- Email: [email protected]
Encephalography guidance of anesthesia to alleviate geriatric syndromes (Engages-Canada) study in cardiac surgery patients: a pragmatic, randomized clinical trial
S156
34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
centers. The effect of case volume on cumulative all-cause mortality was also assessed. Results: A total of 6041 cases were performed in 86 centers. One-year mortality was 10.1% (175/1728), 8.7% (93/1067), and 4.7% (153/3246) in low-, medium-, and high-volume centers, respectively. Low- and medium-volume centers showed increased risk of 1-year mortality compared to high-volume centers (OR [95% CI]; 2.80 [2.15 3.64] and 2.66 [1.94 3.64], respectively.). The risk of cumulative all-cause mortality of up to 10 years was also worse in low- and medium-volume centers (HR [95% CI]; 1.96 [1.68 2.29] and 1.77 [1.47 2.12], respectively.). Discussion: Lower case-volume was associated with higher risk of mortality after mitral valve repair. A minimum case volume may be required for hospitals performing mitral valve repair to guarantee adequate patient outcome. REFERENCES: D’Agostino RS, Jacobs JP, Badhwar V, Paone G, Rankin JS, Han JM, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2017 Update on Outcomes and Quality. Ann Thorac Surg. 2017;103(1):18-24. Falk V, Baumgartner H, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017;52(4):616-64. Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159-e95. Lazam S, Vanoverschelde JL, Tribouilloy C, Grigioni F, Suri RM, Avierinos JF, et al. Twenty-Year Outcome After Mitral Repair Versus Replacement for Severe Degenerative Mitral Regurgitation: Analysis of a Large, Prospective, Multicenter, International Registry. Circulation. 2017;135 (5):410-22. LaPar DJ, Ailawadi G, Isbell JM, Crosby IK, Kern JA, Rich JB, et al. Mitral valve repair rates correlate with surgeon and institutional experience. J Thorac Cardiovasc Surg. 2014;148 (3):995-1003; discussion-4.
PP.02.23
Methods: In this prospective observational study, we included patients who underwent open lobectomy. Cardiovascular markers were recorded postoperatively, in order to correlate the fluctuation of these markers with the application or not of thoracic epidural anesthesia. Results: Forty-eight (48) patients were enrolled, 15 (31.3%) received a combination of thoracic epidural anesthesia with general anesthesia, while 33 (68.7%) received general anesthesia alone. Patients with epidural anesthesia were found to have significantly lower levels of troponin 12-24 hours after surgery (8.9 § 4.1 versus 16.8 § 10.5, p <0.05), while 48 to 72 hours postoperatively, the troponin values of the two groups did not appear to differ (10.7 § 6.9 vs. 14.8 § 8.3, p 0.103). Age, sex and body mass index were not found to be significantly associated with the fluctuation of troponin values in this setting. Discussion: Patients who undergo open lobectomy receiving a combination of general and thoracic epidural anesthesia appear to maintain lower troponin levels in the immediate postoperative period than patients receiving general anesthesia alone. REFERENCES: 1. Minto G, Biccard B. Continuing Education in Anaesthesia. Critical Care & Pain 2014;14:127. 2. Korff S, Katus H, Giannitsis E. Differential diagnosis of elevated troponins. Heart 2006;92:98793. 3. VISION investigators et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012;307:2295-304. 4. Sabesan M. Diagnostic markers of acute myocardial infarction. Biomed rep. 2015 Nov; 3(6): 743748. 5. Karzai W. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology 2009;110:1402-11. 6. Leslie K, Mcllroy D. Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial. Br J Anesth 2016;116:100-12. 7. Botto F. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014;120:564-78.
