931) for values between 180-240pg∙mL-1 and 1.364 (95%-CI: 1.132-1.644) for values 4240pg∙mL-1. Conclusion. S100β is significantly increased after OPCAB- surgery and predictive for the occurrence of POD. Postoperative S100β-serum values of o180pg∙mL-1 measured at admission to the ICU exclude the development of POD. This finding warrants testing whether postoperative levels of S100β could be used for risk stratification of cardiac surgical patients and for the initiation of preventive measures against POD. REFERENCE 1. Herrmann M, Ebert AD, Galazky I, et al: Neurobehavioral Outcome Prediction After Cardiac Surgery: Role of Neurobio- chemical Markers of Damage to Neuronal and Glial Brain Tissue. Stroke 31:645–650, 2000.status: publishe

Serum protein S100 as marker of postoperative delirium after off-pump coronary artery bypass surgery: secondary analysis of two prospective randomized controlled trials

BACKGROUND: To investigate the predictive value of S100 (biochemical marker of neuroglial injury) for the occurrence of postoperative delirium (POD) in patients undergoing off-pump coronary artery bypass (OPCAB)-surgery. METHODS: We enrolled 92 patients older than 18 years undergoing elective OPCAB-surgery. Serum-levels of S100 were determined at baseline (BL), end of surgery (EOS) and on the first postoperative day (PD1). Postoperatively, all-patients were evaluated daily until PD5 for the presence of POD using the confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) for patients in the intensive care unit (ICU). RESULTS: The overall incidence of POD was 21%. S100-values on PD1 significantly predicted the occurrence of POD during the later hospital stay [area under the curve (AUC)=0.724 (95% confidence interval (CI): 0.619-0.814); p=0.0001] with an optimal cut-off level of 123 pg mL-1 (sensitivity 100%, specificity 44%). Below this value, the absence of POD was predicted correctly in 43.66% of patients without POD [negative predictive value (NPV) of 100% (95%CI: 88.8%-100.0%) - positive predictive value of 29.8% (95%CI: 18.4%-43.4%) and likelihood ratio (LR) of the negative result of 0.0]. CONCLUSIONS: S100-levels <123 pg mL-1 measured on PD1 reliably rule out the development of POD after elective OPCAB-surgery. This finding warrants testing whether S100-levels could be used for a risk stratification of cardiac surgical patients and for the initiation of preventive measures against POD in patients with high postoperative S100-levels.status: publishe

Xenon as an adjuvant to propofol anesthesia in patients undergoing off-pump coronary artery bypass graft surgery: a pragmatic randomized controlled clinical trial

BACKGROUND: Xenon was shown to cause less hemodynamic instability and reduce vasopressor needs during off-pump coronary artery bypass (OPCAB) surgery when compared with conventionally used anesthetics. As xenon exerts its organ protective properties even in subanesthetic concentrations, we hypothesized that in patients undergoing OPCAB surgery, 30% xenon added to general anesthesia with propofol results in superior hemodynamic stability when compared to anesthesia with propofol alone. METHODS: Fifty patients undergoing elective OPCAB surgery were randomized to receive general anesthesia with 30% xenon adjuvant to a target-controlled infusion of propofol or with propofol alone. The primary end point was the total intraoperative dose of norepinephrine required to maintain an intraoperative mean arterial pressure >70 mm Hg. Secondary outcomes included the perioperative cardiorespiratory profile and the incidence of adverse and serious adverse events. RESULTS: Adding xenon to propofol anesthesia resulted in a significant reduction of norepinephrine required to attain the predefined hemodynamic goals (cumulative intraoperative dose: median [interquartile range]: 370 [116-570] vs 840 [335-1710] µg, P = .001). In the xenon-propofol group, significantly less propofol was required to obtain a similar depth of anesthesia as judged by clinical signs and the bispectral index (propofol effect site concentration [mean ± SD]: 1.8 ± 0.5 vs 2.8 ± 0.3 mg, P≤ .0001). Moreover, the xenon-propofol group required significantly less norepinephrine during the first 24 hours on the intensive care unit (median [interquartile range]: 1.5 [0.1-7] vs 5 [2-8] mg, P = .048). Other outcomes and safety parameters were similar in both groups. CONCLUSIONS: Thirty percent xenon added to propofol anesthesia improves hemodynamic stability by decreasing norepinephrine requirements in patients undergoing OPCAB surgery.status: publishe