Perioperative Quality Initiative consensus statement on intraoperative blood pressure,risk and outcomes for elective surgery

Background

Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017.

Reducing myocardial injury by minimizing imbalance between oxygen supply and demand

The purpose of this study was to determine whether hemodynamic and pharmacologic factors can influence the extent and severity of myocardial necrosis produced by coronary occlusion. In 48 dogs, 10 to 14 epicardial leads were recorded on the anterior surface of the left ventricle in the distribution and vicinity of the site of occlusion of a branch of the left anterior descending coronary artery. The average S-T segment elevation for each animal was determined at 5-min intervals after occlusion. This elevation was used as an index of the presence and severity of myocardial ischemic injury. Isoproterenol, ouabain, glucagon, bretylium, and tachycardia given prior to a repeated occlusion each increased the severity and extent of ischemic injury, while propranolol decreased it. Elevation of arterial pressure with methoxamine reduced the occlusion-induced S-T segment elevation, and lowering of the mean arterial pressure by hemorrhage had the opposite effect. In 19 additional experiments, propranolol, isoproterenol, and alterations in arterial pressure produced similar alterations in S-T segment elevation when these interventions were applied as long as 3 hr after ligation. Myocardial creatine phosphokinase (CPK) activity determined 24 hr after coronary artery ligation correlated well with S-T segment elevation at the same sites recorded 15 min after ligation. Moreover, isoproterenol increased and propranolol decreased the area of depression of myocardial CPK activity. We conclude that the hemodynamic status and neurohumoral background at the time of coronary occlusion and for at least 3 hr thereafter can alter the extent and severity of myocardial ischemic injury and myocardial necrosis.     

Extended duration of brachially inserted intra-aortic balloon pump for myocardial protection in two patients undergoing urgent coronary artery bypass grafting

Intra-aortic balloon pump (IABP) provides myocardial protection for patients who are at risk of myocardial injury during cardiac surgery. The haemodynamic support is crucial in patients with significant and critical coronary artery disease undergoing revascularisation procedures. Traditionally, the femoral arterial access is the preferred route for IABP insertion. This is, however, not always feasible especially in patients with concomitant occlusive peripheral vascular disease. The trans-brachial route can be used as an alternative for percutaneous insertion of the IABP. We report the technique for left trans-brachial insertion of an IABP, and illustrate our experience with two patients requiring urgent coronary artery bypass grafting (CABG) and for whom the IABP duration was over 50 h.     

Perioperative myocardial injury in patients undergoing aortic valve replacement

In cases of myocardial hypertrophy myocardial protection may be insufficient. In order to determine the factors responsible for myocardial injury we assessed myocardial injury in 54 patients undergoing isolated aortic valve replacement. In all cases hypothermic cardioplegic arrest was induced. At 13 different times we measured the serum level of creatine-kinase (CK), myocardial bound creatine-kinase (CKmb), lactic dehydrogenase (LDH), alpha-hydroxybutyrate dehydrogenase (alpha-HBDH), glutamic oxaloacetic transferase (GOT) and myoglobin. The mean duration of ischemia was 52.6 +/- 16.2 minutes and the mean time of extracorporeal circulation was 85.85 +/- 20.25 minutes. By performance of a multiple regression analysis a significant correlation between ischemia and LDH and alpha-HBDH was found; CK, GOT, LDH and alpha-HBDH correlated with duration of extracorporeal circulation. In none of the patients was a low cardiac output syndrome observed. From our results we conclude that in our study myocardial protection was sufficient and therefore the detrimental effects of extracorporeal circulation were the determining factors of enzyme release.     

