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Objective: We investigated the effects of the maintenance of angiotensinconverting enzyme inhibitors (ACE inhibitors) the day of the surgery on the incidence of postoperative acute kidney injury (AKI) and cardiac events in patients undergoing cardiac surgery. Methods: We performed a multicentric observational study with propensity matching on 1,072 patients treated with ACE inhibitors. We collected their baseline demographic data, comorbidities, and operative and postoperative outcomes. AKI was defined by KDIGO (Kidney Disease: Improving Global Outcome). Results: Maintenance of an ACE inhibitor was not associated with an increased risk of AKI (OR: 1.215 (CI95%:0.657-2.24), p = 0.843, 71 patients (25.1%) vs. 68 patients (24%)). Multivariate logistic regression and sensitive analysis did not demonstrate any association between ACE inhibitor maintenance and AKI, following cardiac surgery (OR: 1.03 (CI95%:0.81-1.3)). No statistically significant difference occurs in terms of incidence of cardiogenic shock (OR: 1.315 (CI95%: 0.620-2.786)), stroke (OR: 3.313 (CI95%:0.356-27.523)), vasoplegia (OR: 0.741 (CI95%:0.419-1.319)), postoperative atrial fibrillation (OR: 1.710 (CI95%: 0.936-3.122)), or mortality (OR: 2.989 (CI95%:0.343-26.034)). ICU and hospital length of stays did not differ (3 [2; 5] vs. 3 [2; 5] days, p = 0.963 and 9.5 [8; 12] vs. 10 [8; 14] days, p = 0.638). Conclusion: Our study revealed that maintenance of ACE inhibitors on the day of the surgery was not associated with increased postoperative AKI. ACE inhibitor maintenance was also not associated with an increased rate of postoperative major cardiovascular events (arterial hypotension, cardiogenic shock, vasopressors use, stroke and death). [ABSTRACT FROM AUTHOR]

Opioid-free anaesthesia (OFA) is general anaesthesia based on the use of several non-opioid molecules that aim to have an analgesic effect, decrease the sympathetic response, decrease hormonal stress, and decrease the inflammatory response during surgery. Although this approach to anaesthesia is regularly used in clinical practice, it remains a novel approach. The literature on this anaesthesia modality finds a number of positive effects on cardiac, respiratory, and cognitive function but no randomised study evaluated these effects during cardiac surgery where there is a high incidence of postoperative complications. The main aim of the study is to compare OFA vs. standard balanced opioid general anaesthesia on the incidence of postoperative complications and the length of stay in intensive care and hospital. OFACAR is a multicentric, randomised, controlled, superiority, single-blind, two parallel-arm clinical trial in patients undergoing cardiac surgery with cardiopulmonary bypass. We compared a balanced general anaesthesia without opioids (OFA group) vs. a balanced opioid general anaesthesia with sufentanil (control group). One hundred and sixty patients will be enrolled in each treatment group. The primary endpoint is a composite one which corresponds to the occurrence of at least one of the postoperative complications, defined according to European standards within 30 days after surgery. Recruitment started in September 2019, and data collection is expected to end in November 2024. [ABSTRACT FROM AUTHOR]

