The Relationship between Prolonged Cerebral Oxygen Desaturation and Postoperative Outcome in Patients Undergoing Coronary Artery Bypass Grafting

58 patients who underwent on-pump coronary artery bypass graft surgery were evaluated for changes in regional cerebral oxygen saturation (rSO2) measured by near infrared spectroscopy (NIRS). If rSO2 during the operation fell to more than 20% under the baseline, standardized interventions were undertaken to maintain rSO2. Despite those interventions, in some cases we observed inability to maintain rSO2 above this threshold. Therefore we divided patients in two subgroups: 1. without prolonged rSO2 desaturation; 2. with prolonged rSO2 desaturation (area under the curve >150 min% for rSO250 min% for rSO2<50% of absolute value). The data were analyzed to determine whether there were major differences in outcome of these two groups. 18 out of 58 patients (31%) had prolonged rSO2 desaturation during operation. There was significantly higher number of diabetic patients in group with prolonged rSO2 desaturation (p=0.02). Intraoperative data revealed significantly more blood consumption during cardiopulmonary bypass (p=0.007) and the need for inotropes (p=0.04) in desaturation group. Three patients in prolonged desaturation group and no one in another group had stroke, coma or stupor (p=0.03). Logistic regression analysis revealed diabetes mellitus and age as predictors for prolonged rSO2 desaturation. We concluded that prolonged intraoperative rSO2 desaturation is significantly associated with worse neurological outcome in patients – nonresponders to standardized interventions for prevention of rSO2 desaturation

A diagnosis of a renal injury by early biomarkers in patients exposed to cardiopulmonary bypass during cardiac surgery

We prospectively studied renal function in 158 patients scheduled for elective cardiac surgery with the use of cardiopulmonary bypass (CPB). The patients involved in this study had normal renal function as well as normal function of the left ventricle. The results of the study showed a statistically significant increase of early markers of renal injury Alpha-1-Microglobulin (A1M) and Neutrophil Gelatinase-Associated Lipocalin (NGAL), which were being traced in the patients’ urine 5 hours and 24 hours after CPB. In contrast with the aforementioned early markers, the so-called “classical” markers of renal injury – serum urea and creatinine – did not show a statistical significance of value increase after CPB. Using early factors of renal injury A1M and NGAL, the study managed to show slight, subclinical injuries of the proximal renal tubules after CPB and cardiac surgeries. The value of these factors lies in their early and precise detection of renal injury, which is a significant clinical parameter for monitoring renal function, especially after cardiac surgery with the use of CPB

NT-pro-BNP, but not C-reactive Protein, is predictive of atrial fibrillation in patients undergoing coronary artery bypass surgery

Objective: Atrial fibrillation (AF) remains the most commonly observed complication following myocardial revascularization surgery. We aimed to evaluate the clinical utility of NT-pro-BNP, troponin T, transcoronary lactate gradient (TCLG) and C-reactive protein as predictors of atrial fibrillation in patients undergoing isolated CABG. ----- Methods: Two hundred and fifteen consecutive patients in sinus rhythm (SR) undergoing elective CABG between May 2007 and May 2008 were included. Patients were grouped according to their respective postoperative rhythm into SR and AF groups. The data are presented as mean values ± standard deviation, or medians with quartiles. ----- Results: Fifty five patients developed AF (26%). The preoperative NT-pro-BNP values were 273 ± 347 and 469 ± 629 pg/ml in the SR and AF groups, respectively (p < 0.0001). The postoperative NT-pro-BNP values were 3110 ± 3600 in the SR and 4625 ± 5640 pg/ml in the AF group (p = 0.027). The transcoronary lactate gradient rose from the pre-cardiopulmonary bypass (CPB) values to those observed 5 minutes after revascularization in both groups (-0.05 ± 0.37 to 0.39 ± 0.46 mmol/l (p < 0.0001) in the SR group and -0.01 ± 0.27 to 0.43 ± 0.46 mmol/l (p < 0.0001) in the AF group). The CRP values increased from 6 ± 13 to 163 ± 88 mg/L (p < 0.0001) in the SR group, and from 6 ± 16 to 163 ± 104 mg/l (p < 0.0001) in the AF group. The dynamics of TCLG and CRP did not differ between the groups (p = 0.71, p = 0.44, respectively). The troponin T values on postoperative day one were significantly higher in the AF than the SR group (0.86 [0.49-2.1] ng/ml vs. 0.67 [0.37-1.16] ng/ml, p = 0.046). The duration of cardiopulmonary bypass (CPB) was 85 ± 24 in the SR and 93 ± 30 min in the AF group (p = 0.05). Patients who developed AF were older (66 ± 7 vs 60 ± 9 years, p < 0.0001) and had a higher EuroSCORE (3.9 ± 2.7 vs 2.9 ± 2.2, p = 0.009). Multivariate analysis identified age (p = 0.0043), preoperative NT-pro-BNP (p = 0.019) and duration of cardiopulmonary bypass (p = 0.035) as independent predictors of AF. ----- Conclusions: Preoperative and postoperative NT-pro-BNP, as well as, TnT values were significantly higher in patients that subsequently developed AF. TCLG and CRP were not useful in identifying patients at higher risk for AF. Multivariate analysis identified age, preoperative NT-pro-BNP and duration of CPB as independent correlates of AF

