Effects of Combined and General Anesthesia on Cognitive Functions for Patients Undergoing Cardiac Surgery Under CPB.

BACKGROUND: Patients may experience a variety of neurological complications after heart surgery. The most common complication observed in clinical practice is delayed neurocognitive recovery (dNCR). The role of the anesthesiologist is very important, as the risk of dNCR may be reduced, depending on the anesthesia tactic chosen. Although the possibility that neuropsychological complications are less common in patients undergoing combined anesthesia (general + epidural) than in patients undergoing general anesthesia is not yet confirmed, the results are being discussed. The aim of this study was to determine impact of combined anesthesia (general + epidural) on cognitive functions of patients after cardiac surgery. METHODS: The prospective, case-controlled study included 80 patients undergoing cardiac surgery from 2015 to 2017 at the Department of Cardiothoracic and Vascular Surgery in the Hospital of Lithuanian University of Health Sciences Kauno Klinikos. After approval from the local bioethics center, informed consent was obtained from all study participants. Inclusion criteria were age 51 to 80 years, elective cardiac surgery, left ventricular ejection fraction > 35%, anamnesis of not using agents affecting the central nervous system, absence of neuropathology, and sufficient renal function. Exclusion criteria were patients suffering from diseases causing cognitive function or using agents affecting the central nervous system, emergency or re-surgery, carotid artery atherosclerosis with artery diameter 50 or more percent reduction, and a patient's disagreement. MMSE test and 6-CIT test were used for a cognitive function assessment, Trail making test and WAIS Digital Symbol Substitution test were used for psychomotor function assessment. All tests were used a day before surgery and seven days after surgery. According to the planned anesthesia, patients were assigned into two groups: 1 - combined general + epidural anesthesia and 2 - general anesthesia. Standardized protocol of anesthesia was followed for all patients. Preoperative patients and surgery factors, preoperative and postoperative neuropsychological test results were recorded. RESULTS: Eighty patients were enrolled in the study. Both groups did not differ in demographic, perioperative values, and baseline (preoperative) test results. Postoperative (7th day) WAIS (P = .042) and 6-item cognitive impairment (P = .016) test results were statistically different when comparing the GA and CA groups. Comparing preoperative and postoperative test results, there was a significant decline in the WAIS test score in the GA group (P = .013).

Association between serum biomarkers and postoperative delirium after cardiac surgery.

BACKGROUND: In cardiac surgery, patients face an increased risk of developing postoperative delirium (POD) that is associated with poor outcomes. Neuron-specific enolase (NSE) and glial fibrillary acidic protein (GFAP) have shown some promising results as potential tools for POD risk stratification, diagnosis, monitoring, and prognosis. MATERIALS AND METHODS: Prospective single-centre study enrolled 44 patients undergoing elective coronary artery bypass grafting (CABG) and/or valve procedures using cardiopulmonary bypass (CPB). The patients were assessed and monitored preoperatively, during surgery, and in the early postoperative period. The blood levels of NSE and GFAP were measured before and after surgery. The early POD was assessed by CAM-ICU criteria and patients were assigned to the POD group (with POD) or to the NPOD group (without POD) retrospectively. RESULTS: The incidence of POD was 18.2%. After surgery, NSE significantly increased in the whole sample (p = 0.002). Comparing between groups, NSE significantly increased in the POD group after surgery (p = 0.042). ΔGFAP (before/after operation) for the whole sample was statistically significant (p = 0.022). There was a significant correlation between ΔGFAP and the lowest MAP during surgery in the POD group (p = 0.033). CONCLUSIONS: Our study demonstrated that NSE and GFAP are associated with early POD. An increase in NSE level during the perioperative period may be associated with subclinical neuronal damage. Serum GFAP levels show the damage of glial cells. Further studies are needed to find the factors influencing the individual limits of optimal MAP during surgery.

Burnout Among Anesthetists and Intensive Care Physicians.

