Propofol requirement titrated to bispectral index: a comparison between hypothermic and normothermic cardiopulmonary bypass

Though propofol requirement is expected to decrease during cardiopulmonary bypass (CPB), a few studies have failed to demonstrate this. The factors affecting pharmacokinetics of propofol and, therefore, the requirement, are different during hypothermic and normothermic CPB. We evaluated and compared the requirement of propofol during hypothermic and normothermic CPB. Fifty adult patients scheduled for elective cardiac surgery on CPB were recruited and randomly allocated into hypothermic CPB (28–300 C) (Group H) and normothermic CPB (35–370 C) (Group N) groups. Patients were induced and maintained with propofol titrated to maintain a target bispectral index (BIS) of 50 ± 10. Propofol requirement (mean ± SD) was similar in normothermic and hypothermic groups, both before CPB (4.9 ± 1.5 mg.kg−1hr−1 in Group N, 4.6 ± 1.5 mg.kg−1hr−1 in Group H) and after cessation of bypass (p > 0.05) (4.6 ± 1.8 mg.kg−1hr−1 in Group N and 4.3 ± 1.7 mg.kg−1hr−1 in Group H). CPB significantly reduced (p < 0.001) propofol requirements in both arms of the study (Group N: 2.9 ± 1.4 mg.kg−1hr−1and Group H: 1.3 ± 0.7 mg.kg−1hr−1). This reduction was more pronounced in the hypothermic group (p < 0.001). The BIS (median ± inter quartile range) remained constant during normothermic CPB (50 ± 8.8), but declined significantly during hypothermic CPB (41 ± 5.6) despite decreased usage of propofol during hypothermia. No patient had recall of intra-operative events. CPB decreases the magnitude of propofol requirements and the effect of hypothermic CPB is significantly more than that of normothermic CPB.

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Relation between Prolonged Cardiopulmonary Bypass Time in Cardiac Surgery in Adult Patients and Post-Operative Acute Kidney Injury

QJM ◽

10.1093/qjmed/hcab086.070 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mohamed Abd-El Khalek Mohamed Ali ◽

Diaa Abd-El Khalek Akl ◽

Mohamed Samir Mohamed Salama

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Kidney Injury ◽

Acute Kidney Injury Network ◽

Adult Patients ◽

Cardiopulmonary Bypass Time ◽

Elective Cardiac Surgery ◽

Short And Long Term ◽

Long Term Prognosis

Abstract Background Cardiac-surgery associated acute kidney injury (CSA-AKI) remains an important and frequent complication in patients undergoing cardiac surgery and is associated with a poor short- and long-term prognosis. The incidence for CSA-AKI according to Acute Kidney Injury Network criteria (AKIN) varies between 3% and 50%. CSA-AKI requiring temporary renal replacement therapy (RRT) occurs in 5% to 20% of these patients and is associated with a high mortality rate. Objective To detect the relation between prolonged cardiopulmonary bypass time in cardiac surgery and the incidence of post-operative acute kidney injury. Patients and Methods This is an observational retrospective study conducted on (80) adult patients who underwent elective cardiac surgery at Aswan Heart Centre (Magdi Yacoub Foundation) after the approval of the Ethical Medical Committee of Aswan Heart Centre. Results Results of the statistical analysis of the present study showed that mean CPB duration was prolonged in the AKI group of patients (155 min) than the non-AKI group of patients (129 min). Conclusion Prolonged cardiopulmonary bypass duration may be an independent risk factor for acute kidney injury post cardiac surgery in adult patients.

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Effect of Subzero-Balanced Ultrafiltration on Lung Gas Exchange Capacity after Cardiopulmonary Bypass in Adult Patients with Heart Valve Disease

The Heart Surgery Forum ◽

10.1532/hsf98.20101075 ◽

2011 ◽

Vol 14 (1) ◽

pp. 22 ◽

Cited By ~ 1

Author(s):

