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Update in Cardiac Anesthesia

Update in Cardiac Anesthesia. Charles Smith, MD Professor of Anesthesia Director, Cardiothoracic Anesthesia MetroHealth Medical Center Case Western Reserve University School of Medicine Cleveland, Ohio. Objectives. Review practice trends

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Update in Cardiac Anesthesia

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  1. Update in Cardiac Anesthesia Charles Smith, MD Professor of Anesthesia Director, Cardiothoracic Anesthesia MetroHealth Medical Center Case Western Reserve University School of Medicine Cleveland, Ohio

  2. Objectives • Review practice trends • Discuss lessons learned from SCA annual meeting, Vancouver, June 2008 • Evaluate controversial issues

  3. Aprotinin • Cardiac surgery pts receive 10% RBCs • Antifibrinolytics: standard of care to ↓ trx • Multiple RCTs: aprotonin ↓ blood loss + trx • 2006 observational study [Mangano]: • Aprotinin AEs: renal, cardiac + neuro outcome. • Labeling changed by manufacturer + ongoing studies stopped abruptly C. David Mazer. The Aprotinin Controversy

  4. Aprotinin, cont’d • Manufacturer released database: • 70,000 pts - ↑ AEs + mortality • BART study: Blood conservation using Antifibrinolytics. Canadian multicenter RCT • Amicar vs tranexamic acid vs aprotinin • Terminated early after 2163 pts b/c ↑ mortality in aprotinin gp despite ↓ bleeding + reop • Subsequent studies: aprotinin assoc w renal dysfunction, ↑ Cr + ↑ mortality C. David Mazer. The Aprotinin Controversy

  5. Recombinant Factor VIIa • Approved for hemophilia if bleeding + inhibitors against replacement coag factors. • First report of its use was in an Israeli soldier with uncontrollable bleeding in 1999 • Rationale: will only induce coagulation in those sites where tissue factor (TF) is also present. • Multiple case reports of success in uncontrolled hemorrhage after failure of standard therapy Ian Black. Anesthesia on the frontlines. Lessons from Iraq

  6. Recombinant Factor VIIa • Military in Iraq using FVIIa off label • Massive trx protocol: • 1-2 doses FVIIa, 35-70 mcg/kg • 1:1 FFP: pRBC • Level of evidence: 2C (weak) b/c lack of studies • AEs: arterial thrombosis, MI, DVT, PE, CVA Ian Black. Anesthesia on the frontlines. Lessons from Iraq

  7. Ascending Aorta + Transverse Arch Surgery • Neuroprotection strategy is key element for repair of ascending aorta + transverse arch • Techniques vary widely: • DHCA • Selective brain perfusion • Retrograde brain perfusion • All geared towards preventing stroke + neurocognitive dysfunction David L. Reich. Brain protection during ascending aortic and transverse aortic arch surgery.

  8. Ascending Aorta + Transverse Arch Surgery • Many non-randomized reports of clinical cohorts- problems w institutional preferences, publication bias, and changes over time: • surgical technique, perfusion technology, anesthesia, monitors, prosthetic graft materials, ICU. • Best method: short periods of DHCA + antegrade axillary artery perfusion David L. Reich. Brain protection during ascending aortic and transverse aortic arch surgery.

  9. DHCA • 30-40 min at 18 C generally safe in infants + children • Longer periods: preferential damage to basal ganglia which controls tone + movement • Formation of free radicals + dopamine release may be major cause of endothelial damage + brain edema • pH stat mgt: delays onset of extracellular dopamine release by ~ 15 min. May have improved brain metabolism + outcome William J. Greeley. Strategies to improve outcome after DHCA

  10. Monitoring the Brain • Available monitors: • multichannel EEG • evoked potentials • TCD • jugular bulb sat • BIS • cerebral oximetry Hilary P. Grocott. Evidence based monitoring during cardiac surgery.

  11. BIS+ Cardiac • Has changed practice of cardiac anesthesia • Allows separation of hemodynamic from anesthetic goals • Hemodynamic changes now treated w vasodilators, pressors, β-blockers if adequate depth of anesthesia • B-AWARE trial: ↓ awareness w BIS • B-UNAWARE trial: 2 cases of awareness in BIS + End Tidal preset alarm gp • Conclusion: BIS is noninvasive, inexpensive, unilateral EEG. Uses: cardiac, elderly, TIVA, DHCA, detecting intraop catastrophic events Hilary P. Grocott. Evidence based monitoring during cardiac surgery.

  12. Cerebral Oximetry • Measures sat of cerebral tissue- “pulse ox of the brain” • Based on relation between jugular bulb sat + outcomes • Severe desat assoc w worsened cognitive outcome • Multiple anecdotal reports of early detection + prompt correction of cerebral perfusion defects during CPB • Stepwise mgt for low or asymmetric rSO2 on CPB: • normalize pCO2 • ↑ MAP • ↑ FiO2 • ↑ Hct • Additional mgt: propofol infusion, hypothermia Hilary P. Grocott. Evidence based monitoring during cardiac surgery.