Measurement of cardiac biomarkers in open lobectomies: comparison of combined thoracic epidural anesthesia with general anesthesia to general anesthesia alone
PP.02.24
A. Panagiotou1, A. Tsaroucha2, A. Chalkias3, S. Giannaraki1, C. Romana1
Encephalography guidance of anesthesia to alleviate geriatric syndromes (Engages-Canada) study in cardiac surgery patients: a pragmatic, randomized clinical trial
1
Evaggelismos General Hospital of Athens, Athens, GREECE Aretaieion University Hospital of Athens, Athens, GREECE 3 Larissa University Hospital, Larissa, GREECE 2
Introduction: Troponin is a sensitive biomarker for cardiovascular injury. In lobectomies, perioperative analgesia can be performed with either a combination of thoracic epidural anesthesia and general anesthesia or general anesthesia alone. We wish to demonstrate that patients who receive the former tend to have lower levels of troponin.
J. Palermo1, C. Overbeek1, A. Dumont1, E. Jacobson2, R. El-Gabalwy2, M. Kavosh2, T. Saha3, R. Tanzola3, D. Dumertonshore3, M. Avidan4, J. Oberhaus4, A. Mickle4, G. Djaiani5, A. Deschamps1 1
Universit e de Montr eal, Montreal, CANADA University of Manitoba, Winnipeg, CANADA 3 Queen’s University, Kingston, CANADA 4 Washington University, Saint-Louis, MA, USA 5 University of Toronto, Toronto, CANADA 2
34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
Introduction: Postoperative delirium (POD) is a syndrome characterized by an acute onset of fluctuating confusion, disorganization and inattention. POD is frequent in the cardiac surgery population (incidence between 11-50%), and associated to complications such as increased risk of falls, prolonged hospital stay, functional decline and increased morbidity and mortality. Risk factors for POD are often non-modifiable, such as age, male sex, underlying cognitive or psychiatric conditions, while risk factors more specific to the cardiac surgery population include the type of surgery, cardiopulmonary bypass time, transfusions, and mechanical ventilation time15-18. Recent studies suggest that the use of a processed EEG for titration of anesthesia may reduce the incidence of POD. Burst suppression, or the pathological patterns of high-voltage electrical activity alternating with periods of quiescence may be associated with POD. Our primary objective is to demonstrate whether guiding anesthesia depth using an EEG monitor to avoid episodes burst suppression can result in a decreased incidence and severity of delirium in the cardiac surgery population. Secondly, we want to examine contributing risk factors and sequelae of delirium. Methods: ENGAGES-Canada is an ongoing multi-center, double-blinded, randomized controlled trial across 4 Canadian sites. Patients included are those over the age of 60 scheduled for elective cardiac surgery with cardiopulmonary bypass. Exclusion criteria are pre-operative delirium, illiteracy, history of awareness, and planned surgery within five days of index surgery. Using an anesthesia protocol for EEG-guided anesthesia to avoid burst suppression, patients are randomized to the intervention or the control group (non-utilization of the monitor). The primary outcome is defined as the incidence of postoperative delirium, assessed using the Confusion Assessment Method (CAM) or CAM-ICU, coupled with chart review from day 1 to 5. Secondary outcomes include the effect of known risk factors on the incidence of delirium and 30-day and 1-year patient-reported outcomes of healthrelated quality of life and prevention of falls. Results: Current enrollment includes 600 patients, out of a target population of 1200. An interim analysis was performed at 570 patients. The incidence of delirium across all subjects was 17.5% when considering CAM alone. Patients in the EEG-blinded group spent more cumulative time in burst suppression than those guided by EEG: median 317 seconds versus 136 seconds in the blind and guided groups respectively. Discussion: ENGAGES-CANADA is the first RCT to examine whether avoidance of burst suppression using EEG guidance can decrease the incidence and severity of delirium in a cardiac surgery population.
