- Email: [email protected]
Intraoperative decrease of regional cerebral oxygen saturation is not associated with the occurrence of delirium after elective cardiac surgery
S35
ORAL ABSTRACT PRESENTATIONS
hypothermic circulatory arrest (HCA) and cerebral perfusion (SACP) in small cohorts. Aim of the study was to describe cerebral oxygen saturation during HCA and SACP in a large cohort of patients. Methods. With IRB approval, 215 patients (age 62⫾12) undergoing thoracic aortic surgery with HCA (24⫾18 min) and SACP (16⫾17 min) at 10 ml kg-1 min-1 were monitored with bifrontal NIRS (NIRO 200NX, Hamamatsu Photonics, Japan). Tissue oxygenation index (TOI) was measured continuously. Results. TOI dropped by 16% (95%CI, 17.6 to 15.1) during HCA and increased again up to 10.1% (95%CI, 8.9 to 11.3) during SACP. TOI at start of HCA correlated with TOI at SACP-start and HCAstop. Absolute TOI values and correlations are shown in Figures
area under the curve of 0.719. The cut-off level of S100β measured at PD1 to predict POD was 160.5pg∙mL-1, with a sensitivity of 68% and a specificity of 58%. The positive predictive value of S100β was 30%, while the negative predictive value was 88%. Positive likelihood ratios for different test result intervals were 0.0 (95%-CI: 0.000-3.942) when the serum value of S100β at admission to the ICU was o180pg∙mL1 , 0.271 (95%-CI: 0.0379-1.931) for values between 180-240pg∙mL-1 and 1.364 (95%-CI: 1.132-1.644) for values 4240pg∙mL-1.
Conclusion. NIRS detects changes in cerebral perfusion accurately and timely. HCA leads consistently to marked cerebral deoxygenation. SACP effectively restores cerebral oxygenation, however not to pre-HCA baseline levels. TOI levels at HCA-start are predictive for TOI-values during SACP and at HCA-end. OP-021 Serum protein S100β for the prediction of postoperative delirium after off-pump coronary artery bypass surgery: a prospective observational trial Layth Al Tmimil, Koen Poesen2, Jan Van Hemelrijckl, Marc Van de Veldel, Paul Sergeant3, Bart Meyns3, Steffen Rexl l
kU Leuven -University of Leuven, Department of Anaesthesiology Leuven, Belgium, 2KU Leuven - University of Leuven,Department of Laboratory Medicines, Leuven, Belgium, 3KU Leuven - University of Leuven, Department of Cardiac Surgery, Leuven, Belgium Introduction. Patients undergoing cardiac surgery are vulnerable for the development of postoperative neuropsychiatric complications. Early recognition of these complications is of great clinical importance. Serum protein S100β is a biomarker that reflects blood brain barrier dysfunction. Serum S100β-levels are significantly increased after cardiac surgery with the use of cardiopulmonary bypass (1). We hypothesized that S100β is also released during off-pump coronary artery bypass (OPCAB)surgery and that S100β is an accurate neurobiochemical marker for the prediction of postoperative delirium (POD). Methods. From January 2012 to June 2013, 91 patients older than 18 years, scheduled for elective OPCAB-surgery were included in this prospective observational trial. All patients underwent baseline neuropsychiatric examination with the confusion assessment score (CAM). Anaesthesia was titrated to achieve bispectral index values between 40-60. Serum S100β-levels were determined in arterial blood at baseline, the end of surgery and at postoperative day (PD) one using batch analysis with the Elecsyss S100-assay (Roche Diagnostics, Mannheim, Germany). Patients were daily evaluated, until discharge, for the presence of POD, using the CAM or the intensive care unit version of the CAM (CAM-ICU). Results. Serum levels of S100β showed a significant increase at end of surgery and on PD1 (Fig.1). The occurrence of POD was 21% (95% confidence interval (CI): 13%-31%). In the receiver-operatingcharacteristic plot, S100β predicted the development of POD with an