Effect of three different anaesthetic agents on the postoperative production of cardiac troponin T in paediatric cardiac surgery

Background. Paediatric cardiac surgery is associated with somedegree of myocardial injury. Ischaemic preconditioning (IP)has been investigated widely in the adult population. Volatileagents have been shown to simulate IP providing extra protectionto the myocardium during adult cardiopulmonary bypass (CPB)while propofol seems to act through different mechanisms. IPhas not been investigated in the paediatric population to thesame extent. Cardiac troponin T (cTnT) is a reliable markerof myocardial injury in neonates and children. We have investigatedthe relationship between three anaesthetic agents, midazolam,propofol, and sevoflurane, and postoperative production of cTnT. Methods. Ninety patients undergoing repair of congenital heartdefect with CPB were investigated in a prospective randomizedstudy. cTnT was measured four times during the first 24 h followingadmission to the paediatric intensive care unit. Other variablesmeasured included arterial blood gases, lactate, fluid balance,use of inotropic drugs,     

断指再植术后血管危象的多因素分析

目的分析影响断指再植术后发生血管危象的危险因素,为早期发现和及时防治血管危象的发生提供理论依据,从而减少断指再植术后血管危象的发生,提高断指再植的成活率。方法回顾性分析712指断指再植的病例,将患者性别、年龄、指别、伤因、断指缺血时间、离断平面、是否完全离断、动脉修复情况、静脉修复情况共九个因素分别与是否发生血管危象进行单因素分析和亚变量多因素Logistic回归分析,探讨断指再植术后发生血管危象的独立预测因素。结果712指断指再植术后共有132指发生血管危象,其中静脉危象44指,动脉危象88指,危象发生率为18．5％。单因素分析结果表明:性别、年龄、指别、伤因、离断平面、是否完全离断、动脉修复情况、静脉修复情况对血管危象的发生均有影响。二分类亚变量Logistic多因素分析表明,性别、年龄、伤因、离断平面、是否完全离断、动脉修复情况是断指再植术后发生血管危象的独立的预测因素。结论性别、年龄、伤因、离断平面、是否完全离断、动脉修复情况是断指再植术后发生血管危象的独立的预测因素。对于发生血管危象机率高的患者术中要精细操作,术后密切观察,预防断指再植术后血管危象的发生。     

Cardiac Trauma: Clinical and Experimental Correlations of Myocardial Contusion

Clinical and experimental observations in myocardial contusion have been correlated. Cardiac arrhythmia is always an important consequence and may be fatal. Reduction in cardiac output often accompanies significant cardiac injury. The coronary arterial circulation is not interrupted and is generally enhanced to the area of injury. Healing of the injury under these circulatory conditions may result in patchy scarring and peculiar adynamic areas of myocardium. Early diagnosis of myocardial contusion may be aided using radionuclide imaging with (99m)Tc-Sn-polyphosphate.     

影响四肢主要动脉损伤修复术后早期肢体血运的术前危险因素研究北大核心CSCD

目的探讨影响四肢主要动脉损伤修复术后早期肢体血运的术前危险因素,以期为预防动脉修复术后发生肢体血运障碍提供线索。方法回顾性分析2003年1月至2019年12月期间中山大学附属第一医院显微创伤手外科收治的139例(140侧肢体)四肢主要动脉损伤伴肢端缺血患者资料。男112例,女27例;中位年龄为30(20,44)岁。以术后患肢早期(48 h内)是否发生血运障碍为主要结局指标,将患者性别、年龄、缺血时间、损伤机制、损伤部位、是否伴发骨折、软组织损伤情况、手术时间等进行单因素分析,再将P<0.1的因素纳入logistic回归分析,P<0.05认为差异有统计学意义。结果44侧(31.4%,44/140)肢体在术后48 h内发生血运障碍。术后肢体发生血运障碍与未发生血运障碍患者的损伤机制、缺血时间、是否伴发骨折、软组织损伤情况比较差异均有统计学意义(P<0.05)。Logistic回归分析结果显示:钝性伤(OR=5.639,95%CI:1.068~29.761,P=0.042)和周围软组织缺损(OR=12.568,95%CI:3.402~46.431,P<0.001)是四肢主要动脉损伤修复术后早期肢体发生血运障碍的术前危险因素。结论钝性伤和周围软组织缺损是四肢主要动脉损伤修复术后早期肢体发生血运障碍的术前危险因素,在诊断及制定手术方案时应重点关注。     

Clinical Significance of Abnormal Electrocardiographic Findings in Individuals Aging With Spinal Injury and Abnormal Lipid Profiles

Abstract

Background: Cardiovascular risk factors are common in individuals with chronic spinal cord injury (SCI), and their prevalence increases with age. The actual prevalence of overt cardiovascular disease (CVD) in this population has not been well established.

