Baroreflex impairment and morbidity after major surgery

Toner, Andrew J.; Jenkins, Nicholas; Ackland, Gareth L.

doi:10.1093/bja/aew257

Cited by 35 publications

(34 citation statements)

References 46 publications

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“…A similar observation in reduced cardiac (vagal) parasympathetic activity has been described during stress echocardiography [36, 37]. Furthermore, we have also shown in separate cohorts of patients that impaired baroreflex dysfunction—which is in part characterized by reduced parasympathetic tone—is also associated with excess morbidity [38, 39]. These autonomic changes may impact on renal dysfunction, since activation of vagal efferent outflow in a murine preclinical model of renal ischaemia-reperfusion minimizes injury, mediated by an anti-inflammatory mechanism requiring nicotinic α7 splenocytes [40].…”

Section: Discussionsupporting

confidence: 82%

Postoperative goal-directed therapy and development of acute kidney injury following major elective noncardiac surgery: post-hoc analysis of POM-O randomized controlled trial

et al. 2017

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Background: The role of goal-directed therapy (GDT) in preventing creatinine rise following noncardiac surgery is unclear. We performed a post-hoc analysis of a randomized controlled trial to assess the relationship between postoperative optimization of oxygen delivery and development of acute kidney injury (AKI)/creatinine rise following noncardiac surgery. Methods: Patients were randomly assigned immediately postoperatively to receive either fluid and/or dobutamine therapy to maintain/restore their preoperative oxygen delivery, or protocolized standard care (oxygen delivery only recorded). Primary end point was serial changes in postoperative creatinine within 48 h postoperatively. Secondary outcomes were development of AKI (KDIGO criteria) and minimal creatinine rise (MCR; no decline from preoperative creatinine), related to all-cause morbidity and length of stay. Results: Postoperative reductions in serum creatinine were similar (P = 0.76) in patients randomized to GDT [10 µmol/L (95% confidence interval, CI: 17 to −1); n = 95] or protocolized care [8 µmol/L (95% CI: 17 to −6); n = 92]. Postoperative haemodynamic management was not associated with the development of MCR [78/187 (41.7%)] or AKI [13/187; (7.0%)]. Intraoperative requirement for norepinephrine was more likely in patients who developed postoperative rises in creatinine [relative risk (RR): 1.66 (95% CI: 1.04–2.67); P = 0.04], despite similar volumes of intraoperative fluid being administered. Persistently higher lactate during the intervention period was associated with AKI (mean difference: 1.15 mmol/L (95% CI: 0.48–1.81); P = 0.01]. Prolonged hospital stay was associated with AKI but not MCR [RR: 2.71 (95% CI: 1.51–4.87); P = 0.0008]. Conclusion: These data provide further insights into how perioperative haemodynamic alterations relate to postoperative increases in creatinine once systemic inflammation is established.

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Section: Discussionsupporting

confidence: 82%

Postoperative goal-directed therapy and development of acute kidney injury following major elective noncardiac surgery: post-hoc analysis of POM-O randomized controlled trial

et al. 2017

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“…The impairment of HRR may in part be due to acquired parasympathetic dysfunction as demonstrated by the loss in high frequency power spectrum found in PMI patients with impaired HRR. This supports our previous work that cardiac vagal dysfunction can be identified by baroreceptor insensitivity (15) is associated with an increased post surgery cardiovascular complications (6).…”

Section: Discussionsupporting

confidence: 92%

“…In the Measurement of exercise Tolerance before Surgery (METS) study, delayed heart rate recovery (HRR) quantified after cessation of preoperative cardiopulmonary exercise testing, the gold-standard measure of cardiac vagal activity (3), was the sole physiological parameter associated with post-surgery myocardial injury. (4) Delayed HRR is also strongly associated with baroreflex dysfunction (5) which predisposes patients to haemodynamic compromise linked to post operative morbidity (6). Patients with impaired cardiac vagal activity acquired during surgery may, therefore, be at particular risk of sustaining PMI after major non-cardiac surgery.…”

Section: Introductionmentioning

confidence: 99%

Acquired loss of cardiac vagal activity is associated with myocardial injury in patients undergoing non-cardiac surgery: prospective observational mechanistic cohort study