Conclusion. S100β is significantly increased after OPCABsurgery and predictive for the occurrence of POD. Postoperative S100β-serum values of o180pg∙mL-1 measured at admission to the ICU exclude the development of POD. This finding warrants testing whether postoperative levels of S100β could be used for risk stratification of cardiac surgical patients and for the initiation of preventive measures against POD. REFERENCE 1. Herrmann M, Ebert AD, Galazky I, et al: Neurobehavioral Outcome Prediction After Cardiac Surgery: Role of Neurobiochemical Markers of Damage to Neuronal and Glial Brain Tissue. Stroke 31:645–650, 2000. OP-022 Intraoperative decrease of regional cerebral oxygen saturation is not associated with the occurrence of delirium after elective cardiac surgery Francisca Santos1, Clara Luís2, Marisa Gonçalo1, Fernando Abelha1, João Viterbo1 Centro Hospitalar de São João, 2Centro Hospitalar de Trás-osMontes e Alto Douro
1
Introduction. Delirium after cardiac surgery is associated with increased morbidity and long-term mortality [1]. Aging and low baseline cerebral oxygen saturation measured by near infrared spectroscopy (rSO2) have been associated with the occurrence of postoperative delirium [2]. In this prospective, observational study, our goal was to assess the association between duration and severity of intraoperative rSO2 decrease and the occurrence of delirium after cardiac surgery. Methods. In patients over 65 years of age, without previous psychiatric, neurological, cerebrovascular or renal disease, rSO2 was continuously monitored and recorded (INVOS 5100s), during
S36
elective cardiac surgery, after ethical committee approval. Medical information was obtained. “Intensive care delirium screening checklist” (ICDSC) was used to evaluate delirium in the ICU. MannWhitney, Student’s T-test, chi-square, Fisher’s test and binary logistic regression were used for statistical analysis. Quantitative results are presented as mean ⫾ SD and median [IQR], as appropriate. Results. Of 42 patients (74.3⫾5.8 years old, 50% female, 2% ASA II, 93% ASA III, 5% ASA IV, EuroSCORE II ¼ 7⫾3.8%), 69% underwent open heart surgery; 31% underwent valve replacement, 31% aortocoronary bypass, 35.7% both, and 2.3% left atrial myxoma exeresis. Six patients (14.3%) presented delirium during ICU stay. They had less severe absolute (AUCabs 3 vs 158 min.%, p¼0.04) and relative (AUC20% 1 vs 72 min.%, p¼0.01) rSO2 decrease. They were not different regarding age (P¼0.32), BMI (P¼0.78), sex (P¼1.00), ASA physical status (0 vs 2,7% ASA IV, P¼1.00), EuroSCORE II (P¼0.20), baseline rSO2 (p¼0.55), frequency of open-heart surgery (P¼0.65) or duration of surgery (P¼0.35), but had higher preoperative C-reactive protein (5.9 [IQR 4.6, 7.2] vs 3.2 [IQR 1.1, 5.0] mg.l-1, P¼0.04) and creatinine (1,1 [IQR 0.9, 1.2] vs 0.8 [IQR 0.6, 0.9] mg.dl-1, p¼0.03) plasma levels. Preoperative creatinine level predicted ICU delirium occurrence (OR 1.34x103 [95% CI 5.46 331x103], P¼0.01) in stepwise multivariate analysis. Discussion. Intraoperative cerebral oxygen saturation decrease was not associated with postoperative delirium occurrence. Preoperative creatinine plasma level was an independent predictor for delirium occurrence after elective cardiac surgery, although our results need to be confirmed in a properly sized sample of patients. REFERENCES 1. Gottesman R, Grega M, Bailey M, et al: Delirium after coronary artery bypass graft surgery and late mortality. Ann Neurol 67:338-344, 2010. 2. Schoen J, Meyerrose J, Paarmann H, et al: Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial. Crit Care 15:R218, 2011.
Oral Abstract Presentations 303 Wednesday, June 24, 2015 12:00 p.m.–12:30 p.m., Room G3 OP-026
ORAL ABSTRACT PRESENTATIONS
pressures were achieved by deep anaesthesia and additional α1blockade with Urapidil. In a 3T MRI scanner, OS-images were acquired at 10-15mmHg increments in a mid left ventricular short axis slice and expressed as %change in signal intensity (SI) from a defined 70mmHg baseline. Blood pressure and coronary artery blood flow were continuously recorded. Results. The auto-regulation range in these animals was visible with MAP between 40-110mmHg (grey). OS-SI changes (black) showed a good correlation to LAD blood flow (R¼0.5, po0.01), a strong correlation with MAP (R¼0.6, p¼0.001) and a weak correlation to the rate pressure product (R¼0.3, po0.05). Conclusion. Myocardial oxygenation parallels LAD blood flow in healthy swine. There is no evidence for a compromise in myocardial oxygenation with increased cardiac afterload at higher blood pressures beyond the auto-regulation range.