Burnout is a syndrome of depersonalization, emotional exhaustion, and low personal accomplishment. Little is known about burnout in physicians. Our objective was to determine the prevalence of burnout among anesthetists and intensive care physicians, and associations between burnout and personal, as well as professional, characteristics. METHODS: In total, 220 anesthetists and intensive care physicians were contacted by email, asking them to participate in the study. For depression screening the PHQ-2 questionnaire, for problem drinking, CAGE items were used. Burnout was measured by the Maslach Burnout Inventory. RESULTS: Overall, 34% anesthetists and intensive care physicians indicated high levels of emotional exhaustion, 25% indicated high levels of depersonalization, and 38% showed low personal accomplishment. Burnout was found more frequent among subjects with problem drinking (OR 3.2, 95% CI 1.5-6.8), depressiveness (OR 10.2, 95% CI 4.6-22.6), cardiovascular disorders (OR 3.4, 95% CI 1.7-7.1), and digestive disorders (OR 2.2, 95% CI 1.2-4.0). Some favorite after-work activities positively correlated with burnout, such as sedative medications abuse (OR 4.8, 95% CI 1.8-12.5), alcohol abuse (OR 2.4, 95% CI 1.3-4.5), eating more than usual (OR 1.9, 95% CI 1.1-3.5), and transferring the accumulated stress to relatives (OR 2.8, 95% CI 1.4-5.5). In contrast, reading of non-medical literature seemed to have a protective effect (OR 0.5, 95% CI 0.2-0.9). CONCLUSIONS: Burnout was highly prevalent among anesthetists and intensive care physicians with two fifths of them meeting diagnostic criteria. It was strongly correlated with problem drinking, depressiveness, cardiovascular and digestive disorders, use of sedatives and overeating.

Influence of early re-infusion of autologous shed mediastinal blood on clinical outcome after cardiac surgery.

Various strategies have been proposed to decrease allogeneic blood transfusion requirements after cardiac surgery. The aim of the study was to evaluate the efficacy of collected and re-infused autologous shed mediastinal blood on a patient's postoperative course. Ninety patients who underwent heart surgery with cardiopulmonary bypass (CPB) were studied. The patients were divided into two groups: Group 1 (n=41) received the centrifuged autologous shed mediastinal blood collected from the cardiotomy reservoir 4 hours after surgery; in Group 2 (n=49) all shed mediastinal blood was discarded (control group). Haemoglobin (Hb), haematocrit (Hct), C-reactive protein values, and leucocyte count were compared before surgery, at 4 h and 20 h after surgery, and on the fifth postoperative day. We have measured serum procalcitonin (PCT) concentration at 4 h and 20 h after CPB. We assessed drained blood loss within 20 postoperative hours. Leucocyte count, Hb, Hct values, C-reactive protein, and procalcitonin concentration did not differ between the groups before and at 4 h after surgery. Hb, Hct level, and leucocyte count were similar at 20 hours and on the fifth day after surgery. At 20 hours after surgery, an increase of serum PCT concentration (>0.5-2 ng/mL) was more frequent in Group 2 (58.3% vs. 33.3%; p = 0.03). On the fifth postoperative day, C-reactive protein concentration was lower in Group 1 (71.74 +/- 15.23; p <0.01) compared to Group 2 (93.53 +/- 20.3). Postoperative blood loss did not differ between the groups. Requirement for allogeneic blood transfusion was significantly lower in Group 1 (14.6% vs. 38.8%; p < 0.02). Patients in Group 1 developed less infective complications compared with Group 2 (2.4% and 16.3%, respectively; p < 0.05). The length of postoperative in-hospital stay was shorter in Group 1 compared with Group 2 (9.32 +/- 2.55 and 16.45 +/- 6.5, respectively; p < 0.05). We conclude that postoperative re-infusion of autologous red blood cells processed from shed mediastinal blood did not increase bleeding tendency and systemic inflammatory response and was effective in reducing the requirement for allogeneic transfusion, the rate of infective complications and the length of postoperative in-hospital stay.

[The diagnostic value of procalcitonin in severe sepsis]. / Prokalcitonino tyrimo reiksme diagnozuojant sepsi.