PP.02.25 A novel oropharyngeal double lumen cannula for transesophageal echocardiography sedation: a case series
S157
C. Nigro Neto, F. Jose Lucena Bezerra, I. Alexander P. Valencia, D. Le Bihan, R. Bellio Mattos Barretto, I. Caroline Bahia de Souza, G. Ramires Silveira, V. Nascimento Dante Pazzanese Institute of Cardiology, S~ ao Paulo, BRAZIL Objectives: Most of the ambulatory transesophageal echocardiography (TEE) are performed under sedation with anesthetists’ accompaniment, and often the patency of the airways is a concern. The main objective of this study was to evaluate a novel oropharyngeal cannula during sedation in a case series of adult patients submitted to ambulatory TEE (Figure 1 Overview of the oropharyngeal double lumen cannula). Methods: After approval by the local ethics committee and obtaining written informed consent, 30 adults patients scheduled to undergo elective ambulatory TEE under sedation were included in the study. Exclusion criteria: Body weight <70kg, emergency procedures, contraindications to elective TEE. Prior to the cannula insertion, all patients received sedation with intravenous Midazolan and bolus doses of Propofol titrated to effect. The cannula was inserted right after loss of consciousness and patient was kept in spontaneous ventilation. We analyzed data of oxygen saturation, capnography, heart rate, noninvasive blood pressure, airways’ patency, cannula insertion and comfort to the examiner. Results: Preliminary results: procedures undergone without major complications and without severe hypoxia and hypercarbia events. We observed a better patency of the airway, allowing capnography monitoring and a port to oxygen supply. This new device also protected the TEE probe against accidental bites and an anchorage for the probe during the exam. Conclusions: The novel double lumen oropharyngeal cannula analyzed in this case series was feasible to be used during ambulatory transesophageal echocardiography. REFERENCES: 1. Jose GM, Silva CE, Ferreira LD et al. Effective dose of sedation in transesophageal echocardiography: relation to age, body surface area and left ventricle function. Arq Bras Cardiol. 2009;93(6):576-81, 623-9. 2. Toman H, Erkilinkc A, Kocak T et al. Sedation for transesophageal echocardiography: comparison of propofol, midazolam and midazolam-alfentanil combination. Med Glas (Zenica). 2016;13(1):18-24.
34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
centers. The effect of case volume on cumulative all-cause mortality was also assessed. Results: A total of 6041 cases were performed in 86 centers. One-year mortality was 10.1% (175/1728), 8.7% (93/1067), and 4.7% (153/3246) in low-, medium-, and high-volume centers, respectively. Low- and medium-volume centers showed increased risk of 1-year mortality compared to high-volume centers (OR [95% CI]; 2.80 [2.15 3.64] and 2.66 [1.94 3.64], respectively.). The risk of cumulative all-cause mortality of up to 10 years was also worse in low- and medium-volume centers (HR [95% CI]; 1.96 [1.68 2.29] and 1.77 [1.47 2.12], respectively.). Discussion: Lower case-volume was associated with higher risk of mortality after mitral valve repair. A minimum case volume may be required for hospitals performing mitral valve repair to guarantee adequate patient outcome. REFERENCES: D’Agostino RS, Jacobs JP, Badhwar V, Paone G, Rankin JS, Han JM, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2017 Update on Outcomes and Quality. Ann Thorac Surg. 2017;103(1):18-24. Falk V, Baumgartner H, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017;52(4):616-64. Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159-e95. Lazam S, Vanoverschelde JL, Tribouilloy C, Grigioni F, Suri RM, Avierinos JF, et al. Twenty-Year Outcome After Mitral Repair Versus Replacement for Severe Degenerative Mitral Regurgitation: Analysis of a Large, Prospective, Multicenter, International Registry. Circulation. 2017;135 (5):410-22. LaPar DJ, Ailawadi G, Isbell JM, Crosby IK, Kern JA, Rich JB, et al. Mitral valve repair rates correlate with surgeon and institutional experience. J Thorac Cardiovasc Surg. 2014;148 (3):995-1003; discussion-4.
