Catecholamine and Volume Therapy for Cardiac Surgery in Germany – Results from a Postal Survey

<div><p>Background</p><p>Management of cardiac surgery patients is a very standardized procedure in respective local institutions. Yet only very limited evidence exists concerning optimal indication, safety and efficacy of hemodynamic monitoring catecholamine and fluid therapy.</p><p>Methods</p><p>Between April and May 2013, all 81 German anaesthesia departments involved in cardiac surgery care were asked to participate in a questionnaire addressing the institutional specific current practice in hemodynamic monitoring, catecholamine and volume therapy.</p><p>Results</p><p>51 (63%) questionnaires were completed and returned. All participating centers used basic hemodynamic monitoring (i.e. invasive arterial blood pressure and central venous pressure), supplemented by transesophageal echocardiography. Pulmonary arterial catheter and calibrated trend monitoring devices were also routinely available. In contrast, non-calibrated trend monitoring and esophageal doppler ultrasound devices were not commonly in use. Cerebral oximetry is increasingly emerging, but lacks clear indications. The majority of patients undergoing cardiac surgery, especially in university hospitals, required catecholamines during perioperative care, In case of low cardiac output syndrome, dobutamine (32%), epinephrine (30%) or phosphodiesterase inhibitors (8%) were first choice. In case of hypotension following vasoplegia, norepinephrine (96%) represented the most common catecholamine. 88% of the participating centers reported regular use of colloid fluids, with hydroxyethyl starches (HES) being first choice (64%).</p><p>Conclusions</p><p>Choice of hemodynamic monitoring is homogenous throughout German centers treating cardiac surgery patients. Norepinephrine is the first line catecholamine in cases of decrease in peripheral vascular resistance. However, catecholamine choice for low cardiac output syndrome varies considerably. HES was the primary colloid used for fluid resuscitation. After conduct of this survey, HES use was restricted by European regulatory authorities in critically ill patients and should only be considered as second-line fluid in surgical patients without renal impairment or severe coagulopathy. Large clinical studies addressing catecholamine and fluid therapy in cardiac surgery patients are lacking.</p></div

Volume used for cardiopulmonary bypass priming in percent.

<p>Volume used for cardiopulmonary bypass priming in percent.</p

Overview of the departments responsible for postoperative intensive care of cardiac surgery patients (in percent) A (left).

<p>Number of operations performed in the respective cardiac surgery departments per year <b>B (right)</b>.</p

intraoperative use of colloids A (left) and type of colloid solution used in percent B (right).

<p>n/a – not applicable in case colloidal fluids were generally avoided in the respective institution.</p

Monitoring for perioperative volume therapy (1–5 Likert scale, where 1 is common, 5 rare, TEE = transesophageal echocardiography, BP = blood pressure, CVP = central venous pressure, UO = urine output, PAC = pulmonary arterial catheter, TMD = trend monitoring devices).

<p>Monitoring for perioperative volume therapy (1–5 Likert scale, where 1 is common, 5 rare, TEE = transesophageal echocardiography, BP = blood pressure, CVP = central venous pressure, UO = urine output, PAC = pulmonary arterial catheter, TMD = trend monitoring devices).</p

First line catecholamine therapy for vasoplegia A (left) and second line catecholamine choice in percent B (right).

<p>First line catecholamine therapy for vasoplegia A (left) and second line catecholamine choice in percent B (right).</p

First line catecholamine therapy for low cardiac output (in percent).

<p>First line catecholamine therapy for low cardiac output (in percent).</p

Availability of monitoring devices (in percent) A (left) and actual use of these devices B (right) (1–5 Likert scale, where 1 is common, 5 rare, ART = arterial blood pressure measurement, CVP = central venous pressure, TEE = transesophageal echocardiography, PAC = pulmonary arterial catheter, TMS = calibrated trend monitoring system, TED = uncalibrated trend evaluation systems).

<p>Availability of monitoring devices (in percent) A (left) and actual use of these devices B (right) (1–5 Likert scale, where 1 is common, 5 rare, ART = arterial blood pressure measurement, CVP = central venous pressure, TEE = transesophageal echocardiography, PAC = pulmonary arterial catheter, TMS = calibrated trend monitoring system, TED = uncalibrated trend evaluation systems).</p

Percentage of patients requiring catecholaminergic therapy in the perioperative period A (left) and target mean arterial pressure (MAP) and systolic blood pressure (Sys BP) in cardiac surgery patients with or without risk factors B (right).

<p>Percentage of patients requiring catecholaminergic therapy in the perioperative period A (left) and target mean arterial pressure (MAP) and systolic blood pressure (Sys BP) in cardiac surgery patients with or without risk factors B (right).</p

Genomic alignment of <i>SMPD1</i> splice-isoforms in human leukocytes.

<p>(A) Black boxes represent protein coding exonic regions identical to ASM-1. Grey boxes indicate altered amino acid sequence and white boxes sequence of untranslated regions (UTR). Fine lines are intronic sequence. Arrows indicate PCR oligonucleotides. Novel splice-isoforms are marked with an asterisk and candidates for nonsense-mediated mRNA decay with NMD. Numbers below indicate nucleotides added or deleted from the transcript by alternative splice sites deviating from ASM-1. (B) Relative splice-isoform frequencies (log scale) in the human leukocytes cDNA pool based on cloned and sequenced PCR products depicted in (A).</p