Sepsis and its complications are the most common cause of the death in the intensive care unit. In spite of the treatment mortality remains up to 28-50%, and 60-90% of the patients are lost because of the complications of sepsis. So it is very important to diagnose this pathology and start the treatment early. The diagnosis of sepsis is complicated for clinical signs and symptoms are not specific and manifest in the patients who have non-infective diseases, when systemic inflammatory response is involved. Parameters of systemic inflammatory response, such as body temperature, heart rate, respiratory rate, leukocyte count, and C-reactive protein concentration, used in clinical practice are neither specific, non sensitive. These parameters often provide information that is inadequate for the discrimination of bacterial and nonbacterial infections and for diagnosis. So it is impossible to differentiate systemic inflammatory response and sepsis. Procalcitonin is a new parameter for diagnosis of bacterial, fungal and parasitical infections. In healthy humans almost all procalcitonin, which is produced in thyroid gland, is resolved and does not reach the blood stream. Its half-life in plasma is only few minutes, so in healthy humans the level of procalcitonin is very low (<0.1 ng/ml) and is not detectable by standard methods. In the case of infection the level of procalcitonin rapidly increases during 2-6 hours and reaches the maximum level after 6-12 hours. The measurement of procalcitonin levels can be used for instant diagnosis as well as for evaluation of the treatment effectiveness. In our article we review the new literature data on the importance of procalcitonin level for sepsis diagnosis in comparison with other parameters of systemic inflammatory reaction, and discuss the indications for procalcitonin analysis.

[Prevention of pulmonary alterations after cardiopulmonary bypass]. / Plauciu pazeidimo prevencija darant sirdies operacijas.

Postoperative lung injury is one of the most frequent complications in cardiac surgery that has a significant impact on health care expenditures and largely has been believed to result from the use of cardiopulmonary bypass. Cardiopulmonary bypass induces the whole body inflammatory response leading to postoperative lung dysfunction. Pulmonary complications after these operations take the first place in morbidity and mortality rates. Despite the modern technologies and new surgical techniques, cases of pulmonary alterations after cardiopulmonary bypass are not rare. Therefore, the prevention of such alterations is an urgent problem worldwide. Still it is not known what is the cause of pulmonary alterations, as well as there are no means to prevent them. In our paper we review the international studies in order to present worldwide practice of prevention of pulmonary alterations using various methods of mechanical lung ventilation.

The influence of cardiopulmonary bypass on respiratory dysfunction in early postoperative period.

BACKGROUND AND OBJECTIVE: Pulmonary dysfunction is one of the most serious problems in an early postoperative period after cardiac surgery. This study was designed to reveal the impact of performed cardiopulmonary bypass on pulmonary function during early postoperative period by evaluating the intrapulmonary shunt. MATERIAL AND METHODS: Twenty-one patients undergoing elective myocardial revascularization surgery were analyzed. The patients were divided into two groups. Group 1 included 11 patients who underwent cardiac surgery on cardiopulmonary bypass. Group 2 included 10 patients who underwent cardiac surgery without cardiopulmonary bypass. Preoperative data were similar in the both groups. Blood gas analysis for intrapulmonary shunt calculations was made at 20 minutes after the induction of anesthesia and at 4 hours after the surgery. Intrapulmonary shunt size (Qs/Qt) was also calculated and the records were studied for additional data. RESULTS: At 4 hours after surgery Qs/Qt increased, compared to the preoperative data in Group 1 (from 8.6+/-2.1 to 16.8+/-2.6%, p<0.02). Intrapulmonary shunt was great in Group 1 compared with Group 2 at four hours after the surgery (16.8+/-2.6 and 7.8+/-2.1%, p<0.02). In Group 1 80 % of alterations in a pulmonary function were caused by atelectasis, detected by chest X-ray. In Group 2 no increase in intrapulmonary shunt and no atelectasis were determined. CONCLUSIONS: Arterial hypoxemia and increase in intrapulmonary shunt (due to atelectasis) have proven that alterations in pulmonary function are found more often and are more pronounced in patients after surgery on cardiopulmonary bypass.

[Acute respiratory distress syndrome]. / Uminis respiracinis distreso sindromas.