Diagnostic accuracy of central venous saturation in estimating mixed venous saturation is proportional to cardiac performance among cardiac surgical patients

PURPOSE: Advanced hemodynamic monitoring in cardiac surgery translates into improvement in outcomes. We evaluated the relationship between central venous (ScvO2) and mixed venous (SvO2) saturations over the early postoperative period. The adequacy of their interchangeability was tested in patients with varying degrees of cardiac performance. ----- METHODS: In this prospective observational study, we evaluated 156 consecutive cardiac surgical patients in an academic center. The ScvO2 and SvO2 data were harvested from 468 paired samples taken preoperatively (T0), after weaning from cardiopulmonary bypass (T1) and on postoperative day 1 (T2). ----- RESULTS: The relationship between ScvO2 and SvO2 was inconsistent, with inferior correlations in patients with lower cardiac indices (CI) (Pearson r(2) = 0.37 if CI ≤2.0 L/min per square meter vs r(2) = 0.73 if CI >2.0 L/min per square meter, both P < .01). Patients with lower CI also had wider 95% limits of agreement between SvO2 and ScvO2. The proportion of patients with a negative SvO2-ScvO2 gradient increased over time (48/156 [31%] at T0 to 73/156 [47%] at T2; P < .01). This subgroup more frequently required inotropes at T2 than patients with a positive SvO2-ScvO2 gradient (odds ratio, 6.46 [95% confidence interval, 0.81-51.87], P = .06) and also had higher serum lactate levels (1.5 ± 0.8 vs 1.0 ± 0.4; P < .01). ----- CONCLUSIONS: The diagnostic accuracy of ScvO2 for estimating SvO2 is proportional to cardiac performance. A negative SvO2-ScvO2 gradient at T2 correlated with inotropic support requirement, higher operative risk score, age, lactate level, and duration of cardiopulmonary bypass

Extracorporeal blood purification is associated with improvement in biochemical and clinical variables in the critically-ill COVID-19 patients

This study tried to investigate the impact of oXiris filter on both clinical and laboratory parameters in critically-ill COVID-19 intensive care unit (ICU) patients receiving extracorporeal blood purification and the clinical setting for the initiation of therapy. A consecutive sample of 15 ICU patients with COVID-19 was treated with oXiris membrane for blood purification or for support of renal function due to acute kidney injury. We have included 19 non treated ICU COVID-19 patients as a control group. Two chest x-rays were analyzed for determining the chest x-ray severity score. We have found a significant decrease of SOFA score, respiratory status improved and the chest x-ray severity score was significantly decreased after 72 h of treatment. IL-6 significantly decreased after 72 h of treatment while other inflammatory markers did not. Respiratory status in the control group worsened as well as increase in SOFA score and chest x-ray severity score. Survived patients have shorter time from the onset of symptoms before starting with extracorporeal blood purification treatment and shorter time on vasoactive therapy and invasive respiratory support than deceased patients. Critically-ill patients with COVID-19 treated with extracorporeal blood purification survived significantly longer than other ICU COVID-19 patients. Treatment with oXiris membrane provides significant reduction of IL-6, leads to improvement in respiratory status, chest x-ray severity score, and reduction of SOFA score severity. Our results can suggest that ICU COVID-19 patients in an early course of a disease could be potentially a target group for earlier initiation of extracorporeal blood purification