Methods: Electrocardiograms (ECGs) were examined for abnormalities in 43 individuals with abnormal lipid profiles being followed in the outpatient SCI clinic of our institution. The mean age of the study population of predominantly men was 43 ± 9.9 years and the mean duration of injury 16.6 ± 8 years.

Results: ECG abnormalities were common and present in 60.5% of participants. ST-T wave abnormalities were the most commonly observed (35%). Evidence of previous myocardial infarction was present in 7% of all individuals and in 12% of those with ECG abnormalities. The only clinical parameter differentiating the group with normal vs abnormal ECG was the duration of injury (19.5 ± 8 y vs 12 ± 5 y; P= 0.0026). Analysis of variance showed that injury duration was the sole predictor of abnormal ECG with 68% accuracy (P = 0.006). Among those with ECG abnormalities, although no significant differences were detected between those with and without evidence of previous myocardial infarction, mean total cholesterol and low-density lipoprotein were higher, and mean high-density lipoprotein was lower. Mean age and injury duration were greater in those with evidence of previous myocardial infarction.

Conclusion: Although age is an important risk factor for CVD in the population of individuals without disabilities, injury duration is at least as important as age in those with SCI. Our findings support the recommendation that individuals with SCI and abnormal lipids should be screened for CVD regardless of age.     

低氧诱导因子-1/低氧反应元件通路在心肌保护中的研究进展

背景 低氧诱导因子-1 (hypoxia inducible factor-1,HIF-1)是目前公认的在缺氧状态下发挥重要作用的核转录因子,其活化后可介导低氧反应保护作用,在一定程度上能够减轻心肌的缺血/再灌注损伤(ischemic reperfusion injury,I/RI).目的 探究HIF-1/低氧反应元件(hypoxia response element,HRE)通路是如何被激活并发挥心肌保护的作用. 内容 从HIF-I的概述、调节以及HIF-1/HRE通路的激活机制及其心肌保护作用方面进行综述,并以HIF-1为靶点探究后处理的心肌保护作用的机制,对其在心肌保护作用中与其他关键性的转录因子之间的内在联系作一简要综述. 趋向 后处理能否激活HIF-1/HRE通路诱导红细胞生成素(erythropoietin,EPO)、血红素加氧酶1(hemeoxygenase1,HO-1)、诱导型一氧化氮合酶(inducible nitric oxide synthase,iNOS)和血管内皮生长因子(vascular endothelial growth factor,VEGF)等保护性蛋白的表达,以减轻心肌I/RI,尚需进一步探讨.     

Reperfusion after cardioplegic cardiac arrest - effects on intracoronary leucocyte elastase release and oxygen free radical mediated lipid peroxidation

In experimental animal models reperfusion of ischaemic myocardium causes sequestration of leucocytes within the coronary circulation. Leucocytes contribute to postischaemic myocardial injury by releasing proteolytic enzymes and by generating oxygen free radicals. The aim of this study was to investigate whether leucocytes also contribute to myocardial injury following ischaemia and reperfusion associated with cardioplegic cardiac arrest. Therefore, we studied the release of the proteolytic enzyme elastase and oxygen free radical initiated myocardial lipid peroxidation in coronary sinus blood during reperfusion after cardioplegic cardiac arrest. The elastase-alpha-1-proteinase inhibitor complex and malondialdehyde (a byproduct of myocardial lipid peroxidation) were measured in arterial, central venous and coronary sinus blood samples in 19 patients undergoing elective coronary artery bypass grafting before aortic crossclamping and 1,5, 10 and 20 min after aortic declamping. Malondialdehyde concentrations did not increase significantly during the study period, whereas elastase concentrations showed a significant increase during cardiopulmonary bypass in arterial, central venous as well as coronary sinus blood. Neither elastase nor malondialhyde concentrations in coronary sinus blood differed significantly from arterial or central venous blood at any time point measured. Our data demonstrated increased elastase concentrations during cardiopulmonary bypass, but we did not find enhanced intracoronary elastase release or myocardial lipid peroxidation. Our data suggest that patients are sufficiently protected from leucocyte mediated ischaemia reperfusion injury during uncomplicated coronary artery bypass grafting with cardioplegic arrest.     