Acute respiratory distress syndrome (ARDS) - is a life-threatening acute clinical syndrome of pulmonary insufficiency with high mortality. The causes of the syndrome are of every description - from crustacean poisoning to cardiopulmonary bypass. The rate of ARDS is not clear, because of diagnostical variety of ARDS and acute pulmonary dysfunction. The discussion on ARDS diagnostical criteria lasted for many years. The clinical criteria depend on how the essence of the disease is understood, on the size of lung infiltration, lung compliance and failure as well as degree of hypoxemia. The risk of ARDS increases with the increase of number of predisposing factors. The investigation data depend mainly on used datum-point for diagnostics of ARDS. It is obvious that non-cardiogenic light pulmonary edema is found very often, and serious lung lesions are rare enough. The aim of nowadays treatment is to cure the disease that causes the syndrome and to sustain vital functions. The early diagnostics of ARDS predisposing factors and minimization of their influence, the prevention, early diagnostics and timely treatment of complications are essential. In many cases ARDS caused by collateral factors is the constituent of multiple organ dysfunction syndrome. Anyway the ARDS predisposed by direct factors is often complicated by other organ (cardiovascular, renal, hepatic, hematogenous, central nervous system, gastrointestinal tract, etc.) dysfunction. In this case the treatment becomes more difficult and includes therapy correcting the function of other systems. In spite of intensive treatment, mortality of this syndrome still remains 50-90% according to the literature data. Though some authors state that recently the ARDS mortality decreased, but most of the authors did not notice any improvement during the last 20 years. The prognosis is determinated not only by pulmonary insufficiency itself (the cause of death in 5% of patients), but by the ARDS predisposing factor (the worst is sepsis and septic shock), multiple organ dysfunction syndrome, difficult physical state of the patient, sepsis as a cause or as a complication of ARDS, nosocomial pneumonia, progressive fibroproliferation in the lung. Considering the actuality of ARDS, the diagnostical criteria of ARDS, pathogenesis, clinical course and new treatment methods are reviewed in the publication.

[Procalcitonin: a new infection marker. Its use in intensive care]. / Prokalcitoninas--naujas infekcijos rodmuo. Jo panaudojimas intensyviojoje terapijoje.

In daily routine diagnosis, there are few parameters available to monitor critically ill patients and to control the course of therapy in severe inflammations. There are also few reliable parameters differentiating acute bacterial infection from other types of inflammation. Most of the presently used indicators of the inflammatory response, like body temperature, white cell count, erythrocyte sedimentation rate or C reactive protein are unspecific parameters with changing reliability. Procalcitonin is a diagnostic parameter of bacterial infections with systemic reaction of the organism. It is an innovative diagnostic parameter with feature different from other presently available indicators of the inflammatory response. The incidence of noninfectious systemic inflammatory response syndrome associated with coronary artery bypass surgery and the potential role of several inflammatory parameters as early markers of pulmonary dysfunction induced by cardiopulmonary bypass were investigated. Procalcitonin seems to be appropriate parameter indicating the early development of severe noninfectious systemic inflammatory response syndrome and for predicting pulmonary dysfunction secondary to cardiopulmonary bypass. Hence, the review of the data of different authors may lead to the conclusion that because of wide spectrum of indications procalcitonin concentration can be used for differential diagnosis of bacterial versus non-bacterial inflammation, as monitoring parameter in critically ill patients, the course of disease, treatment control evaluating the effectiveness of antibacterial treatment, for evaluation of high risk patients to see if there are no postoperative bacterial complications as a prognostic indicator.

[Tracheostomy and prolonged artificial ventilation of patients after heart surgery]. / Tracheostoma ir ilgalaike dirbtine plauciu ventiliacija ligoniams po sirdies operaciju.

Dysfunction of respiratory system after open heart surgery is one of the main problems in postoperative period. When mechanical ventilation is prolonged because of different causes, tracheostomy is usually performed, but the optimal time is still being discussed. In order to elucidate the influence of tracheostomy to subsequent course of disease we reviewed the indications, frequency and complications of postoperative tracheostomies performed in 1998-2000 in Cardiosurgical clinic after open heart surgery. The survey of our experience (only 15 tracheostomy procedures have been performed) showed that ventilation through tracheostomy tube is safe and comfortable way of application of prolonged mechanical ventilation: it is easier to stabilize, suction, and attach respiratory equipment. The patient can eat and, with some adjustments, can talk. Complications of tracheostomy are not often. If tracheostomy was well timed, the risk of trachea stenosis, infection of respiratory tract and other possible complications would decrease.