OP-027 Echocardiographic prognosis of right-ventricular failure after implantation of a paediatric left ventricular assist device (LVAD) Matthias Hommel, MD MBA1, Helmut Habazettl, MD PHD2, Marian Kukucka, MD PHD1 1
Department of Anesthesiology, German Heart Institute Berlin, Institute of Physiology, Charité Berlin
2
Myocardial blood flow reflects myocardial oxygenation in healthy swine Dominik P. Guensch Bern University Hospital, Department Anaesthesiology and Pain Therapy Background & Aim. Myocardial auto-regulation secures a near constant myocardial blood flow through a wide range of systemic blood pressures. However, it is not clear if coronary auto-regulation can maintain myocardial oxygenation in the face of increasing peripheral resistance and cardiac workload. Oxygenation-sensitive (OS) cardiovascular magnetic resonance (CMR) can detect changes in myocardial oxygenation. The aim of this study was to assess myocardial oxygenation during and beyond the myocardial auto-regulation range. Methods. Five anaesthetized swine underwent a left-sided thoracotomy to install a flow probe around the proximal left descending coronary artery (LAD). Blood pressure was manipulated from mean arterial pressures (MAP) of 40-180mmHg by continuous administration of Phenylephrine (16-500mg/min). Lower blood
Introduction. Right ventricular failure is the most common complication in the early post-operative period after implantation of a LVAD. Multiple clinical and echocardiographic criteria have been published for the prognosis of right ventricular failure in adult and paediatric patients. To date, in the paediatric population no quantitative echocardiographic parameter has been validated for the prognosis of right ventricular failure after implantation of an LVAD. Methods. Retrospective analysis of clinical and echocardiographic data from paediatric patients pre- and post-implantation of an LVAD was performed. Right ventricular failure was defined by minimal central- or mixed-venous oxygen saturation, maximal dosage of catecholamines and maximal central venous pressure during the first 48 hours after implantation of the LVAD. Results. Inclusion of 48 patients with a median age of 6,2 years was possible. The percentage of right ventricular failure after implantation of the LVAD was 48 %. Diagnosis and concomitant organ dysfunctions were not correlated with the development of right ventricular failure. Among echocardiographic parameters only the tricuspid annular plane systolic excursion (TAPSE; p ¼ 0.01) and the ratio of TAPSE to the apico-basal diameter of the right ventricle (TAPSE /
ORAL ABSTRACT PRESENTATIONS
hypothermic circulatory arrest (HCA) and cerebral perfusion (SACP) in small cohorts. Aim of the study was to describe cerebral oxygen saturation during HCA and SACP in a large cohort of patients. Methods. With IRB approval, 215 patients (age 62⫾12) undergoing thoracic aortic surgery with HCA (24⫾18 min) and SACP (16⫾17 min) at 10 ml kg-1 min-1 were monitored with bifrontal NIRS (NIRO 200NX, Hamamatsu Photonics, Japan). Tissue oxygenation index (TOI) was measured continuously. Results. TOI dropped by 16% (95%CI, 17.6 to 15.1) during HCA and increased again up to 10.1% (95%CI, 8.9 to 11.3) during SACP. TOI at start of HCA correlated with TOI at SACP-start and HCAstop. Absolute TOI values and correlations are shown in Figures
area under the curve of 0.719. The cut-off level of S100β measured at PD1 to predict POD was 160.5pg∙mL-1, with a sensitivity of 68% and a specificity of 58%. The positive predictive value of S100β was 30%, while the negative predictive value was 88%. Positive likelihood ratios for different test result intervals were 0.0 (95%-CI: 0.000-3.942) when the serum value of S100β at admission to the ICU was o180pg∙mL1 , 0.271 (95%-CI: 0.0379-1.931) for values between 180-240pg∙mL-1 and 1.364 (95%-CI: 1.132-1.644) for values 4240pg∙mL-1.