May

Reyes

Martir

et al. 2019

Preprint

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Background: Myocardial injury is more frequent after non-cardiac surgery in patients with preoperative cardiac vagal dysfunction as quantified by delayed heart rate recovery after cessation of cardiopulmonary exercise testing. Here, we hypothesised that serial and dynamic measures of perioperative cardiac vagal activity should also be associated with myocardial injury after non-cardiac surgery. Methods: Serial measures in cardiac vagal activity were quantified preoperatively and daily using heart rate variability and a standardised orthostatic challenge in patients undergoing elective non-cardiac surgery. The primary outcome was myocardial injury (high-sensitivity troponin (hsTnT) ≥15ng.L -1 ) within 48h of surgery. Clinicians, patients and investigators were blinded to hsTnT. The exposure of interest was cardiac vagal activity (high-frequency power spectral analysis [HFlog]) and heart rate recovery after a standardised orthostatic challenge. Results: hsTnT≥15ng.L -1 occurred in 48/189 [25%] patients, of whom 41/48 [85%] had a revised cardiac risk index score <2. Patients with a post surgery troponin HsTnT ≥15ng.L -1 were associated with an early loss (within 24h) of cardiac vagal activity (HFLog) post surgery compared to day of surgery (4.19 [95%CI:3.62-4.75] vs 5.22 [95%CI:4.64-5.81]; p<0.001).Heart rate recovery after a standardised orthostatic challenge after surgery was slower in patients with hsTnT≥15ng.L -1 (5 beats minute -1 (95% CI: 3 -7), compared to heart rate recovery in patients who remained free of myocardial injury (10 beats minute -1 (95%CI:7 to 12]; p = 0.02). Conclusions:Real-time, serial heart rate measures indicating loss of cardiac vagal activity are associated with perioperative myocardial injury in lower-risk patients undergoing non-cardiac surgery.

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“…[22] The cut-off value for a depressed BRS in this study was set at < 6 ms/mmHg, higher than the one of the present study, and the cut-off for severely depressed BRS was set at < 3 ms/mmHg, like in our series. The differences in BRS measuring techniques (the sequence method technique in the study of Toner and associates [22], and the spectral method in ours) can account for this difference. Moreover, all our patients undergoing cardiac surgery had coronary artery disease.…”

Section: Discussionmentioning

confidence: 77%

“…While it is well-recognized that cardiovascular autonomic neuropathy in diabetic patients may result in unexpected hemodynamic instability during surgery, [20] very few studies have analyzed the impact of autonomic dysfunction on post/peri-operative outcomes in a general population or in cardiac surgery patients. [21, 22]…”

Section: Introductionmentioning

confidence: 99%

Baroreflex sensitivity and outcomes following coronary surgery

Ranucci¹,

Porta²,

Bari³

et al. 2017

PLoS ONE

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Postoperative atrial fibrillation, acute kidney dysfunction and low cardiac output following coronary surgery are associated with morbidity and mortality. The purpose of this study is to determine if the preoperative autonomic control is a determinant of these postoperative complications. This is a prospective cohort study on 150 adult patients undergoing surgical coronary revascularization with cardiopulmonary bypass. The patients received an autonomic control assessment after the induction of anesthesia. Baroreflex sensitivity was computed by spectral analysis and expressed as BRSαHF and BRSαLF for measure respectively in the high and low frequency domains. Atrial fibrillation was adjudicated at any postoperative time during the hospital stay. Acute kidney dysfunction was defined as any increase of serum creatinine levels from preoperative values within the first 48 hours after surgery, and acute kidney injury was adjudicated at a 50% increase. Low cardiac ouput syndrome was defined as the need for inotropic support > 48 hours. Thirty-eight (26.4%) patients experienced postoperative atrial fibrillation; 32 (22.2%) had acute kidney dysfunction and 5 (3.5%) acute kidney injury; 14(10%) had a low cardiac output state. No indices of baroreflex sensitivity were associated with atrial fibrillation or acute kidney injury. A low value of BRSαLF was associated with acute kidney dysfunction and low cardiac output state. A BRSαLF < 3 msec/mmHg was an independent risk factor for acute kidney dysfunction (odds ratio 3.0, 95% confidence interval 1.02–8.8, P = 0.045) and of low cardiac output state (odds ratio 17.0, 95% confidence interval 2.9–99, P = 0.002). Preoperative baroreflex sensitivity is linked to postoperative complications through a number of possible mechanisms, including an autonomic nervous system-mediated vasoconstriction, a poor response to hypotension, and an increased inflammatory reaction.

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Baroreflex impairment and morbidity after major surgery

Cited by 35 publications

References 46 publications

Postoperative goal-directed therapy and development of acute kidney injury following major elective noncardiac surgery: post-hoc analysis of POM-O randomized controlled trial

Postoperative goal-directed therapy and development of acute kidney injury following major elective noncardiac surgery: post-hoc analysis of POM-O randomized controlled trial

Acquired loss of cardiac vagal activity is associated with myocardial injury in patients undergoing non-cardiac surgery: prospective observational mechanistic cohort study

Baroreflex sensitivity and outcomes following coronary surgery

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