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Predictors of end-stage renal disease after cardiac surgery
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34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
PP.02.19 Hyperalgesia and fentanyl dosing in on-pump coronary artery bypass grafting
meta-analysis. Br J Anaesth. 2014 Jun;112(6):991 1004. 2. Angst M, Clark J. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006 Mar;104(3):570 87.
H. Priem, M. Vandenheuvel University Hospital Ghent - Department of Anesthesiology and Perioperative Medicine, Ghent, BELGIUM Introduction: Opioids have many known side-effects. However opioid-induced hyperalgesia (OIH), as a result of central sensitization, remains more obscure. The increase in hyperalgesia is dose-related and postoperatively an increased secondary wound hyperalgesia may be a factor in the development of chronic or persistent pain. This prospective, randomized and double-blind clinical trial aims to investigate the effects of fentanyl on secondary wound hyperalgesia in patients undergoing on-pump coronary artery bypass grafting. Methods: Secondary wound hyperalgesia was investigated between two study-groups, respectively a low dose bolus group (n = 14, 3mcg/ kg) and a continuous infusion group (n = 17, Shibutani). The primary endpoint of this study was the area of secondary wound hyperalgesia after 24 hours. The area was measured using a Von Frey filament (256mN). Additionally we looked at hyperalgesia after 48 hours and we investigated following secondary endpoints: time to extubation, ICU/ hospital length of stay, PONV, pain scores, the need for additional analgesia and the total dose of opioids administered 24 and 48 hours after surgery. This study is a subgroup analysis of a larger study, in which the possible association between the area of secondary wound hyperalgesia and persistent pain at 3, 6 and 12 months after surgery will be investigated. Results: The examination of preliminary results showed no statistically significant difference for the area of secondary wound hyperalgesia after 24 hours (p = 0.3268). However the results became significant after 48 hours, where the area of secondary wound hyperalgesia was smaller in the low dose bolus group (p = 0.0389). No significant differences were found for the other secondary endpoints.
PP.02.20 Predictors of end-stage renal disease after cardiac surgery
Z. Povsic Cevra, Z. Baudoin, V.J. Juranko, M. Novkoski, D. Prajdic Predrijevac, K. Tomulic Brusich, A. Simunic Foric, V. Klaric Clinic Magdalena, Krapinske Toplice, CROATIA Introduction: Cardiac surgery associated acute kidney injury (CSI AKI) is severe complication. Incidence in literature varies up to 30%. In 2-5% of AKI patients introducing renal replacement therapy (RRT) is necessary and they are prone to development of a terminal renal failure. Aim of this study was to analyse incidence of AKI in our institution, compare to literature and benchmark institutions and define probably perioperative variables that are manageable and could be altered in order to reduce incidence of AKI. In order to analyse perioperative factors that can cause development of end-stage renal disease (ESRD) we collected data from Croatian Institute of Public Health (CIPH) registry of chronic renal disease and connected with our data.
Discussion: There was less secondary wound hyperalgesia in the low dose bolus group after 48 hours, although at 24 hours this was not statistically significant. These findings are the result of preliminary data. We need to wait for the definitive results of hyperalgesia and for the results regarding chronic pain to draw any conclusions about the clinical significance of OIH.
Methods: Study design: a single centre retrospective observational study. Institutional board of Clinic Magdalena as well as Ethical Board of CIPH approved the study. There were 2181 heart operation in our institution during period 2013-2017. Eligible for study (all data collected) were 1817 patients. Categorical variables were analysed using Pearson Chi-square test, continuous variables were analysed using an unpaired T-test. The p value below 0.05 was considered statistically significant. AKIN classification was used for diagnosis of AKI.
