A randomised controlled trial of prehabilitation in patients undergoing elective cardiac surgery

The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre-operative care or prehabilitation, consisting of pre-operative exercise and inspiratory muscle training. The primary outcome was change in six-minute walk test distance from baseline to pre-operative assessment. Secondary outcomes included change in inspiratory muscle strength (maximal inspiratory pressure); sarcopenia (handgrip strength); quality of life and compliance. Safety outcomes were pre-specified surgical and pulmonary complications and adverse events. All outcomes were assessed at baseline; at pre-operative assessment; and 6 and 12 weeks following surgery. Mean (SD) age was 64.7 (10.2) years; 33/180 (18%) were women. In total, 65/91 (71.4%) participants who were allocated to prehabilitation attended at least four of eight supervised in-hospital exercise classes; participants aged > 50 years were more likely than younger participants to attend (odds ratio (95%CI) of 4.6 (1.0–25.1)). Six-minute walk test was not significantly different between groups (mean difference (95%CI) -7.8 m (-30.6–15.0), p = 0.503) in the intention-to-treat analysis. Subgroup analyses based on tests for interaction indicated improvements in six-minute walk test distance were larger amongst sarcopenic patients in the prehabilitation group (p = 0.004). Change in maximal inspiratory pressure from baseline to all time-points was significantly greater in the prehabilitation group, with the greatest mean difference (95%CI) observed 12 weeks after surgery (10.6 cmH₂O (4.6–16.6) cmH₂O, p < 0.001). There were no differences in handgrip strength or quality of life up to 12 weeks after surgery. There was no significant difference in postoperative mortality (one death in each group), surgical or pulmonary complications. Of 71 pre-operative adverse events, six (8.5%) were related to prehabilitation. The combination of exercise and inspiratory muscle training in a prehabilitation intervention before cardiac surgery was not superior to standard care in improving functional exercise capacity measured by six-minute walk test distance pre-operatively. Future trials should target patients living with sarcopenia and include inspiratory muscle strength training.     

Haemodynamic effects of a milrinone infusion without a bolus in patients undergoing off-pump coronary artery bypass graft surgery

The haemodynamic effects of a continuous infusion of milrinone without an initial bolus dose were evaluated in patients undergoing off-pump coronary artery bypass graft surgery. After internal mammary artery harvest, milrinone 0.5 microg.min(-1).kg(-1) (29 patients) or a normal saline infusion (33 patients) was started and continued until all graft anastomoses were completed. Haemodynamic variables were recorded before application of the tissue stabiliser, at 1, 3, 5 and 10 min after the application of the stabiliser, and after its removal. The administration of a milrinone infusion was associated with a smaller decrease in cardiac output and mixed venous oxygen saturation during all the coronary artery anastomoses, with no severe complications and a decreased dose of norepinephrine infused to maintain systemic arterial pressure.     

七氟醚和异丙酚对冠状动脉旁路移植术患者心肌保护作用比较的Meta分析

目的 采用Meta分析法比较七氟醚和异丙酚对冠状动脉旁路移植术患者心肌的保护作用.方法 通过电子数据库检索比较冠状动脉旁路移植术患者七氟醚和异丙酚心肌保护作用的临床随机对照研究,文献检索至2008年9月.由两位作者分别对研究质量进行评估,并提取有关资料,主要包括患者术前情况、术中情况、体外循环后心脏指数、术后心肌肌钙蛋白Ⅰ水平、机械通气时间、正性肌力药物使用情况、ICU停留时间、住院时间、术后死亡、心肌梗死、心肌缺血和房颤的发生情况,采用RevMan 5.0软件进行Meta分析.结果 共纳入13项前瞻性临床随机对照研究,包括696例患者,其中七氟醚组402例,异丙酚组294例.两组患者术后机械通气时间、正性肌力药物使用率、术后病死率、心肌梗死和房颤的发生率差异无统计学意义(P>0.05).与异丙酚组相比,七氟醚组患者体外循环后心脏指数升高,术后心肌肌钙蛋白Ⅰ水平和心肌缺血发生率降低,ICU停留时间和住院时间缩短(P<0.05).结论 冠状动脉旁路移植术患者七氟醚的心肌保护作用优于异丙酚.     

Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial

Paracetamol is a commonly used drug in the intensive care unit. There have been reports in the literature of an association with significant hypotension, a potentially important interaction for labile critically ill patients. Route of administration may influence the incidence of hypotension. This single‐centre, prospective, open‐label, randomised, parallel‐arm, active‐control trial was designed to determine the incidence of hypotension following the administration of paracetamol to critically ill patients. Fifty adult patients receiving paracetamol for analgesia or pyrexia were randomly assigned to receive either the parenteral or enteral formulation of the drug. Paracetamol concentrations were measured at baseline and at multiple time points over 24 h. The maximal plasma paracetamol concentration was significantly different between routes; 156 vs. 73 micromol.l^?1 [p = 0.0005] following the first dose of parenteral or enteral paracetamol, respectively. Sixteen hypotensive events occurred in 12 patients: parenteral n = 12; enteral n = 4. The incident rate ratio for parenteral vs. enteral paracetamol was 2.94 (95% CI 0.97–8.92; p = 0.06). The incidence of hypotension associated with paracetamol administration is higher than previously reported and tends to be more frequent with parenteral paracetamol.     

Associations between mean arterial pressure during cardiopulmonary bypass and biomarkers of cerebral injury in patients undergoing cardiac surgery: secondary results from a randomized controlled trial

Open in a separate window OBJECTIVESCardiac surgery is associated with risk of cerebral injury and mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) is suggested to be associated with cerebral injury. The ‘Perfusion Pressure Cerebral Infarcts’ (PPCI) trial randomized patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement to a MAP of 40–50 or 70–80 mmHg during CPB and found no difference in clinical or imaging outcomes between the groups. We here present PPCI trial predefined secondary end points, consisting of biomarkers of brain injury.METHODSBlood was collected from PPCI trial patients at baseline, 24 and 48 h after induction of anaesthesia and at discharge from the surgical ward. Blood was analysed for neuron-specific enolase, tau, neurofilament light and the glial marker glial fibrillary acidic protein. Linear mixed models were used to analyse differences in biomarker value changes from baseline between the 2 MAP allocation groups.RESULTSA total of 193 (98%) patients were included. We found no differences in biomarker levels over time from baseline to discharge between the 2 MAP allocation groups (P_NSE = 0.14, P_Tau = 0.46, P_NFL = 0.21, P_GFAP = 0.13) and the result did not change after adjustment for age, sex and type of surgery.CONCLUSIONSWe found no significant differences in levels of biomarkers of neurological injury in patients undergoing elective or subacute CABG and/or aortic valve replacement randomized to either a target MAP of 40–50 mmHg or a target MAP of 70–80 mmHg during CBP.     

A randomised controlled trial of dexmedetomidine for delirium in adults undergoing heart valve surgery

Dexmedetomidine might reduce delirium after cardiac surgery. We allocated 326 participants to an infusion of dexmedetomidine at a rate of 0.6 μg kg⁻¹ for 10 min and then at 0.4 μg.kg⁻¹.h⁻¹ until the end of surgery; 326 control participants received comparable volumes of saline. We detected delirium in 98/652 (15%) participants during the first seven postoperative days: 47/326 after dexmedetomidine vs. 51/326 after placebo, p = 0.62, adjusted relative risk (95%CI) 0.86 (0.56–1.33), p = 0.51. Postoperative renal impairment (Kidney Disease Improving Global Outcomes stages 1, 2 and 3) was detected in 46, 9 and 2 participants after dexmedetomidine and 25, 7 and 4 control participants, p = 0.040. Intra-operative dexmedetomidine infusion did not reduce the incidence of delirium after cardiac valve surgery but might impair renal function.     