Conclusion. NIRS detects changes in cerebral perfusion accurately and timely. HCA leads consistently to marked cerebral deoxygenation. SACP effectively restores cerebral oxygenation, however not to pre-HCA baseline levels. TOI levels at HCA-start are predictive for TOI-values during SACP and at HCA-end. OP-021 Serum protein S100β for the prediction of postoperative delirium after off-pump coronary artery bypass surgery: a prospective observational trial Layth Al Tmimil, Koen Poesen2, Jan Van Hemelrijckl, Marc Van de Veldel, Paul Sergeant3, Bart Meyns3, Steffen Rexl l
kU Leuven -University of Leuven, Department of Anaesthesiology Leuven, Belgium, 2KU Leuven - University of Leuven,Department of Laboratory Medicines, Leuven, Belgium, 3KU Leuven - University of Leuven, Department of Cardiac Surgery, Leuven, Belgium Introduction. Patients undergoing cardiac surgery are vulnerable for the development of postoperative neuropsychiatric complications. Early recognition of these complications is of great clinical importance. Serum protein S100β is a biomarker that reflects blood brain barrier dysfunction. Serum S100β-levels are significantly increased after cardiac surgery with the use of cardiopulmonary bypass (1). We hypothesized that S100β is also released during off-pump coronary artery bypass (OPCAB)surgery and that S100β is an accurate neurobiochemical marker for the prediction of postoperative delirium (POD). Methods. From January 2012 to June 2013, 91 patients older than 18 years, scheduled for elective OPCAB-surgery were included in this prospective observational trial. All patients underwent baseline neuropsychiatric examination with the confusion assessment score (CAM). Anaesthesia was titrated to achieve bispectral index values between 40-60. Serum S100β-levels were determined in arterial blood at baseline, the end of surgery and at postoperative day (PD) one using batch analysis with the Elecsyss S100-assay (Roche Diagnostics, Mannheim, Germany). Patients were daily evaluated, until discharge, for the presence of POD, using the CAM or the intensive care unit version of the CAM (CAM-ICU). Results. Serum levels of S100β showed a significant increase at end of surgery and on PD1 (Fig.1). The occurrence of POD was 21% (95% confidence interval (CI): 13%-31%). In the receiver-operatingcharacteristic plot, S100β predicted the development of POD with an
Conclusion. S100β is significantly increased after OPCABsurgery and predictive for the occurrence of POD. Postoperative S100β-serum values of o180pg∙mL-1 measured at admission to the ICU exclude the development of POD. This finding warrants testing whether postoperative levels of S100β could be used for risk stratification of cardiac surgical patients and for the initiation of preventive measures against POD. REFERENCE 1. Herrmann M, Ebert AD, Galazky I, et al: Neurobehavioral Outcome Prediction After Cardiac Surgery: Role of Neurobiochemical Markers of Damage to Neuronal and Glial Brain Tissue. Stroke 31:645–650, 2000. OP-022 Intraoperative decrease of regional cerebral oxygen saturation is not associated with the occurrence of delirium after elective cardiac surgery Francisca Santos1, Clara Luís2, Marisa Gonçalo1, Fernando Abelha1, João Viterbo1 Centro Hospitalar de São João, 2Centro Hospitalar de Trás-osMontes e Alto Douro
1
Introduction. Delirium after cardiac surgery is associated with increased morbidity and long-term mortality [1]. Aging and low baseline cerebral oxygen saturation measured by near infrared spectroscopy (rSO2) have been associated with the occurrence of postoperative delirium [2]. In this prospective, observational study, our goal was to assess the association between duration and severity of intraoperative rSO2 decrease and the occurrence of delirium after cardiac surgery. Methods. In patients over 65 years of age, without previous psychiatric, neurological, cerebrovascular or renal disease, rSO2 was continuously monitored and recorded (INVOS 5100s), during
S36
elective cardiac surgery, after ethical committee approval. Medical information was obtained. “Intensive care delirium screening checklist” (ICDSC) was used to evaluate delirium in the ICU. MannWhitney, Student’s T-test, chi-square, Fisher’s test and binary logistic regression were used for statistical analysis. Quantitative results are presented as mean ⫾ SD and median [IQR], as appropriate. Results. Of 42 patients (74.3⫾5.8 years old, 50% female, 2% ASA II, 93% ASA III, 5% ASA IV, EuroSCORE II ¼ 7⫾3.8%), 69% underwent open heart surgery; 31% underwent valve replacement, 31% aortocoronary bypass, 35.7% both, and 2.3% left atrial myxoma exeresis. Six patients (14.3%) presented delirium during ICU stay. They had less severe absolute (AUCabs 3 vs 158 min.%, p¼0.04) and relative (AUC20% 1 vs 72 min.%, p¼0.01) rSO2 decrease. They were not different regarding age (P¼0.32), BMI (P¼0.78), sex (P¼1.00), ASA physical status (0 vs 2,7% ASA IV, P¼1.00), EuroSCORE II (P¼0.20), baseline rSO2 (p¼0.55), frequency of open-heart surgery (P¼0.65) or duration of surgery (P¼0.35), but had higher preoperative C-reactive protein (5.9 [IQR 4.6, 7.2] vs 3.2 [IQR 1.1, 5.0] mg.l-1, P¼0.04) and creatinine (1,1 [IQR 0.9, 1.2] vs 0.8 [IQR 0.6, 0.9] mg.dl-1, p¼0.03) plasma levels. Preoperative creatinine level predicted ICU delirium occurrence (OR 1.34x103 [95% CI 5.46 331x103], P¼0.01) in stepwise multivariate analysis. Discussion. Intraoperative cerebral oxygen saturation decrease was not associated with postoperative delirium occurrence. Preoperative creatinine plasma level was an independent predictor for delirium occurrence after elective cardiac surgery, although our results need to be confirmed in a properly sized sample of patients. REFERENCES 1. Gottesman R, Grega M, Bailey M, et al: Delirium after coronary artery bypass graft surgery and late mortality. Ann Neurol 67:338-344, 2010. 2. Schoen J, Meyerrose J, Paarmann H, et al: Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial. Crit Care 15:R218, 2011.