Tao Zhang ◽

Sheng-li Jiang ◽

Chang-qing Gao ◽

Jin Luo ◽

Lan Ma ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Gas Exchange ◽

Heart Valve ◽

Exchange Capacity ◽

Adult Patients ◽

Heart Valve Disease ◽

Arterial Oxygen ◽

Control Group ◽

Study Group

Objectives: This study was conducted to evaluate the effect of a new ultrafiltration techniquethe subzerobalanced ultrafiltration (SBUF)on lung gas exchange capacity after cardiopulmonary bypass (CPB) in adult patients with heart valve disease.Background: Attenuation of lung gas exchange capacity is one of the most common manifestations of an inflammatory response after CPB.Methods: Ninety-four patients who required CPB for cardiac surgery were randomized into 2 groups according to whether they received SBUF. Gas exchange capacity expressed as the oxygen index (OI), the respiratory index (RI), and the alveolar-arterial oxygen pressure difference (P(A-a)O2) were measured after intubation (T1), at the termination of CPB (T2), on admission to the intensive care unit (ICU) (T3), at postoperative hour 6 (T4), and at postoperative hour 12 (T5).Results: There were no significant differences in gas exchange capacity between the 2 groups at T1, T4, and T5. CPB produced significant changes in OI, RI, and P(A-a)O2 in the control group, whereas these changes were not significantly different in the study group. The OI in the study group was significantly higher at T2, and RI and P(A-a)O2 were significantly lower at T2 and T3. In the study group, the intubation time was shorter, and the transfusion volume within 24 hours postoperatively was less. The 2 groups were comparable with respect to the incidence of respiratory complications, length of stay in the ICU, duration of hospital stay, need for infusions of inotropic agents, and drainage volumes within 24 hours postoperatively.Conclusions: SBUF during CPB can produce an immediate improvement in lung gas exchange capacity, which may effectively minimize pulmonary dysfunction in adult patients undergoing cardiac surgery.

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Early pulmonary compliance increase during cardiac surgery predicted post-operative lung dysfunction

Perfusion ◽

10.1177/0267659117713592 ◽

2017 ◽

Vol 32 (8) ◽

pp. 631-638 ◽

Cited By ~ 1

Author(s):

Yann Sacuto ◽

Thierry Sacuto

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Lung Injury ◽

Experimental Studies ◽

Anesthetic Induction ◽

Elective Cardiac Surgery ◽

Surgical Closure ◽

Pulmonary Compliance ◽

Heart Operation ◽

Lung Dysfunction

Introduction: Lung dysfunction following cardiac surgery is currently viewed as the consequence of atelectasis and lung injury. While the mechanism of atelectasis has been largely detailed, the pathogenesis of lung injury after cardiopulmonary bypass is still unclear. Based upon clinical and experimental studies, we hypothesized that lungs could be injured through a mechanical phenomenon. Methods: We recorded pulmonary compliance at six key moments of a heart operation in 62 adult patients undergoing elective cardiac surgery. We focused on the period lasting from anesthetic induction to aorta unclamping. We calculated the variation of static and dynamic pulmonary compliance caused by thorax opening; ΔCstat1 and ΔCdyn1 and that caused by cardiopulmonary bypass, ΔCstat2 and ΔCdyn2. Blood gases were performed under standardized ventilation after anesthetic induction and after surgical closure. The PaO2/FiO2 ratio was calculated. ∆PaO2/FiO2 was the criterion for lung dysfunction. We compared ΔCstat1 and ΔCdyn1 with both ∆PaO2/FiO2 and, respectively, ΔCstat2 and ΔCdyn2. Results: Static and dynamic compliance increased with the opening of the thorax and decreased with the start of cardiopulmonary bypass. The PaO2/FiO2 ratio diminished after surgery. ΔCstat1 and ΔCdyn1 were negatively correlated with both ∆PaO2/FiO2 (r=-0.42; p<0.001 and r=-0.44; p<0.001) and, respectively, with ΔCstat2 and ΔCdyn2 (r=-0.59; p<0.001 and r=-0.53; p<0.001). Conclusions: Increased pulmonary compliance induced by the opening of the thorax is correlated with worsened intrapulmonary shunt after cardiopulmonary bypass. A mechanical phenomenon could be partly responsible for post-operative hypoxemia.

