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Bedside monitoring of cerebral energy state during cardiac surgery – a novel approach utilizing intravenous microdialysis
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ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S1–S33
REFERENCE: 1. Carlo Banfi, Matteo Pozzi, Marie-Eve Brunner, Fabio Rigamonti, Nicolas Murith, Damiano Mugnai, Jean- Francois Obadia, Karim Bendjelid, Raphaël Giraud. Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques. J Thorac Dis. 2016;8(9):E875-E885. PP09 Bedside monitoring of cerebral energy state during cardiac surgery – a novel approach utilizing intravenous microdialysis
Simon Mölström1, C Andersen1, T Halfeld Nielsen2, C-H Nordström2, P Toft1 1
Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark 2 Department of Neurosurgery, Odense University Hospital, Odense, Denmark Introduction: Brain damage remains an important complication of cardiac surgery1. During neurocritical care cerebral energy state is routinely evaluated from the lactate to pyruvate (LP) ratio obtained by intracerebral microdialysis (MD). In an experimental study we have recently shown that a global decrease in cerebral oxygenation due to a pronounced decrease in MAP is reflected in an increased LP ratio of the draining venous blood2. This study investigates whether the LP ratio obtained by MD of the cerebral venous outflow reflects a derangement of global cerebral energy state during cardio-pulmonary bypass (CPB). Method: Ten patients undergoing primary, elective coronary artery bypass grafting, were blindly randomised to low MAP (40 to 60 mmHg, n ¼ 5) or high MAP (60 to 80 mmHg, n ¼ 5) during CPB. MD catheters were positioned in a retrograde direction into the jugular bulb and a reference catheter was inserted into the brachial artery. Association between biochemical MD variables, MAP, data obtained from simultaneous bi-frontal near infrared spectroscopy (NIRS), and postoperative neurological outcome measures (MMSE) were assessed. Results: During CPB the mean LP ratio obtained from microdialysis of the internal jugular vein increased significantly by 160 % (low MAP) and 130 % (high MAP). The correlated difference between pooled LP ratio (low and high MAP) of the jugular venous and the arterial blood was significant (LPartery 17 [15-20] vs. LPbulb 26 [23-27]; p ¼ 0.0001). No cerebral desaturations (decrease in rSO2 4 20 % from baseline) were observed in either group utilising NIRS. In both groups 50 % of the patients showed significant cognitive decline (MMSE 3 points) two days after surgery. Discussion: It is technically simple and feasible to place a microdialysis catheter in the jugular bulb and monitor
biochemical variables related to energy metabolism bedside. The LP ratio of cerebral venous blood increased significantly during CPB indicating compromised cerebral oxidative metabolism and was correlated to the decrease in MAP. The increase in the jugular bulb LP ratio was significantly higher than the increase in LP ratio of the arterial blood. There was no significant difference between low and high MAP groups regarding their venous outflow LP ratio during CPB but low MAP patients had tendency to higher LP ratios. Conventional monitoring of rSO2 by NIRS did not show a corresponding decrease in cerebral oxygenation. As the patients exhibited decreased cognitive functions after CPB increase in jugular venous LP ratio may be a sensitive indicator of impending cerebral damage. REFERENCE: 1. McDonagh DL, Berger M, Mathew JP, et al. Neurological complications of cardiac surgery. Lancet neurology. 2014. 2. Jakobsen R, Halfeld Nielsen T, Granfeldt A, et al. A technique for continuous bedside monitoring of global cerebral energy state. Intensive Care Med Exp. 4:3, 2016.
