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Peri-operative cardiac protection

IRCCS Ospedale San Raffaele Milano Università Vita-Salute San Raffaele. Peri-operative cardiac protection. Tutorial in General Anesthesia, Milano, 28 Marzo 2009. Relatore: Dott. Giovanni Landoni. Cardioprotection & anaesthesia Volatile Anesthetics. b blockers “recommended”

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Peri-operative cardiac protection

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  1. IRCCS Ospedale San Raffaele Milano Università Vita-Salute San Raffaele Peri-operativecardiacprotection Tutorial in General Anesthesia, Milano, 28 Marzo 2009 Relatore: Dott. Giovanni Landoni

  2. Cardioprotection & anaesthesiaVolatile Anesthetics • b blockers“recommended” • Statins “suggested” in selected pts • a2 agonists “may be considered” in selected pts • Ca++ antagonists “may be considered” in selected pts • Insulin “reasonable” in hyperglycaemic pts • Volatile Anesthetics “can be beneficial”

  3. REDUCING PERIOPERATIVE MYOCARDIAL INFARCTION • EPIDURAL ANESTHESIA (non-cardiac surgery) • BETA BLOCKERS (non-cardiac surgery) ??!! • VOLATILE AGENTS (cardiac surgery) • LEVOSIMENDAN (cardiac surgery)

  4. REDUCING PERIOPERATIVE MORTALITY AND MYOCARDIAL INFARCTION • VOLATILE AGENTS (cardiac surgery) • LEVOSIMENDAN (cardiac surgery)

  5. REDUCING PERIOPERATIVE MORTALITY • FENOLDOPAM • PEXELIZUMAB (cardiac surgery) • DOPEXAMINE • EARLY ENTERAL NUTRITION (intestinal surgery) • INSULINE !!?? • STATINS

  6. Anaesthesia and Outcome Volatile Anesthetics Could VOLATILE anaesthetics influence outcome? Could VOLATILE anaesthetics have non-anaesthetic properties?

  7. DESFLURANEversusPROPOFOL(fentanyl-based cardiac anesthesia)

  8. Troponin I after OFF-PUMP CABG

  9. Troponin I after CABG (CPB)

  10. Troponin I after MITRAL SURGERY

  11. Evidence? IMeta-analysis and/or large randomized studies II Randomized trials III Non-randomized prospective trials IV Retrospective studies V Case reports and Expert Opinion VI Animal / Laboratories Studies

  12. Volatile Anesthetics

  13. META-ANALYSIS(cardiac anaesthesia) • 22 randomized studies (15 CPB-CABG; 6 OP-CABG; 1 mitral valve surgery) • 1922 patients (904 TIVA and 1018 DES or SEVO) • 16 studies administered volatile anesthetics throughout all the procedure (6 studies for 5-30 minutes)

  14. Evidence! Mortality

  15. Evidence! Mortality • 4/977=0.4% v 14/872=1.6% • NNT=84 • RRR=(1,6-0,4)/1,6=75% • OR: 0.31(0.12-0.80) • P=0.02

  16. Mortality NNT=84 Treat 84 to save one

  17. Evidence! Myocardial infarction

  18. Evidence! Myocardial infarction • 24/979=2.4% v 45/874=5.1% • NNT=37 • RRR: (5.1-2.4)/5.1 = 53% • OR: 0.51(0.32-0.84) • p=0.008

  19. Myocardial infarction NNT=37 Treat 37 to save one

  20. Evidence! PEAK CARDIAC TROPONIN I WMD -2.35 ng/dL [-3.09,-1.60], p<0.00001

  21. Evidence! INOTROPE USE IN ICU OR 0.47 [0.29, 0.76], p < 0.002

  22. Evidence! Mechanical ventilation WMD -0.49 hours [-0.97,-0.02], p = 0.4

  23. Evidence! ICU STAY WMD -7.10 hours [-11.47,-2.73], p < 0.001

  24. Evidence! HOSPITAL STAY WMD -2.26 days [-3.83,-0.68], p = 0.005

  25. Conclusions: Volatile Anesthetics in cardiac surgery Sevoflurane&Desflurane: ↓post cardiac surgery mortality Desflurane in CABG surgery: • ↓postoperative cTnI release • ↓postoperative inotropic support • ↓hospitalization +/- cardiopulmonary bypass Volatile Anesthetics Direct and indirect protection

  26. Have we forgotten about noncardiac surgery?

  27. A meta-analysis in noncardiac surgery Evidence? 6219 patients 2842 sevoflurane 609 desflurane 2768 propofol

  28. 4281 citations retrieved from database searches 3936 titles/abstracts excluded because non-relevant 344 studies assessed according to the selection criteria 265 studies excluded according to explicit exclusion criteria 35 duplicate reports 51 no TIVA group 75 cardiac surgery 46 retrospective 25 non randomised 21 paediatric 12 not available 79 Randomised Controlled Trials finally included in the systematic review Evidence? A meta-analysis in noncardiac surgery

  29. Evidence? A meta-analysis in noncardiac surgery Total 79 Anesth analg 20 BJA 14 EJA 11 Acta anaesthesiol scand 8 Anaesthesia 5 J Anesth 4 Anesthesiology 3 Minerva anestesiol 2 Altri 13

  30. Evidence? A meta-analysis in noncardiac surgery • 400 authors • 240 reviewers • 90 editors 0 deaths 0 myocardial infarctions

  31. Have we forgotten about CARDIAC MORBIDITY and MORTALITY in noncardiac surgery?

  32. WHAT’S NEXT

  33. SEVOFLURANE IN STENTING PROCEDURES: A RANDOMIZED CONTROLLED STUDY. METHODS 30 patients 20’ 16 SEVOFLURANE 0,5 MAC + oxygen/air 14 Oxygen/air PTCA+stenting Endpoint primario: TnI postprocedurale

  34. SEVOFLURANE IN STENTING PROCEDURES: A RANDOMIZED CONTROLLED STUDY. RESULTS SEVOFLURANE TnI, median (25°-75° percentile) 0.15 (0-4.73) ng/dl PLACEBO TnI, median (25°-75° percentile) 0.14 (0-0.87) ng/dl vs P = 0,4 Landoni et al. JCVA 2008

  35. Take home message • RCTs should confirm the promisingresults of volatile anesthetics in noncardiac surgery • Cardiac Troponin I couldbe anexcellent intermediate (surrogate?) outcome in cardiac and non-cardiac high risk surgical patients

  36. Cardioprotection & anaesthesiaEpidural analgesia

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