REFERENCES: 1. Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a
Results: Data was collected from 1817 patients; 303 (16,6%) patients developed some kind of AKI; stage I 258
34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
(85%), stage II 38 (12,5%) and stage III 9 patients (2,97%). Overall mortality was 1,98% (36) and in AKI group 5,28% (16). Thirteen patients developed ESRD (0,71%), 5 of them had AKI during hospitalisation (stage I 4, and stage III 1 patient). We found age, body mass index (BMI), Euroscore II score, cerebrovascular disease, pre-existing renal disease, peripheral vascular disease, hypertension, haemoglobin (Hb), haematocrit (Htc) and C reactive protein level to be preoperative variables related to development of AKI. Intraoperative variables with statistically significant difference among groups are operating time and clamp time. As for variables related to development of ESRD we found preoperative Hb and Htc level as well as preoperative creatinine clearens (CrCl), pre-existing renal disease, diabetes mellitus, and atrial fibrillation to be statistically significant. Discussion: Discussion: Our data are comparable with literature data. Interestingly both level of Hb and Htc are variables related to development of AKI as well as ESRD after cardiac surgery. It seems that preoperative correction of anaemia and intraoperative meticulous blood management, among others perioperative tactics, could lead to reduction of incidence of AKI and ESRD after car diac surgery. REFERENCE: Engoren M, Habib RH, Arslanian-Engoren C, Kheterpal S, Schwann TA. The effect of acute kidney injury and discharge creatinine level on mortality following cardiac surgery. Crit Care Med. 2014 Sep;42(9): 2069-74.
PP.02.21 Left atrial dissection: taken from darkness by transoesophageal echocardiography
J.M. Perdomo Linares1, C. Iba~ nez1, M.J. Arguis1, 2 2 E. Sandoval , D. Pereda , M.J. Carretero1, R. Navarro1, P. Matute1, A. Carrami~ nana1, M. L opez1, G. Fita1, C. Gomar1, 1 I. Rovira
S153
Introduction: Left atrial dissection (LATD) is an infrequent (incidence 0.16%) however serious condition (mortality 13.8%). Methods: The authors present three-LATD between 2016 and 2018 (from 2475 cardiac-surgery cases). Results: Case 1 - A 57-year-old female with severe mitral regurgitation (P2 prolapse) was admitted for elective mitral valve repair (MVr). After two unsuccessful MVr attempts due to systolic anterior motion, a mitral valve replacement (MVR) was performed. LATD was diagnosed on the transoesophageal echocardiography (TOE). Conservative approach was decided based on the patient stability. However, LATD increased on the TOE and surgical treatment was required. She was successfully weaned form cardiopulmonary bypass (CPB) and transferred to the intensive care unit (ICU) stable on inotropes. Unfortunately, the patient died thirteen days after surgery due to airway and respiratory complications. A post-mortem study confirmed the patency of cardiac sutures. Case 2 - A 74-year-old male with severe mitral regurgitation (P2-P3 prolapse) was admitted for elective mitral valve repair and pulmonary vein ablation. A LATD associated to intra and peri- annular leaks was diagnosed on the post- repair TOE. Surgical treatment on CPB was required. The LATD was repaired and MVR was performed. The patient was weaned form CPB and transferred to the ICU on Right-Ventricular Assistance Device (RVAD) and inotropes due to RV failure. He was successfully weaned from RVAD and then discharged from hospital two months after the initial surgery. Case 3 - A 85-year-old female with severe aortic and moderate mitral regurgitation was admitted for elective aortic valve replacement and MVr. A LATD was diagnosed on the postCPB TOE without affecting pulmonary-vein drainage or left atrial filling. Conservative approach was decided based on patient’s stability. Consecutive TOE controls showed no changes. Therefore, he was transferred to the ICU and discharged from hospital one month after surgery. Discussion: As in the authors’ three-case series, this infrequent cardiac-surgery complication has been mainly related to mitral valve surgery (56.3%). Treatment depends on patients’ clinical status, left-atrial filing impairment and LATD progression on TOE. Both surgical and conservative treatments have been reported successfully. Therefore, TOE is paramount in order to diagnosed and deal with this condition.
1
Hospital Clinic, Cardiothoracic and Vascular Anaesthesia, Barcelona, SPAIN 2 Hospital Clinic, Cardiac Surgery, Barcelona, SPAIN
REFERENCE: 1. Fukuhara S, Zhou E, Geller CM et al. Left atrial dissection: an almost unknown entity. Interact Cardiovasc Thorac Surg. 20;96-100. 2015.