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Predictors of postoperative cognitive dysfunction in adult patients undergoing elective cardiac surgery

Indian Journal of Anaesthesia ◽

10.4103/0019-5049.135077 ◽

2014 ◽

Vol 58 (3) ◽

pp. 334 ◽

Cited By ~ 3

Author(s):

Madanmohan Shiraboina ◽

Syamasundara Ayya ◽

RV Kumar ◽

Padmaja Durga ◽

Ramachandran Gopinath ◽

...

Keyword(s):

Cardiac Surgery ◽

Cognitive Dysfunction ◽

Postoperative Cognitive Dysfunction ◽

Adult Patients ◽

Elective Cardiac Surgery

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Low dose aprotinin and low dose tranexamic acid in elective cardiac surgery with cardiopulmonary bypass

Clinical Hemorheology and Microcirculation ◽

10.3233/ch-2009-1197 ◽

2009 ◽

Vol 42 (4) ◽

pp. 269-277 ◽

Cited By ~ 4

Author(s):

Thomas Waldow ◽

Diana Krutzsch ◽

Michael Wils ◽

Katrin Plötze ◽

Klaus Matschke

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Tranexamic Acid ◽

Low Dose ◽

Elective Cardiac Surgery

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Esmolol before cardioplegia and as cardioplegia adjuvant reduces cardiac troponin release after cardiac surgery. A randomized trial

Perfusion ◽

10.1177/0267659116681437 ◽

2016 ◽

Vol 32 (4) ◽

pp. 313-320 ◽

Cited By ~ 9

Author(s):

Elena Bignami ◽

Marcello Guarnieri ◽

Annalisa Franco ◽

Chiara Gerli ◽

Monica De Luca ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Placebo Group ◽

Cardiopulmonary Bypass ◽

Hospital Stay ◽

Troponin T ◽

Mechanical Activity ◽

Double Blind ◽

Elective Cardiac Surgery

Background: Cardioplegic solutions are the standard in myocardial protection during cardiac surgery, since they interrupt the electro-mechanical activity of the heart and protect it from ischemia during aortic cross-clamping. Nevertheless, myocardial damage has a strong clinical impact. We tested the hypothesis that the short-acting beta-blocker esmolol, given immediately before cardiopulmonary bypass and as a cardioplegia additive, would provide an extra protection to myocardial tissue during cardiopulmonary bypass by virtually reducing myocardial activity and, therefore, oxygen consumption to zero. Materials and methods: This was a single-centre, double-blind, placebo-controlled, parallel-group phase IV trial. Adult patients undergoing elective valvular and non-valvular cardiac surgery with end diastolic diameter >60 mm and ejection fraction <50% were enrolled. Patients were randomly assigned to receive either esmolol, 1 mg/kg before aortic cross-clamping and 2 mg/kg with Custodiol® crystalloid cardioplegia or equivolume placebo. The primary end-point was peak postoperative troponin T concentration. Troponin was measured at Intensive Care Unit arrival and at 4, 24 and 48 hours. Secondary endpoints included ventricular fibrillation after cardioplegic arrest, need for inotropic support and intensive care unit and hospital stay. Results: We found a reduction in peak postoperative troponin T, from 1195 ng/l (690–2730) in the placebo group to 640 ng/l (544–1174) in the esmolol group (p=0.029) with no differences in Intensive Care Unit stay [3 days (1-6) in the placebo group and 3 days (2-5) in the esmolol group] and hospital stay [7 days (6–10) in the placebo group and 7 days (6–12) in the esmolol group]. Troponin peak occurred at 24 hours for 12 patients (26%) and at 4 hours for the others (74%). There were no differences in other secondary end-points. Conclusions: Adding esmolol to the cardioplegia in high-risk patients undergoing elective cardiac surgery reduces peak postoperative troponin levels. Further investigation is necessary to assess esmolol effects on major clinical outcomes.