PP.02.23
Methods: In this prospective observational study, we included patients who underwent open lobectomy. Cardiovascular markers were recorded postoperatively, in order to correlate the fluctuation of these markers with the application or not of thoracic epidural anesthesia. Results: Forty-eight (48) patients were enrolled, 15 (31.3%) received a combination of thoracic epidural anesthesia with general anesthesia, while 33 (68.7%) received general anesthesia alone. Patients with epidural anesthesia were found to have significantly lower levels of troponin 12-24 hours after surgery (8.9 § 4.1 versus 16.8 § 10.5, p <0.05), while 48 to 72 hours postoperatively, the troponin values of the two groups did not appear to differ (10.7 § 6.9 vs. 14.8 § 8.3, p 0.103). Age, sex and body mass index were not found to be significantly associated with the fluctuation of troponin values in this setting. Discussion: Patients who undergo open lobectomy receiving a combination of general and thoracic epidural anesthesia appear to maintain lower troponin levels in the immediate postoperative period than patients receiving general anesthesia alone. REFERENCES: 1. Minto G, Biccard B. Continuing Education in Anaesthesia. Critical Care & Pain 2014;14:127. 2. Korff S, Katus H, Giannitsis E. Differential diagnosis of elevated troponins. Heart 2006;92:98793. 3. VISION investigators et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012;307:2295-304. 4. Sabesan M. Diagnostic markers of acute myocardial infarction. Biomed rep. 2015 Nov; 3(6): 743748. 5. Karzai W. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology 2009;110:1402-11. 6. Leslie K, Mcllroy D. Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial. Br J Anesth 2016;116:100-12. 7. Botto F. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014;120:564-78.
Measurement of cardiac biomarkers in open lobectomies: comparison of combined thoracic epidural anesthesia with general anesthesia to general anesthesia alone
PP.02.24
A. Panagiotou1, A. Tsaroucha2, A. Chalkias3, S. Giannaraki1, C. Romana1
Encephalography guidance of anesthesia to alleviate geriatric syndromes (Engages-Canada) study in cardiac surgery patients: a pragmatic, randomized clinical trial
1
Evaggelismos General Hospital of Athens, Athens, GREECE Aretaieion University Hospital of Athens, Athens, GREECE 3 Larissa University Hospital, Larissa, GREECE 2
Introduction: Troponin is a sensitive biomarker for cardiovascular injury. In lobectomies, perioperative analgesia can be performed with either a combination of thoracic epidural anesthesia and general anesthesia or general anesthesia alone. We wish to demonstrate that patients who receive the former tend to have lower levels of troponin.
J. Palermo1, C. Overbeek1, A. Dumont1, E. Jacobson2, R. El-Gabalwy2, M. Kavosh2, T. Saha3, R. Tanzola3, D. Dumertonshore3, M. Avidan4, J. Oberhaus4, A. Mickle4, G. Djaiani5, A. Deschamps1 1
Universit e de Montr eal, Montreal, CANADA University of Manitoba, Winnipeg, CANADA 3 Queen’s University, Kingston, CANADA 4 Washington University, Saint-Louis, MA, USA 5 University of Toronto, Toronto, CANADA 2
34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
Introduction: Postoperative delirium (POD) is a syndrome characterized by an acute onset of fluctuating confusion, disorganization and inattention. POD is frequent in the cardiac surgery population (incidence between 11-50%), and associated to complications such as increased risk of falls, prolonged hospital stay, functional decline and increased morbidity and mortality. Risk factors for POD are often non-modifiable, such as age, male sex, underlying cognitive or psychiatric conditions, while risk factors more specific to the cardiac surgery population include the type of surgery, cardiopulmonary bypass time, transfusions, and mechanical ventilation time15-18. Recent studies suggest that the use of a processed EEG for titration of anesthesia may reduce the incidence of POD. Burst suppression, or the pathological patterns of high-voltage electrical activity alternating with periods of quiescence may be associated with POD. Our primary objective is to demonstrate whether guiding