Purpose: Cardiac surgery with cardiopulmonary bypass triggers sterile inflammation that is responsible for post-operative morbidity. Automated flow cytometry devices used for leucocyte count provide cell population data (CPD) regarding fluorescence intensity, size and granularity of leukocytes that have never been studied in the context of sterile inflammation. Our objective was to explore leukocyte cell population data in patients undergoing cardiac surgery with cardiopulmonary bypass in order to determine whether CPD could be used to monitor immune cell activation. Methods: This is an ancillary study of a cohort of patients undergoing cardiac surgery with cardiopulmonary bypass. Cell population data (CPD) extracted from a routine automated flow cytometer were analyzed (Fluorescence targeted to nucleic acids). The time points of interest were: pre-operative, postoperative and 5 days after surgery. The variations in those parameters were studied. Data were then compared between patients according to the occurrence of a composite criteria (supra-ventricular arrythmia, stroke, acute renal failure, and/or death). Results: Data from 1453 patients were analyzed. The neutrophil count, fluorescence granularity (NE-SCC), intensity (NE-SFL) and size (NE-FSC) increased with surgery. Heterogeneity of neutrophils decreased in terms of fluorescence granularity (NE-WX) and size (NE-WZ) but increased in terms of intensity (NE-WY). The lymphocyte count decreased with surgery. While fluorescence granularity (LY-X) and size increased (LY-Z), Lymphocyte intensity decreased (LY-Y). Lymphocytes were less heterogeneous in terms of their granularity, size and intensity after surgery (LY-WX, LY-WY, LY-WZ). Patients who developed the composite complication criteria had a higher pre-operative neutrophil count (5.08 [3.89;6.95] vs 4.76 [3.60;6.13], p = 0.02; AUC = 0.56 [0.51;0.60]), and more heterogeneous neutrophils in terms of fluorescence granularity (NE-WX, AUC = 0.57 [0.52;0.62]) and intensity (NE-WY, AUC 0.61 [0.56;0.65]). Those patients also had lower pre-operative lymphocyte count (1.49 [1.10;1.14] vs 1.81 [1.39;2.39], p<0.01, AUC = 0.61 [0.57;0.66]) and fluorescence granularity (LY-X, AUC = 0.57 [0.53;0.62]). NE-WX, NE-WY and LYX were associated with post-operative complications after adjustment on the EuroSCORE 2 (adjusted odd ratio of 1.01 [1.00;1.02]; 1.01 [1.00;1.01] and 1.08 [1.02;1.15] respectively). Conclusion: Cardiac surgery with cardiopulmonary bypass was associated with substantial alterations of CPD probably reflecting leukocytes activation in sterile inflammation. Pre-operative NE-WX, NE-WY and LY-X biomarkers levels were associated with post-operative complications, independently of the EuroSCORE 2. Such routine, unexploited and low cost parameters might represent useful tools likely to monitor immune function and predict outcomes for patients undergoing cardiac surgery. Our findings requires validation on a larger external cohort. [ABSTRACT FROM AUTHOR]

Introduction: The use of extracorporeal life support (ECLS) is increasing worldwide, in particular for the management of refractory cardiac arrest, cardiogenic shock and post cardiopulmonary bypass ventricular failure. Extubation of patients under extracorporeal membrane oxygenation (ECMO) for respiratory failure is a growing practice for adult and pediatric patients, especially for lung transplantation candidates. Because of potential complications and, specifically, accidental arterial decannulation, extubation of patients under ECLS is not standard practice. Our goal was to evaluate the interest in patient extubation under ECLS. Materials and methods: We performed a monocentric, retrospective study of all ECLS cases between January 2014 and January 2016. We excluded patients who died within the first 48 hours of ECLS. Results: We analyzed 57 of the initial 109 patients included in the study. The initial SOFA score was higher in the non-extubated group under ECLS, without significant difference (8.6 ± 2.8 vs 7.2 ± 2.1, p=0.065). Patients who were not extubated had a higher rate of acquired ventilator pneumonia (61.9% vs 26.7%, p=0.03). Moreover, patients who were extubated under ECLS had better 30-day survival rates (73.3% vs 40.5%, p=0.04). In multivariate analyses, the independent factors associated with mortality were age, duration of ECLS and the lack of extubation under ECLS. Conclusion: Extubation of patients under ECLS is safe and feasible. Furthermore, in extubated patients, we observed fewer cases of ventilator-associated pneumonia and better 30-day survival rates. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to evaluate the ability of the ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content to predict an increase in oxygen consumption (VO2) upon fluid challenge (FC). Methods and results: 110 patients admitted to cardiothoracic ICU and in whom the physician had decided to perform an FC (with 500 ml of Ringer's lactate solution) were included. The arterial pressure, cardiac index (Ci), and arterial and venous blood gas levels were measured before and after FC. VO2 and CO2-O2 derived variables were calculated. VO2 responders were defined as patients showing more than a 15% increase in VO2. Of the 92 FC responders, 43 (46%) were VO2 responders. At baseline, pCO2 gap, C(a-v)O2 were lower in VO2 responders than in VO2 non-responders, and central venous oxygen saturation (ScvO2) was higher in VO2 responders. FC was associated with an increase in MAP, SV, and CI in both groups. With regard to ScvO2, FC was associated with an increase in VO2 non-responders and a decrease in VO2 responders. FC was associated with a decrease in pvCO2 and pCO2 gap in VO2 non-responders only. The pCO2 gap/C(a-v)O2 ratio and C(a-v)CO2 content /C(a-v)O2 content ratio did not change with FC. The CO2 gap content/C(a-v)O2 content ratio and the C(a-v)CO2 content /C(a-v)O2 content ratio did not predict fluid-induced VO2 changes (area under the curve (AUC) [95% confidence interval (CI)] = 0.52 [0.39‒0.64] and 0.53 [0.4–0.65], respectively; p = 0.757 and 0.71, respectively). ScvO2 predicted an increase of more than 15% in the VO2 (AUC [95%CI] = 0.67 [0.55‒0.78]; p<0.0001). Conclusions: Our results showed that the ratios of central venous to arterial carbon dioxide content and tension to arteriovenous oxygen content were not predictive of VO2 changes following fluid challenge in postoperative cardiac surgery patients. [ABSTRACT FROM AUTHOR]