断指再植术后坏死的相关因素分析

目的:探讨断指再植术后坏死的主要相关因素以采取有效的预防和控制措施。方法:对2013年1月至2013年12月收治的236例断指再植患者进行回顾性分析,共311指,其中男183例,女53例;年龄2～62岁,平均34.5岁,其中6岁以下6例,6岁以上230例。拇指51指,示指87指,中指78指,环指63指,小指32指。将再植术后坏死的40例40指作为观察组,其他再植存活病例作为对照组。比较两组年龄、性别、指别、吸烟史、受伤类型、断指缺血时间、离断平面、动静脉修复质量等方面的差异,分析引起再植术后坏死的相关因素。结果:手指完全离断再植236例共311指,术后坏死40指。完全离断指体再植术后坏死的主要相关影响因素包括:吸烟史、受伤类型、离断平面、动静脉修复情况(P<0.05).而与年龄、性别、指别、断指缺血时间无明显相关性(P>0.05).结论:吸烟史、受伤类型、离断平面及动静脉修复情况是完全离断指体再植术后坏死的独立预测因素,提示断指再植时应综合考虑患者基本情况、伤情,严格把握手术适应证,积极做好手术处理。     

Myocardial cooling for reperfusion injury protection achieved by organ specific hypothermic autologous perfusion

OBJECTIVE: Whole body hypothermia has been suggested to reduce myocardial injury in patients with ST-segment elevation myocardial infarction. Because of the large human thermal mass, induction of generalized hypothermia is slow and the technique has encountered considerable side effects. The aim was to develop and validate a method for regional cooling during myocardial reperfusion using hypothermic autologous blood. DESIGN: In a myocardial ischemia-reperfusion pig model (n = 10), arterial blood was cooled in a closed circuit, and returned to the myocardium during reperfusion either through a perfusion catheter or through the guiding catheter. Myocardial temperatures were recorded using temperature electrodes. RESULTS: Stabile regional myocardial cooling was induced without complications within 4 min. Both flow rate and blood temperature had significant impact on temperature in the reperfused myocardium but did not influence systemic temperature. CONCLUSION: A method for organ specific hypothermic autologous arterial blood reperfusion has been developed and validated. The method is a simple and much faster alternative to systemic cooling and may have the potential to reduce myocardial injury in patients with acute myocardial infarction.     

Improving myocardial metabolic and functional recovery after cardioplegic arrest

The myocardial oxidation of fatty acids and glucose, the predominant substrates for aerobic metabolism, is impaired after cardioplegic arrest for coronary revascularization. Because lactate can be readily metabolized to pyruvate, it may be the preferred substrate for aerobic metabolism after cardioplegic arrest when arterial concentrations are elevated. Nineteen patients undergoing elective coronary revascularization with blood cardioplegia were randomized to receive LOW (nine patients, no exogenous lactate) or HIGH (10 patients, a perioperative infusion of Ringer's lactate) arterial lactate concentrations. Coronary sinus catheterization and lactate labeled with carbon 14 permitted calculation of myocardial oxygen consumption and lactate oxidation which were significantly increased during reperfusion in the group with HIGH arterial lactate concentrations. Atrial pacing at 110 beats/min on cardiopulmonary bypass resulted in myocardial lactate production (suggesting ischemic anaerobic metabolism) in the LOW lactate group, but atrial pacing increased lactate consumption and oxidation in the HIGH lactate group (suggesting increased aerobic metabolism). Systolic function (the relation between end-systolic pressure and volume) as assessed by nuclear ventriculography 3 hours postoperatively was significantly better (p less than 0.05 by analysis of covariance) in the HIGH lactate group. Postoperative myocardial creatine kinase release was significantly lower in the HIGH lactate group, which suggested less perioperative ischemic injury. Lactate was the preferred substrate for myocardial oxidative metabolism after cardioplegic arrest, and the higher arterial lactate concentrations improved myocardial metabolic and functional recovery and reduced perioperative ischemic injury.     