anesthesia depth using an EEG monitor to avoid episodes burst suppression can result in a decreased incidence and severity of delirium in the cardiac surgery population. Secondly, we want to examine contributing risk factors and sequelae of delirium. Methods: ENGAGES-Canada is an ongoing multi-center, double-blinded, randomized controlled trial across 4 Canadian sites. Patients included are those over the age of 60 scheduled for elective cardiac surgery with cardiopulmonary bypass. Exclusion criteria are pre-operative delirium, illiteracy, history of awareness, and planned surgery within five days of index surgery. Using an anesthesia protocol for EEG-guided anesthesia to avoid burst suppression, patients are randomized to the intervention or the control group (non-utilization of the monitor). The primary outcome is defined as the incidence of postoperative delirium, assessed using the Confusion Assessment Method (CAM) or CAM-ICU, coupled with chart review from day 1 to 5. Secondary outcomes include the effect of known risk factors on the incidence of delirium and 30-day and 1-year patient-reported outcomes of healthrelated quality of life and prevention of falls. Results: Current enrollment includes 600 patients, out of a target population of 1200. An interim analysis was performed at 570 patients. The incidence of delirium across all subjects was 17.5% when considering CAM alone. Patients in the EEG-blinded group spent more cumulative time in burst suppression than those guided by EEG: median 317 seconds versus 136 seconds in the blind and guided groups respectively. Discussion: ENGAGES-CANADA is the first RCT to examine whether avoidance of burst suppression using EEG guidance can decrease the incidence and severity of delirium in a cardiac surgery population.
PP.02.25 A novel oropharyngeal double lumen cannula for transesophageal echocardiography sedation: a case series
S157
C. Nigro Neto, F. Jose Lucena Bezerra, I. Alexander P. Valencia, D. Le Bihan, R. Bellio Mattos Barretto, I. Caroline Bahia de Souza, G. Ramires Silveira, V. Nascimento Dante Pazzanese Institute of Cardiology, S~ ao Paulo, BRAZIL Objectives: Most of the ambulatory transesophageal echocardiography (TEE) are performed under sedation with anesthetists’ accompaniment, and often the patency of the airways is a concern. The main objective of this study was to evaluate a novel oropharyngeal cannula during sedation in a case series of adult patients submitted to ambulatory TEE (Figure 1 Overview of the oropharyngeal double lumen cannula). Methods: After approval by the local ethics committee and obtaining written informed consent, 30 adults patients scheduled to undergo elective ambulatory TEE under sedation were included in the study. Exclusion criteria: Body weight <70kg, emergency procedures, contraindications to elective TEE. Prior to the cannula insertion, all patients received sedation with intravenous Midazolan and bolus doses of Propofol titrated to effect. The cannula was inserted right after loss of consciousness and patient was kept in spontaneous ventilation. We analyzed data of oxygen saturation, capnography, heart rate, noninvasive blood pressure, airways’ patency, cannula insertion and comfort to the examiner. Results: Preliminary results: procedures undergone without major complications and without severe hypoxia and hypercarbia events. We observed a better patency of the airway, allowing capnography monitoring and a port to oxygen supply. This new device also protected the TEE probe against accidental bites and an anchorage for the probe during the exam. Conclusions: The novel double lumen oropharyngeal cannula analyzed in this case series was feasible to be used during ambulatory transesophageal echocardiography. REFERENCES: 1. Jose GM, Silva CE, Ferreira LD et al. Effective dose of sedation in transesophageal echocardiography: relation to age, body surface area and left ventricle function. Arq Bras Cardiol. 2009;93(6):576-81, 623-9. 2. Toman H, Erkilinkc A, Kocak T et al. Sedation for transesophageal echocardiography: comparison of propofol, midazolam and midazolam-alfentanil combination. Med Glas (Zenica). 2016;13(1):18-24.