We investigated the effects of maintaining beta-blockers on the day of surgery on the incidence of atrial fibrillation and postoperative acute kidney injury (AKI) in patients undergoing cardiac surgery. We conducted a multicentre prospective observational study with propensity matching on patients treated with beta-blockers. We collected their baseline patient characteristics, comorbidities, and operative and postoperative outcomes. The endpoints were postoperative atrial fibrillation and AKI after cardiac surgery. Of the 1789 included patients, propensity matching led to 583 patients in each group. Maintenance of beta-blockers was not associated with a reduced risk of atrial fibrillation (odds ratio: 0.86 [95% confidence interval 0.66–1.14], P =0.335; 141 patients [24.2%] vs 126 patients [21.6%]). Sensitivity analysis did not demonstrate association between beta-blocker maintenance and atrial fibrillation after cardiac surgery (odds ratio: 0.93 [95% confidence interval: 0.72–1.22], P =0.625). Maintenance of beta-blockers was associated with a higher rate of norepinephrine use (415 [71.2%] vs 465 [79.8%], P =0.0001) and postoperative AKI (124 [21.3%] vs 159 [27.3%], P =0.0127). No statistically significant difference was observed in ICU length of stay. Maintenance of beta-blockers on the day of surgery was not associated with a reduced incidence of postoperative atrial fibrillation. However, maintenance of beta-blockers was associated with increased usage of vasopressors, potentially contributing to adverse postoperative renal events. NCT04769752. [ABSTRACT FROM AUTHOR]

Pupillometry has proven effective for the monitoring of intraoperative analgesia in non-cardiac surgery. We performed a prospective randomized study to evaluate the impact of an analgesia-guided pupillometry algorithm on the consumption of sufentanyl during cardiac surgery. Fifty patients were included prior to surgery. General anesthesia was standardized with propofol and target-controlled infusions of sufentanyl. The standard group consisted of sufentanyl target infusion left to the discretion of the anesthesiologist. The intervention group consisted of sufentanyl target infusion based on the pupillary pain index. The primary outcome was the total intraoperative sufentanyl dose. The total dose of sufentanyl was lower in the intervention group than in the control group and (55.8 µg [39.7–95.2] vs 83.9 µg [64.1–107.0], p = 0.04). During the postoperative course, the cumulative doses of morphine (mg) were not significantly different between groups (23 mg [15–53] vs 24 mg [17–46]; p = 0.95). We found no significant differences in chronic pain at 3 months between the 2 groups (0 (0%) vs 2 (9.5%) p = 0.49). Overall, the algorithm based on the pupillometry pain index decreased the dose of sufentanyl infused during cardiac surgery. Clinical trial number: NCT03864016. [ABSTRACT FROM AUTHOR]