Serum S100 protein as a marker of cerebral damage during cardiac surgery

The identification of a serum marker to assist in the diagnosisof cerebral injury after cardiac surgery is potentially useful.S100 protein is an early marker of cerebral damage. It is releasedafter cardiac surgery performed under cardiopulmonary bypass(CPB). Its level is correlated with the duration of CPB, deepcirculatory arrest and aortic cross-clamping. Increased levelsof S100 protein are correlated with the age of the patient andthe number of microemboli, especially during aortic cannulation.Perioperative cerebral complications such as stroke, delayedawakening and confusion are associated with increased levelsof S100 protein directly after bypass and from 15 to 48 hafter it. In addition, increased levels of S100 protein arerelated to neuropsychological dysfunction after cardiac surgery.S100 protein has early and late release patterns after CPB;the early pattern may be due to sub-clinical brain injury. Thelate release pattern may be due to perioperative cerebral complications.Patients undergoing intracardiac operations combined with coronaryartery bypass surgery are more susceptible to brain injury andhave higher levels of S100 after CPB. Furthermore, adults andchildren undergoing deep circulatory arrest are more susceptibleto brain injury, in terms of higher S100 protein release afterCPB. Serum S100 protein levels are reduced after using arterialline filtration and covalent-bonded heparin to coat the innersurface of the CPB circuit. Br J Anaesth 2000; 85: 287–98     

Risk factors for early lower limb loss after embolectomy for acute arterial occlusion: a population-based case-control study.

To identify risk factors for lower limb loss after arterial embolectomy a cohort of 1189 patients was studied. Detailed data were obtained for 165 patients who underwent a major amputation within 30 days of embolectomy and for 165 matched controls. The amputation risk was increased in patients with two or more myocardial infarctions (odds ratio (OR) 3.1, 95 per cent confidence interval (CI) 0.8-11.2), chronic ischaemia (OR 2.1, CI 0.9-4.9), long duration of symptoms (OR 4.3, CI 1.9-9.6, for greater than or equal to 25 h versus less than or equal to 6 h) or postoperative heart failure (OR 3.4, CI 1.8-6.5). Reduced risks were found in association with acute myocardial infarction (OR 0.3, CI 0.1-0.9) and postoperative anticoagulation treatment with warfarin (OR 0.3, CI 0.1-0.9). The independent prognostic value of chronic ischaemia and symptom duration, and the beneficial effect of postoperative anticoagulation gained additional support in multivariate analysis. We conclude that the risk of early amputation after arterial embolectomy or thrombectomy can be predicted by several clinical characteristics.     

选择性肋间动脉灌注在降主动脉手术中的应用

目的 探讨选择性肋间动脉灌注在降主动脉手术中对脊髓的保护作用.方法 2007年8月至2009年3月,5例降主动脉夹层和2例降主动脉瘤病人行降主动脉置换术.术中保留置换降主动脉上所有肋间动脉,进行选择性肋间动脉灌注,以减少脊髓缺血时间及程度以达到脊髓保护的目的 .术后早期观察和中期随访是否有截瘫发生.结果 术中脊髓缺血23～27 min,平均(24.8±1.6) min.7例术后均未发生截瘫,治愈出院.随访1～19个月,全组无截瘫,生活质量良好.结论 选择性肋间动脉灌注可缩短脊髓缺血时间和程度,脊髓保护效果良好,并可大大降低手术操作难度.     