34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
PP.02.19 Hyperalgesia and fentanyl dosing in on-pump coronary artery bypass grafting
meta-analysis. Br J Anaesth. 2014 Jun;112(6):991 1004. 2. Angst M, Clark J. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006 Mar;104(3):570 87.
H. Priem, M. Vandenheuvel University Hospital Ghent - Department of Anesthesiology and Perioperative Medicine, Ghent, BELGIUM Introduction: Opioids have many known side-effects. However opioid-induced hyperalgesia (OIH), as a result of central sensitization, remains more obscure. The increase in hyperalgesia is dose-related and postoperatively an increased secondary wound hyperalgesia may be a factor in the development of chronic or persistent pain. This prospective, randomized and double-blind clinical trial aims to investigate the effects of fentanyl on secondary wound hyperalgesia in patients undergoing on-pump coronary artery bypass grafting. Methods: Secondary wound hyperalgesia was investigated between two study-groups, respectively a low dose bolus group (n = 14, 3mcg/ kg) and a continuous infusion group (n = 17, Shibutani). The primary endpoint of this study was the area of secondary wound hyperalgesia after 24 hours. The area was measured using a Von Frey filament (256mN). Additionally we looked at hyperalgesia after 48 hours and we investigated following secondary endpoints: time to extubation, ICU/ hospital length of stay, PONV, pain scores, the need for additional analgesia and the total dose of opioids administered 24 and 48 hours after surgery. This study is a subgroup analysis of a larger study, in which the possible association between the area of secondary wound hyperalgesia and persistent pain at 3, 6 and 12 months after surgery will be investigated. Results: The examination of preliminary results showed no statistically significant difference for the area of secondary wound hyperalgesia after 24 hours (p = 0.3268). However the results became significant after 48 hours, where the area of secondary wound hyperalgesia was smaller in the low dose bolus group (p = 0.0389). No significant differences were found for the other secondary endpoints.
PP.02.20 Predictors of end-stage renal disease after cardiac surgery
Z. Povsic Cevra, Z. Baudoin, V.J. Juranko, M. Novkoski, D. Prajdic Predrijevac, K. Tomulic Brusich, A. Simunic Foric, V. Klaric Clinic Magdalena, Krapinske Toplice, CROATIA Introduction: Cardiac surgery associated acute kidney injury (CSI AKI) is severe complication. Incidence in literature varies up to 30%. In 2-5% of AKI patients introducing renal replacement therapy (RRT) is necessary and they are prone to development of a terminal renal failure. Aim of this study was to analyse incidence of AKI in our institution, compare to literature and benchmark institutions and define probably perioperative variables that are manageable and could be altered in order to reduce incidence of AKI. In order to analyse perioperative factors that can cause development of end-stage renal disease (ESRD) we collected data from Croatian Institute of Public Health (CIPH) registry of chronic renal disease and connected with our data.
Discussion: There was less secondary wound hyperalgesia in the low dose bolus group after 48 hours, although at 24 hours this was not statistically significant. These findings are the result of preliminary data. We need to wait for the definitive results of hyperalgesia and for the results regarding chronic pain to draw any conclusions about the clinical significance of OIH.
Methods: Study design: a single centre retrospective observational study. Institutional board of Clinic Magdalena as well as Ethical Board of CIPH approved the study. There were 2181 heart operation in our institution during period 2013-2017. Eligible for study (all data collected) were 1817 patients. Categorical variables were analysed using Pearson Chi-square test, continuous variables were analysed using an unpaired T-test. The p value below 0.05 was considered statistically significant. AKIN classification was used for diagnosis of AKI.