PP10 Vasoplegia syndrome in cardiac surgery: combined use of hydrocortisone and N-acetylcysteine, description of two clinical cases
Francesca Volpi1, C Todisco1, R Ciampichini1, V Beato1, L Quondam Girolamo1, EV Manini1, F Mencarelli1, F Bocci1, P Sini1, L Pompili1, C Serra1, I di Bella2, A Affronti2, N Dentini1 1
Santa Maria Della Misericordia Hospital, Department of Anaesthesia, Post Cardiac Surgery Intensive Therapy, Perugia, Italy 2 Santa Maria della Misericordia Hospital, Department of Cardiac Surgery, Perugia, Italy Introduction: Vasoplegia syndrome is a known complication after heart surgery and is associated with high morbidity and mortality. It is characterised by marked vasodilation and loss of peripheral vascular resistance. The pathogenesis is multifactorial and involves activation from contact, intrinsic and extrinsic coagulation pathway, the complement system, activation of cytokines, endothelial cells and platelets resulting in widespread syndrome. Interleukin 6 (IL-6) and interleukin 8 (IL8) produced during this inflammatory process have a negative inotropic effect that could worsen the cardiac outcome also. IL6 and free oxygen radicals cause no reply to vasopressors. Treatment requires the administration of vasopressors, but hypotension may be refractory to such drugs. Corticosteroids significantly reduces the inflammatory response associated with cardiopulmonary bypass and Nacetylcysteine works as a powerful antioxidant
ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S1–S33
REFERENCE: 1. Carlo Banfi, Matteo Pozzi, Marie-Eve Brunner, Fabio Rigamonti, Nicolas Murith, Damiano Mugnai, Jean- Francois Obadia, Karim Bendjelid, Raphaël Giraud. Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques. J Thorac Dis. 2016;8(9):E875-E885. PP09 Bedside monitoring of cerebral energy state during cardiac surgery – a novel approach utilizing intravenous microdialysis
Simon Mölström1, C Andersen1, T Halfeld Nielsen2, C-H Nordström2, P Toft1 1
Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark 2 Department of Neurosurgery, Odense University Hospital, Odense, Denmark Introduction: Brain damage remains an important complication of cardiac surgery1. During neurocritical care cerebral energy state is routinely evaluated from the lactate to pyruvate (LP) ratio obtained by intracerebral microdialysis (MD). In an experimental study we have recently shown that a global decrease in cerebral oxygenation due to a pronounced decrease in MAP is reflected in an increased LP ratio of the draining venous blood2. This study investigates whether the LP ratio obtained by MD of the cerebral venous outflow reflects a derangement of global cerebral energy state during cardio-pulmonary bypass (CPB). Method: Ten patients undergoing primary, elective coronary artery bypass grafting, were blindly randomised to low MAP (40 to 60 mmHg, n ¼ 5) or high MAP (60 to 80 mmHg, n ¼ 5) during CPB. MD catheters were positioned in a retrograde direction into the jugular bulb and a reference catheter was inserted into the brachial artery. Association between biochemical MD variables, MAP, data obtained from simultaneous bi-frontal near infrared spectroscopy (NIRS), and postoperative neurological outcome measures (MMSE) were assessed. Results: During CPB the mean LP ratio obtained from microdialysis of the internal jugular vein increased significantly by 160 % (low MAP) and 130 % (high MAP). The correlated difference between pooled LP ratio (low and high MAP) of the jugular venous and the arterial blood was significant (LPartery 17 [15-20] vs. LPbulb 26 [23-27]; p ¼ 0.0001). No cerebral desaturations (decrease in rSO2 4 20 % from baseline) were observed in either group utilising NIRS. In both groups 50 % of the patients showed significant cognitive decline (MMSE 3 points) two days after surgery. Discussion: It is technically simple and feasible to place a microdialysis catheter in the jugular bulb and monitor
biochemical variables related to energy metabolism bedside. The LP ratio of cerebral venous blood increased significantly during CPB indicating compromised cerebral oxidative metabolism and was correlated to the decrease in MAP. The increase in the jugular bulb LP ratio was significantly higher than the increase in LP ratio of the arterial blood. There was no significant difference between low and high MAP groups regarding their venous outflow LP ratio during CPB but low MAP patients had tendency to higher LP ratios. Conventional monitoring of rSO2 by NIRS did not show a corresponding decrease in cerebral oxygenation. As the patients exhibited decreased cognitive functions after CPB increase in jugular venous LP ratio may be a sensitive indicator of impending cerebral damage. REFERENCE: 1. McDonagh DL, Berger M, Mathew JP, et al. Neurological complications of cardiac surgery. Lancet neurology. 2014. 2. Jakobsen R, Halfeld Nielsen T, Granfeldt A, et al. A technique for continuous bedside monitoring of global cerebral energy state. Intensive Care Med Exp. 4:3, 2016.
PP10 Vasoplegia syndrome in cardiac surgery: combined use of hydrocortisone and N-acetylcysteine, description of two clinical cases
Francesca Volpi1, C Todisco1, R Ciampichini1, V Beato1, L Quondam Girolamo1, EV Manini1, F Mencarelli1, F Bocci1, P Sini1, L Pompili1, C Serra1, I di Bella2, A Affronti2, N Dentini1 1
Santa Maria Della Misericordia Hospital, Department of Anaesthesia, Post Cardiac Surgery Intensive Therapy, Perugia, Italy 2 Santa Maria della Misericordia Hospital, Department of Cardiac Surgery, Perugia, Italy Introduction: Vasoplegia syndrome is a known complication after heart surgery and is associated with high morbidity and mortality. It is characterised by marked vasodilation and loss of peripheral vascular resistance. The pathogenesis is multifactorial and involves activation from contact, intrinsic and extrinsic coagulation pathway, the complement system, activation of cytokines, endothelial cells and platelets resulting in widespread syndrome. Interleukin 6 (IL-6) and interleukin 8 (IL8) produced during this inflammatory process have a negative inotropic effect that could worsen the cardiac outcome also. IL6 and free oxygen radicals cause no reply to vasopressors. Treatment requires the administration of vasopressors, but hypotension may be refractory to such drugs. Corticosteroids significantly reduces the inflammatory response associated with cardiopulmonary bypass and Nacetylcysteine works as a powerful antioxidant