Comparison of etomidate and propofol for anaesthesia in microlaryngeal surgery

Propofol and etomidate were compared as hypnotics in total intravenous anaesthesia for microlaryngeal surgery combined with jet ventilation. Two groups of 15 patients were studied. In group 1, propofol 2.0 mg/kg was used for induction. For maintenance a continuous infusion of 12 mg/kg/hour was used for the first 10 minutes, followed by 9 mg/kg/hour for the next 10 minutes and 6 mg/kg/hour thereafter. In group 2, the induction dose of etomidate was 0.3 mg/kg followed by continuous infusion of 1.8 mg/kg/hour for 10 minutes, 1.5 mg/kg/hour for the next 10 minutes and 1.0 mg/kg/hour thereafter. Alfentanil was given for analgesia and suxamethonium for muscle relaxation. The propofol group showed better surgical conditions, more stable anaesthesia and better recovery according to the Steward score. Recovery times to opening eyes on command were comparable for both groups.     

Impact of concomitant cardiac procedure on coronary artery surgery in hemodialysis-dependent patients

Objective Coronary artery bypass grafting (CABG) in hemodialysis-dependent patients is associated with high mortality and morbidity rates. This retrospective study was undertaken to identify the risk factors for in-hospital mortality for hemodialysis-dependent patients.Methods: Subjects included 87 consecutive hemodialysis-dependent patients (81 men and 6 women), aged 47–82 years (mean age, 65 years), who underwent CABG. Operative procedures included CABG alone (n=77) and CABG with valve replacement, repair, or the Dor procedure (n=10). Thirty-one perioperative risk factors were subjected to univariate and multivariate analyses to identify the risk factors for hospital death. Results: The overall in-hospital mortality rate, including operative death, was 14.9% (13/87). Univariate analysis showed the following 7 risk factors to be statistically significant predictors of hospital death: age≧70 years, a concomitant cardiac procedure, left ventricular ejection fraction<30%, left ventricular end-systolic volume index>70 ml/m², a left main lesion, emergency/urgent surgery, and anemia (hemoglobin<10 mg/dl) (p<0.05 for each predictor). Multivariate logistic regression analysis confirmed that a concomitant cardiac procedure (X ²=17.080,p=0.013) and age≧ 70 years (X ²=9.112,p=0.019) are statistically significant independent risk factors for hospital death.Conclusion: A concomitant cardiac procedure and age ≧ 70 years were identified as significant independent risk factors for hospital mortality after CABG for hemodialysis-dependent patients. These preoperative risk factors may help in predicting operative risks and improving clinical outcomes in hemodialysis-dependent patients undergoing CABG. (Jpn J Thorac Cardiovasc Surg 2006; 54:142-148)     

七氟醚与丙泊酚对冠心病患者行非心脏手术心肌的影响

目的 比较冠心病患者行非心脏手术时七氟醚与丙泊酚对心肌的影响.方法 40例心功能Ⅰ或Ⅱ级择期行上腹部手术的冠心病患者随机分为丙泊酚组(PR组)与七氟醚组(SE组).PR组丙泊酚靶控输注血药浓度维持在2～3μg/ml,SE组呼气末七氟醚浓度维持在2%～3%,连续监测血流动力学及ECC变化,检测麻醉前与术毕血清白细胞介素-6(IL-6)、肿瘤坏死因子α(TNF-α)、心肌钙蛋白(cTnI)及糖原磷酸化酶BB(GP-BB)浓度.结果 术毕PR组血清IL-6、TNF-α、cTnI及GP-BB浓度明显高于麻醉前及SE组(P＜0.05).结论 冠心病行非心脏手术时七氟醚对心肌的保护效应优于丙泊酚.     

Impact of concomitant cardiac procedure on coronary artery surgery in hemodialysis-dependent patients