Oral Abstract Presentations 303 Wednesday, June 24, 2015 12:00 p.m.–12:30 p.m., Room G3 OP-026
ORAL ABSTRACT PRESENTATIONS
pressures were achieved by deep anaesthesia and additional α1blockade with Urapidil. In a 3T MRI scanner, OS-images were acquired at 10-15mmHg increments in a mid left ventricular short axis slice and expressed as %change in signal intensity (SI) from a defined 70mmHg baseline. Blood pressure and coronary artery blood flow were continuously recorded. Results. The auto-regulation range in these animals was visible with MAP between 40-110mmHg (grey). OS-SI changes (black) showed a good correlation to LAD blood flow (R¼0.5, po0.01), a strong correlation with MAP (R¼0.6, p¼0.001) and a weak correlation to the rate pressure product (R¼0.3, po0.05). Conclusion. Myocardial oxygenation parallels LAD blood flow in healthy swine. There is no evidence for a compromise in myocardial oxygenation with increased cardiac afterload at higher blood pressures beyond the auto-regulation range.
OP-027 Echocardiographic prognosis of right-ventricular failure after implantation of a paediatric left ventricular assist device (LVAD) Matthias Hommel, MD MBA1, Helmut Habazettl, MD PHD2, Marian Kukucka, MD PHD1 1
Department of Anesthesiology, German Heart Institute Berlin, Institute of Physiology, Charité Berlin
2
Myocardial blood flow reflects myocardial oxygenation in healthy swine Dominik P. Guensch Bern University Hospital, Department Anaesthesiology and Pain Therapy Background & Aim. Myocardial auto-regulation secures a near constant myocardial blood flow through a wide range of systemic blood pressures. However, it is not clear if coronary auto-regulation can maintain myocardial oxygenation in the face of increasing peripheral resistance and cardiac workload. Oxygenation-sensitive (OS) cardiovascular magnetic resonance (CMR) can detect changes in myocardial oxygenation. The aim of this study was to assess myocardial oxygenation during and beyond the myocardial auto-regulation range. Methods. Five anaesthetized swine underwent a left-sided thoracotomy to install a flow probe around the proximal left descending coronary artery (LAD). Blood pressure was manipulated from mean arterial pressures (MAP) of 40-180mmHg by continuous administration of Phenylephrine (16-500mg/min). Lower blood
Introduction. Right ventricular failure is the most common complication in the early post-operative period after implantation of a LVAD. Multiple clinical and echocardiographic criteria have been published for the prognosis of right ventricular failure in adult and paediatric patients. To date, in the paediatric population no quantitative echocardiographic parameter has been validated for the prognosis of right ventricular failure after implantation of an LVAD. Methods. Retrospective analysis of clinical and echocardiographic data from paediatric patients pre- and post-implantation of an LVAD was performed. Right ventricular failure was defined by minimal central- or mixed-venous oxygen saturation, maximal dosage of catecholamines and maximal central venous pressure during the first 48 hours after implantation of the LVAD. Results. Inclusion of 48 patients with a median age of 6,2 years was possible. The percentage of right ventricular failure after implantation of the LVAD was 48 %. Diagnosis and concomitant organ dysfunctions were not correlated with the development of right ventricular failure. Among echocardiographic parameters only the tricuspid annular plane systolic excursion (TAPSE; p ¼ 0.01) and the ratio of TAPSE to the apico-basal diameter of the right ventricle (TAPSE /