To evaluate the impact of a dynamic arterial elastance guided norepinephrine weaning strategy on the occurrence of acute kidney injury (AKI) in patients with vasoplegia after cardiac surgery. A post-hoc analysis of a monocentric randomized controlled trial. A tertiary care hospital in France. Vasoplegic cardiac surgical patients treated with norepinephrine. Patients were randomized to an algorithm-based norepinephrine weaning intervention (dynamic arterial elastance) group or a control group. The primary endpoint was the number of patients with AKI defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The secondary endpoint were major adverse cardiac post-operative events (new onset of atrial fibrillation or flutter, low cardiac output syndrome, and in-hospital death). End points were evaluated during the first seven post-operative days. 118 patients were analyzed. In the overall study population, the mean age was 70 (62–76) years, 65% were male and the median EuroSCORE was 7 (5–10). Overall, 46 (39%) patients developed AKI (30 KDIGO 1, 8 KDIGO 2, 8 KDIGO 3), and 6 patients required renal replacement therapy. The incidence of AKI was significantly lower in the intervention group than in the control group (16 patients (27%) vs 30 patients (51%), p = 0.12). Higher dose and longer duration of norepinephrine were associated with AKI severity. Decreasing norepinephrine exposure by using a dynamic arterial elastance guided norepinephrine weaning strategy was associated with a reduced incidence of acute kidney injury in patients with vasoplegia after cardiac surgery. Further prospective multicentric studies are needed to confirm these results. • Norepinephrine dose is associated with acute kidney injury (AKI) after cardiac surgery. • A dynamic elastance based norepinephrine weaning strategy decreased the incidence of acute kidney injury. • Higher dose and longer duration of norepinephrine were associated with AKI severity. [ABSTRACT FROM AUTHOR]

The present study was designed to describe the prevalence of norepinephrine use, the factors associated with its use, and the incidence of postoperative complications according to norepinephrine use, in patients undergoing cardiac surgery with cardiopulmonary bypass. We performed a prospective, multicenter, observational study in 4 University-affiliated medico-surgical cardiovascular units. We analyzed all patients treated with cardiac surgery after excluding pre-ECMO surgery, LVAD implantation, heart transplantation and intra-operative hemorrhage. Of 9316 patients screened during the study period, 2862 were included and 2510 were analyzed. Among them, 1549 (61%) were treated with norepinephrine with a median maximal dose of 0.11 [0.06−0.2] μg.kg−1.min−1 and a median duration of 10 h [2–24]. Norepinephrine was most often started in the operating room before cardiopulmonary bypass. The multiple regression logistic analysis identified several modifiable (haematocrit, maintenance of beta-blocker, cardiopulmonary bypass time, glucose-insulin-potassium, Custodiol cardioplegia, Delnido cardioplegia, and fibrinogen transfusion) and non-modifiable factors (age, ASA score, chronic high blood pressure, coronary disease, dyslipidemia, right ventricular dysfunction, left ventricular dysfunction, active endocarditis, and valvular aortic surgery) associated with norepinephrine use. Mortality, morbidity (neurological and renal complications, death) and length of stay in the ICU were higher in patients treated with norepinephrine. Norepinephrine is often used in cardiac surgical patients but for <24 h with a low dose. Many preoperative and surgical factors are associated with norepinephrine use. Patients supported by norepinephrine have a higher incidence of major postoperative events. [ABSTRACT FROM AUTHOR]

• In patient with cardiopulmonary by-pass, GLP-1 was associated with LPS translocation. • GLP-1 and LPS translocation were associated with inflammation and complications. • There was no correlation between I-FABP and LPS plasma concentration. • Our results support that GLP-1 could be a marker of mucosal integrity in human. Cardiac surgery with cardiopulmonary bypass (CPB) is associated with gut barrier dysfunction. Gut barrier dysfunction might be estimated non-invasively by lipopolysaccharide (LPS) plasma concentration. Glucagon-like peptide-1 (GLP-1) is a gut secreted hormone that is a potential marker of mucosal integrity. Our objective was to evaluate GLP-1 as a peri -operative marker of gut barrier dysfunction in patients undergoing cardiac surgery with CPB. GLP-1, intestinal fatty acid binding protein (I-FABP) and lipopolysaccharide were assayed: at induction, after CPB and 24 h after admission in the intensive care unit. The primary end-point was peri -operative lipopolysaccharide concentration (LPS concentration at those 3 time points). Seventy-two patients were included in the present analysis. The highest measured post-operative GLP-1 concentration was in the sample taken 24 h after admission to intensive care, which was associated with peri -operative lipopolysaccharide plasma concentration. Patients who had the highest GLP-1 concentrations at 24 h experienced more severe inflammation and worse clinical outcomes. Our study supports that GLP-1 is not only a hormone of glucose metabolism but is also secreted when gut barrier is impaired in cardiac surgery with CPB. The GLP-1 levels measured 24 h after admission to the intensive care unit were associated with LPS concentration, inflammation and clinical outcomes. [ABSTRACT FROM AUTHOR]