OBJECTIVE: Coronary artery bypass grafting (CABG) in hemodialysis-dependent patients is associated with high mortality and morbidity rates. This retrospective study was undertaken to identify the risk factors for in-hospital mortality for hemodialysis-dependent patients. METHODS: Subjects included 87 consecutive hemodialysis-dependent patients (81 men and 6 women), aged 47-82 years (mean age, 65 years), who underwent CABG. Operative procedures included CABG alone (n=77) and CABG with valve replacement, repair, or the Dor procedure (n=10). Thirty-one perioperative risk factors were subjected to univariate and multivariate analyses to identify the risk factors for hospital death. RESULTS: The overall in-hospital mortality rate, including operative death, was 14.9% (13/87). Univariate analysis showed the following 7 risk factors to be statistically significant predictors of hospital death: age > or = 70 years, a concomitant cardiac procedure, left ventricular ejection fraction <30%, left ventricular end-systolic volume index >70 ml/m2, a left main lesion, emergency/urgent surgery, and anemia (hemoglobin <10 mg/dl) (p<0.05 for each predictor). Multivariate logistic regression analysis confirmed that a concomitant cardiac procedure (chi-squared = 17.080, p=0.013) and age > or = 70 years (chi-squared = 9.112, p=0.019) are statistically significant independent risk factors for hospital death. CONCLUSION: A concomitant cardiac procedure and age > or = 70 years were identified as significant independent risk factors for hospital mortality after CABG for hemodialysis-dependent patients. These preoperative risk factors may help in predicting operative risks and improving clinical outcomes in hemodialysis-dependent patients undergoing CABG.     

胸段硬膜外阻滞对全麻下非停跳冠状动脉搭桥术病人心肌保护作用

目的观察胸段硬膜外阻滞（TEA）对冠心病行非停跳冠状动脉搭桥术（OPCAB）病人血浆内皮素（ET）及心钠素（ANP）的影响。方法20例拟行OPCAB病人分为两组：A组为单纯全麻组;B组为TEA复合全麻组。采用放免法测定术前、术后1h、术后24h及术后48h血浆ET及ANP浓度,记录血液动力学参数及所用血管活性药剂量。结果B组术后1、24、48hET及ANP显著低于A组（P〈0．05）,血液动力学稳定,所用血管活性药物少（P〈0．05）。结论TEA能抑制麻醉手术所致的应激反应,对OPCAB病人的心脏有保护作用。     

舒芬太尼在非体外循环冠脉搭桥术应用中的临床研究

目的 观察舒芬太尼在非体外循环冠状动脉搭桥手术应用中的安全性和有效性.方法 择期行OPCABG病人54例,被随机分成两组,舒芬太尼组和芬太尼组,每组27例,麻醉诱导应用丙泊酚1 mg/ks～2 ms/ks,同时分别静注舒芬太尼0.5 μg/ks～1μg/kg,或芬太尼4 μg/ks-8 μg/ks,同时吸入安氟醚维持麻醉,持续输注舒芬太尼0.08 μg·ks-1min-1,或芬太尼0.6 μg·ks-1·min-1.记录各组气管插管、切片、麻醉维持和拨除气管导管各时间的收缩压和舒张压.结果 在气管插管过程中,浅麻醉反应的病人数舒芬太尼组明显低于芬太尼组,在气管插管切皮,麻醉维持和拔管期间,芬太尼组收缩压、舒张压明显高于舒芬太尼组,术后清醒和拔管时间两组病人无统计学差异.结论 舒芬太尼的麻醉效果优于芬太尼,舒芬太尼能提供术中更稳定的血液动力学.     

Clinical and economic choices in anaesthesia for day surgery: a prospective randomised controlled trial

We compared the cost-effectiveness of general anaesthetic agents in adult and paediatric day surgery populations. We randomly assigned 1063 adult and 322 paediatric elective patients to one of four (adult) or two (paediatric) anaesthesia groups. Total costs were calculated from individual patient resource use to 7 days post discharge. Incremental cost-effectiveness ratios were expressed as cost per episode of postoperative nausea and vomiting (PONV) avoided. In adults, variable secondary care costs were higher for propofol induction and propofol maintenance (propofol/propofol; p < 0.01) than other groups and lower in propofol induction and isoflurane maintenance (propofol/isoflurane; p < 0.01). In both studies, predischarge PONV was higher if sevoflurane/sevoflurane (p < 0.01) was used compared with use of propofol for induction. In both studies, there was no difference in postdischarge outcomes at Day 7. Sevoflurane/sevoflurane was more costly with higher PONV rates in both studies. In adults, the cost per extra episode of PONV avoided was pound 296 (propofol/propofol vs. propofol/ sevoflurane) and pound 333 (propofol/sevoflurane vs. propofol/isoflurane).