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Minimal invasive extracorporeal circulation preserves platelet function after cardiac surgery: a prospective observational study

Perfusion ◽

10.1177/0267659119866289 ◽

2019 ◽

Vol 35 (2) ◽

pp. 138-144

Author(s):

Helena Argiriadou ◽

Polychronis Antonitsis ◽

Anna Gkiouliava ◽

Evangelia Papapostolou ◽

Apostolos Deliopoulos ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Correlation Coefficient ◽

Platelet Function ◽

Extracorporeal Circulation ◽

Point Of Care ◽

Postoperative Bleeding ◽

Minimal Invasive ◽

Elective Cardiac Surgery ◽

Impedance Aggregometry

Introduction: Cardiac surgery on conventional cardiopulmonary bypass induces a combination of thrombocytopenia and platelet dysfunction which is strongly related to postoperative bleeding. Minimal invasive extracorporeal circulation has been shown to preserve coagulation integrity, though effect on platelet function remains unclear. We aimed to prospectively investigate perioperative platelet function in a series of patients undergoing cardiac surgery on minimal invasive extracorporeal circulation using point-of-care testing. Methods: A total of 57 patients undergoing elective cardiac surgery on minimal invasive extracorporeal circulation were prospectively recruited. Anticoagulation strategy was based on individualized heparin management and heparin level–guided protamine titration performed in all patients with a specialized point-of-care device (Hemostasis Management System – HMS Plus; Medtronic, Minneapolis, MN, USA). Platelet function was evaluated with impedance aggregometry using the ROTEM platelet (TEM International GmbH, Munich, Germany). ADPtest and TRAPtest values were assessed before surgery and after cardiopulmonary bypass. Results: ADPtest value was preserved during surgery on minimal invasive extracorporeal circulation (58.2 ± 20 U vs. 53.6 ± 21 U; p = 0.1), while TRAPtest was found significantly increased (90 ± 27 U vs. 103 ± 38 U; p = 0.03). Postoperative ADPtest and TRAPtest values were inversely related to postoperative bleeding (correlation coefficient: −0.29; p = 0.03 for ADPtest and correlation coefficient: −0.28; p = 0.04 for TRAPtest). The preoperative use of P2Y12 inhibitors was identified as the only independent predictor of a low postoperative ADPtest value (OR = 15.3; p = 0.02). Conclusion: Cardiac surgery on minimal invasive extracorporeal circulation is a platelet preservation strategy, which contributes to the beneficial effect of minimal invasive extracorporeal circulation in coagulation integrity.

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Impact of Bispectral Index Monitoring on Propofol Administration in Patients Undergoing Cardiopulmonary Bypass

Anaesthesia and Intensive Care ◽

10.1177/0310057x0703500304 ◽

2007 ◽

Vol 35 (3) ◽

pp. 342-347 ◽

Cited By ~ 10

Author(s):

C. L. Chiu ◽

G. Ong ◽

A. A. Majid

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Bispectral Index ◽

Standard Dose ◽

Controlled Trial ◽

Target Concentration ◽

Hypothermic Cardiopulmonary Bypass ◽

Bispectral Index Monitoring ◽

Group B ◽

Index Value

Propofol anaesthesia using target control infusion during cardiac surgery has become more popular recently. However, without depth of anaesthesia monitoring, the standard target concentration used may be higher than necessary to maintain adequate hypnosis during hypothermic cardiopulmonary bypass. The purpose of this study was to evaluate the effect of bispectral index monitoring on propofol administration during hypothermic cardiopulmonary bypass. After ethics committee approval and written informed consent, 20 New York Heart Association class I-III patients scheduled for elective cardiac surgery requiring hypothermic cardiopulmonary bypass were studied in this prospective randomised controlled trial. In group C, routine anaesthesia was practised, where patients received propofol at target concentration between 1.5 to 2.5 μ/ml during cardiopulmonary bypass. In group B, the target concentration was titrated to a bispectral index value of 40 to 50. Mean arterial pressure and bispectral index were recorded at various time intervals. The use of propofol, phenylephrine, sodium nitroprusside and adrenaline were recorded. The median propofol administration in group B was significantly less than that in group C (2.9 mg/kg/h compared to 6.0 mg/kg/h). The bispectral index value during bypass was significantly lower in group C than in group B, reflecting a deeper state of anaesthesia. There was no difference in the use of inotropes, vasoconstrictors or vasodilators. Bispectral index monitoring enables a 50% reduction in propofol administration at this standard dose during hypothermic cardiopulmonary bypass.

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