REFERENCES: 1. Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a
Results: Data was collected from 1817 patients; 303 (16,6%) patients developed some kind of AKI; stage I 258
34TH EACTA ANNUAL CONGRESS ABSTRACTS / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) S140 S168
(85%), stage II 38 (12,5%) and stage III 9 patients (2,97%). Overall mortality was 1,98% (36) and in AKI group 5,28% (16). Thirteen patients developed ESRD (0,71%), 5 of them had AKI during hospitalisation (stage I 4, and stage III 1 patient). We found age, body mass index (BMI), Euroscore II score, cerebrovascular disease, pre-existing renal disease, peripheral vascular disease, hypertension, haemoglobin (Hb), haematocrit (Htc) and C reactive protein level to be preoperative variables related to development of AKI. Intraoperative variables with statistically significant difference among groups are operating time and clamp time. As for variables related to development of ESRD we found preoperative Hb and Htc level as well as preoperative creatinine clearens (CrCl), pre-existing renal disease, diabetes mellitus, and atrial fibrillation to be statistically significant. Discussion: Discussion: Our data are comparable with literature data. Interestingly both level of Hb and Htc are variables related to development of AKI as well as ESRD after cardiac surgery. It seems that preoperative correction of anaemia and intraoperative meticulous blood management, among others perioperative tactics, could lead to reduction of incidence of AKI and ESRD after car diac surgery. REFERENCE: Engoren M, Habib RH, Arslanian-Engoren C, Kheterpal S, Schwann TA. The effect of acute kidney injury and discharge creatinine level on mortality following cardiac surgery. Crit Care Med. 2014 Sep;42(9): 2069-74.
PP.02.21 Left atrial dissection: taken from darkness by transoesophageal echocardiography
J.M. Perdomo Linares1, C. Iba~ nez1, M.J. Arguis1, 2 2 E. Sandoval , D. Pereda , M.J. Carretero1, R. Navarro1, P. Matute1, A. Carrami~ nana1, M. L opez1, G. Fita1, C. Gomar1, 1 I. Rovira
S153
Introduction: Left atrial dissection (LATD) is an infrequent (incidence 0.16%) however serious condition (mortality 13.8%). Methods: The authors present three-LATD between 2016 and 2018 (from 2475 cardiac-surgery cases). Results: Case 1 - A 57-year-old female with severe mitral regurgitation (P2 prolapse) was admitted for elective mitral valve repair (MVr). After two unsuccessful MVr attempts due to systolic anterior motion, a mitral valve replacement (MVR) was performed. LATD was diagnosed on the transoesophageal echocardiography (TOE). Conservative approach was decided based on the patient stability. However, LATD increased on the TOE and surgical treatment was required. She was successfully weaned form cardiopulmonary bypass (CPB) and transferred to the intensive care unit (ICU) stable on inotropes. Unfortunately, the patient died thirteen days after surgery due to airway and respiratory complications. A post-mortem study confirmed the patency of cardiac sutures. Case 2 - A 74-year-old male with severe mitral regurgitation (P2-P3 prolapse) was admitted for elective mitral valve repair and pulmonary vein ablation. A LATD associated to intra and peri- annular leaks was diagnosed on the post- repair TOE. Surgical treatment on CPB was required. The LATD was repaired and MVR was performed. The patient was weaned form CPB and transferred to the ICU on Right-Ventricular Assistance Device (RVAD) and inotropes due to RV failure. He was successfully weaned from RVAD and then discharged from hospital two months after the initial surgery. Case 3 - A 85-year-old female with severe aortic and moderate mitral regurgitation was admitted for elective aortic valve replacement and MVr. A LATD was diagnosed on the postCPB TOE without affecting pulmonary-vein drainage or left atrial filling. Conservative approach was decided based on patient’s stability. Consecutive TOE controls showed no changes. Therefore, he was transferred to the ICU and discharged from hospital one month after surgery. Discussion: As in the authors’ three-case series, this infrequent cardiac-surgery complication has been mainly related to mitral valve surgery (56.3%). Treatment depends on patients’ clinical status, left-atrial filing impairment and LATD progression on TOE. Both surgical and conservative treatments have been reported successfully. Therefore, TOE is paramount in order to diagnosed and deal with this condition.
1
Hospital Clinic, Cardiothoracic and Vascular Anaesthesia, Barcelona, SPAIN 2 Hospital Clinic, Cardiac Surgery, Barcelona, SPAIN
REFERENCE: 1. Fukuhara S, Zhou E, Geller CM et al. Left atrial dissection: an almost unknown entity. Interact Cardiovasc Thorac Surg. 20;96-100. 2015.