  13. Is Propofol Based Anesthesia Good for You? • Free radical scavenging • Stabilizes lipid membranes • Converts O2 + N2 derived free radicals to < toxic species • Enhances antioxidant capacity during reperfusion • Prevents arachidonic acid peroxidation • Inhibits plasma membrane Ca++ channels • Inhibits cytokine generation • ↓ mitochondrial permeability transition: < oxidative stress. • Several studies w clinical evidence of propofol cardioprotection (superior to volatiles) • Dose/conc + therapeutic window being evaluated David M. Ansley. Propofol for myocardial protection.

  14. Dexmedetomidine? • Prospective blinded RCT: lorazepam vs dex in mechanically ventilated ICU pts • N= 106. Up to 120 hrs sedation • Dex: more days alive without delirium or coma • Dex : more time at targeted sedation level • Conclusion: Dex = 1 intervention for preventing delirium in hospitalized patients Pandharipande et al; JAMA 2007;298:2644. Siddiqi et al; The Cochrane Collaboration, 2008

  15. Endovascular Repair of TAA + AAA • 4 FDA approved devices since original cases in 1991 • ↓ cardiac, respiratory, renal complications • ↓ surgery time, blood trx, LOS, mortality • Patient selection: anatomy of aneurysm+ proximal + distal landing zones • Complications: related to stent deployment (perforation, rupture, dissection), structural failure of device + endoleaks. Michael Andritsos. Anesthesia and the endovascular stenting patient

  16. Endovascular Repair of TAA + AAA • Anesthesia- have evolved w improvements in surgical/radiological technique. Low incidence conversion to open repair • Types: local anesthesia + sedation / regional / combined regional/GA or GA alone • AAA- std ASA monitors, art line, 2 PIVs TAA- add CSF drain, IOTEE • May need to ↓ BP during stent deployment: • SNP, NTG, adenosine, rapid pacing Michael Andritsos. Anesthesia and the endovascular stenting patient

  17. Ultrasound: Line Placement to LV Assessment + Beyond • CVCs routinely inserted w std landmark techniques by experienced operators w low morbidity • 1996 study: anatomical variation of CA w respect to IJ • 2001 study: asymmetry between RIJ+ LIJ including several pts with v small RIJ (CSA <0.4 cm2) or thrombus 2003 study: US:↓ failed placement rate + complications • Other studies: US- ↑ first time success, ↓ time to insertion + infections, ↓ number of CVC kits opened • Conclusion: US guidance beneficial to ↓ CVC complications • [Similar benefit as skin antisepsis, sterile gloves, gown + drape to ↓ infection] Gregg Hartman. The use of ultrasound during cardiac anesthesia

  18. Ultrasound + Line Placement • Ultrasound guided internal jugular access now a recommended practice by Agency for Healthcare Research and Quality Feller-Kopman; Chest 2007;132:302

  19. Ultrasound: Line Placement to LV Assessment + Beyond • TEE has changed cardiac anesthesia • Baseline + real time wall motion, end-diastolic volume, RV+ LV function, intracardiac air, diastolic function, valve anatomy + function, intracardiac shunting, PE in transit, great vessel anatomy. • Better than Swan for response to therapy • Guides line placement: cannula+ wires in SVC/RA. IABP in descending thoracic aorta Gregg Hartman. The use of ultrasound during cardiac anesthesia

  20. Echocardiography in the ICU: From Evolution to Revolution • Recommend echo (TTE) as first line diagnostic tool for evaluation of unstable ICU patients • Specific programs required to educate + train intensivists+ anesthesiologists prior to implementation (France) Viellard-Baron et al: Intensive Care Med 2008;34:243

  21. The Anemia Paradox • Anemia: assoc w multiple AE in cardiac • ↑ kidney injury • ↓ tissue O2 delivery • impaired coag • oxidative stress • ↓ NO • ↑ mortality + morbidity Keyvan Karkouti. Worse outcome after cardiac surgery from both anemia + transfusion

  22. The Anemia Paradox • RBC Trx: assoc w multiple AE in cardiac • Storage injury: RBCs < deformable, ↓ ATP + 2,3 DPG, inability to generate NO, etc. • ↓ tissue O2 delivery • Promote pro-inflammatory state • Exacerbate tissue oxidative stress • Activate leukocytes + coagulation cascade • ↑ mortality, morbidity + cost Keyvan Karkouti. Worse outcome after cardiac surgery from both anemia + transfusion. Murphy et al; Circulation 2007;116:2544

  23. Does Shelf Life Matter? • 6000 cardiac surgery patients @ CCF • Compared young (< 14 d) vs old (> 14 d) RBC Trx • Propensity scoring to balance differences in population • Regression analysis: • Worse outcomes in “old” gp • ↑ renal failure (2.7 vs 1.6%) • ↑ sepsis (4 vs 2.8%) • Prolonged intubation (9.7 vs 5.6%) • ↑ in-hospital + 1-year mortality Koch CG et al; N Engl J Med 2008;358:1229-39. Mazer CD; Age of red cells: does shelf life matter?