七氟醚后处理对体外循环下冠状动脉旁路移植术病人心肌缺血再灌注损伤的影响

目的 探讨七氟醚后处理对体外循环(CPB)下冠状动脉旁路移植术病人心肌缺血再灌注损伤的影响.方法 择期行冠状动脉旁路移植术病人40例,性别不限,年龄55～64岁,BMI＜30 kg/m2,NYHA心功能分级Ⅰ～Ⅲ级,随机分为2组(n=20):对照组(C组)和七氟醚后处理组(S组).S组于主动脉开放即刻通过体外循环机吸入2%七氟醚,持续15 min,C组不给予任何处理.分别于麻醉诱导后、CPB转流前、停机后10 min、术毕、术后6和24 h时,记录MAP、HR、CVP、平均肺动脉压、肺动脉楔压、CO和S(v)O2,计算CI、SVI、体循环血管阻力指数和肺循环血管阻力指数.分别于主动脉阻断前、复灌6 h和术后24 h时,中心静脉取血样,测定血浆肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)和乳酸脱氢酶(LDH)的活性以及肌钙蛋白I(TnI)浓度.分别于主动脉阻断前和CPB停机时,取右心耳心肌组织,观察心肌细胞超微结构,并对心肌细胞损伤程度进行评分.结果 两组间各时点血液动力学和心功能指标比较差异无统计学意义(P＞0.05).与C组比较,S组复灌6 h时血浆CK-MB和LDH活性降低,术后24 h时血浆CK活性和TnI浓度降低,CPB停机后心肌细胞损伤程度评分降低(P＜0.05).结论 七氟醚后处理可减轻CPB下冠状动脉旁路移植术病人心肌缺血再灌注损伤.     

Pulmonary reperfusion syndrome.

"Reperfusion syndrome" of the lung may play a role in the pulmonary edema and hemorrhage that occur following pulmonary embolectomy, cardiopulmonary bypass, and shock. Bioenergetic, metabolic, and ultrastructural studies of canine lungs indicate that ventilated lung tissue could tolerate 5 hours of pulmonary arterial occlusion with minimal damage. However, a 24-hour interruption of pulmonary arterial blood flow produced a significant decrease in the ratio of adenosine triphosphate to adenosine disphosphate, and glycogen, and an increase in tissue lactate. Reperfusion of these lungs resulted in even more pronounced biochemical and ultrastructural deterioration, as well as gross pulmonary edema and hemorrhage. The lesion appears to be similar to the reperfusion damage that occurs in other organs, such as the kidney, and the skeletal and cardiac muscles.     

Recognition of arterial injury in elbow dislocation.

The clinical presentation of patients with elbow dislocations was reviewed to identify those factors indicating an increased risk for arterial injury. Sixty-two patients were treated for 63 elbow dislocations between January 1981 and July 1991. Eight patients (13%) sustained a concomitant arterial injury involving the brachial (7) and radial (1) arteries. Three clinical findings, absence of a radial pulse, open dislocation, and presence of systemic injuries, were correlated with arterial injury. A palpable radial pulse was absent in six (75%) patients with an arterial injury but in only two (4%) with normal vessels (p less than 0.0001, chi square). Five (33%) open dislocations had an associated arterial injury, whereas three (6%) arterial injuries occurred in closed dislocations (p less than 0.006, chi square). Systemic injury occurred in five dislocations (63%) with arterial injuries and 14 dislocations (25%) without arterial injury (p less than 0.04, chi square). Multivariate analysis showed that absence of a radial pulse was the only factor that significantly predicted arterial injury (p less than 0.0001). Although most elbow dislocations are not associated with arterial injury, absence of a radial pulse or presence of an open dislocation or both should alert the clinician to the increased possibility of an associated vascular injury.