  24. Implications of The Anemia Paradox • Treat anemia before surgery • Antifibrinolytics routinely • Minimize blood letting + hemodilution: retrograde autologous priming (RAP) • Cell saver: spin +hemoconcentrate • Use RBC stored for short duration Keyvan Karkouti. Worse outcome after cardiac surgery from both anemia + transfusion

  25. Erythropoetin/ Darbepoetin Preop? • 3 trials of erythropoesis stimulating agents (ESAs) vs placebo in cancer • ↑ venous thromboembolism + mortality in ESA gp • FDA “black box” warning for off-label use of ESAs Bennett et al; Crit Care Med 2007;299:914. Mitka: JAMA 2007;297;1868

  26. Post-Op Intensive Insulin Therapy • Van den Berghe: 42% risk reduction in mortality with tight glucose control (80-110 mg/dl) vs conventional tx. N Engl J Med 2001;345:1359 • ↓ bacteremia, dialysis, CVVH, polyneuropathy, prolonged ventilation, ICU + antibiotics • Concerns: single center, not blinded, stopped early, high mortality, risk of hypoglycemia • Data extrapolated to other settings including OR

  27. Observational Study of Intraop Hyperglycemia + Outcome in Cardiac • Independent contribution of intra-op hyperglycemia on outcome not known • Reviewed 409 pts undergoing cardiac surgery • Glucose levels were higher in pts who had event : 141 vs 127 mg/dl • ↑ renal failure, death, pulmonary events Gandhi et al; Mayo Clin Proc 2005;80:862

  28. Randomized Trial of Intensive Insulin Therapy Intraop, N= 371 pts • Intensive gp: IV insulin, gluc 80-110 • Controls: Insulin for gluc > 200 • Both gps: intensive insulin postop, gluc 80-110 • Endpoints: 30 day incidence of • Death • Deep sternal infection • Stroke • Acute renal failure • Cardiac: new AF, heart block, cardiac arrest • Prolonged ventilation Gandhi et al; Ann Intern Med 2007;146:233-43

  29. Randomized Trial of Intensive Insulin Therapy Intraop, N=371 pts • Insulin infusion protocol maintained intraop gluc levels in desired range, but did not reduce morbidity or mortality • More strokes in intensive gp patients vs controls, (8 vs 1, P =0.02) • Conclusion- tight gluc control does not add benefit, may cause harm, + ↑ resource use Gandhi et al; Ann Intern Med 2007;146:233-43

  30. POISE Results + Prophylactic Periop β-Blockade • PeriOperative ISchemic Evaluation Trial • 190 hospitals, 8351 patients • ↓ MI in metoprolol gp vs placebo (4.2 vs 5.7%) but • ↑ stroke in metoprolol gp (1.0 vs 0.5%) • ↑ mortality in metoprolol gp (3.1 vs 2.3%) • Conclusion- β-blockers ↑ risk, especially in context of anemia + hypotension POISE Study Group; Devereaux PJ, Yang H, et al; Lancet 2008;371:1839-47. Yang H; Can J Anesth 2008;55:11 (Editorial)

  31. CT Anesthesia Credentialing? • Multiple complaints + questions from SCA members • E.g., surgeons want TEE certified anesthesiologists… • but in our gp everyone does everything • there isn’t enough business for multiple fellowship trained cardiac anesthesiologists • By the way, how many cases per yr should a cardiac anesthesiologist do? Glenn P. Gravlee. Should the SCA recommend credentialing guidelines to hospitals for CT anesthesia?

  32. CT Anesthesia Credentialing, cont’d • SCA should recommend CT anesthesia credentialing + board certification, similar to pain, critical care, cardiology, CT surgery • 1 yr ACGME cardiac fellowship + NBE testamur/boards + > 25 cardiac cases/yr • Equivalent clinical experience for “grandfathering” period of 3-5 yrs • There will be problems supporting cardiac anesthesiologists in low volume programs Glenn P. Gravlee. Should the SCA recommend credentialing guidelines to hospitals for CT anesthesia?

  33. Summary • Reviewed practice trends + discussed lessons learned from SCA 2008 • Insulin + hyperglycemia • Neuromonitoring + protecting the brain • Ultrasound • Propofol, Dexmedetomidine • Anemia + transfusion • Prophylactic β-blockade + stroke

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