Effects of single dose, postinduction dexamethasone on recovery after cardiac surgery

Yared, Jean-Pierre; Starr, Norman J.; Torres, Frederick K; Bashour, C. Allen; Bourdakos, G.; Piedmonte, Marion; Michener, Judith A; Davis, Jeffrey A.; Rosenberger, Thomas E

doi:10.1016/s0003-4975(00)01180-2

Cited by 134 publications

(75 citation statements)

References 17 publications

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“…20,21 Yared and colleagues 20 demonstrated that patients receiving corticosteroid therapy had a significantly lower incidence of postoperative AF after both CABG and valvular surgery than patients who did not receive corticosteroid therapy. The present study showed that antiinflammatory therapy significantly decreased inhomogeneity of atrial conduction after atriotomy and the duration of induced AF.…”

Section: Discussionmentioning

confidence: 99%

Inflammation of Atrium After Cardiac Surgery Is Associated With Inhomogeneity of Atrial Conduction and Atrial Fibrillation

et al. 2005

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Background— Atrial fibrillation (AF) is common after cardiac surgery. Abnormal conduction is an important substrate for AF. We hypothesized that atrial inflammation alters atrial conduction properties. Methods and Results— Normal mongrel canines (n=24) were divided into 4 groups consisting of anesthesia alone (control group); pericardiotomy (pericardiotomy group); lateral right atriotomy (atriotomy group); and lateral right atriotomy with antiinflammatory therapy (methylprednisolone 2 mg/kg per day) (antiinflammatory group). Right atrial activation was examined 3 days after surgery. Inhomogeneity of conduction was quantified by the variation of maximum local activation phase difference. To initiate AF, burst pacing was performed. Myeloperoxidase activity and neutrophil cell infiltration in the atrial myocardium were measured to quantify the degree of inflammation. The inhomogeneity of atrial conduction of the atriotomy and pericardiotomy groups was higher than that of the control group (2.02±0.10, 1.51±0.03 versus 0.96±0.08, respectively; P <0.005). Antiinflammatory therapy decreased the inhomogeneity of atrial conduction after atriotomy (1.16±0.10; P <0.001). AF duration was longer in the atriotomy and pericardiotomy groups than in the control and antiinflammatory groups ( P =0.012). There also were significant differences in myeloperoxidase activity between the atriotomy and pericardiotomy groups and the control group (0.72±0.09, 0.41±0.08 versus 0.18±0.03 ΔOD/min per milligram protein, respectively; P <0.001). Myeloperoxidase activity of the antiinflammatory group was lower than that of the atriotomy group (0.17±0.02; P <0.001). Inhomogeneity of conduction correlated with myeloperoxidase activity ( r =0.851, P <0.001). Conclusions— The degree of atrial inflammation was associated with a proportional increase in the inhomogeneity of atrial conduction and AF duration. This may be a factor in the pathogenesis of early postoperative AF. Antiinflammatory therapy has the potential to decrease the incidence of AF after cardiac surgery.

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Section: Discussionmentioning

confidence: 99%

Inflammation of Atrium After Cardiac Surgery Is Associated With Inhomogeneity of Atrial Conduction and Atrial Fibrillation

et al. 2005

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“…[15][16][17] On the contrary, another study of moderate dose (dexamethasone 0.6 mg/kg after induction) in 236 patients undergoing elective surgery showed that whereas duration of ventilation was not statistically different between groups (11.6 ± 11.9 hours dexamethasone vs 13.1 ± 13.8 hours placebo, P = .074), the corticosteroid group had a larger percentage of patients with a short (6 hours or less) intubation time (10% vs 26%, P = .02) compared to placebo. 18 Most recently, analysis of secondary outcomes in the DECS study described above demonstrated a reduction in respiratory failure, defi ned as the need for mechanical ventilation for at least 48 hours postoperatively, in the group receiving a moderate dose corticosteroid (dexamethasone 1 mg/kg) compared to placebo (3% vs 4.3%; RR, 0.69; 95% CI, 0.51-0.94; P = .02). 8 Although there was little difference in the median time to weaning mechanical ventilation, the average time was higher in the placebo group (11 vs 14.3 hours; P < .001) due to a higher number of patients requiring prolonged (>24 hours) intubation in the placebo group (3.4 vs 4.9%; P value not reported).…”

Section: Respiratory Failurementioning

confidence: 99%

“…One factor associated with prolonged duration of intubation is shivering, 18 which can be prevented with dexamethasone. 19 Given that shivering patients are commonly treated with opioid analgesics, a reduction in ventilator time may be related to a reduced need for opioids.…”

Section: Respiratory Failurementioning

confidence: 99%

“…20 As expected, several clinical trials of corticosteroids have shown an increase in the incidence of hyperglycemia as well as higher insulin requirements. 15,17,18,21,22 The Cochrane analysis did not fi nd an increased risk of infection in 15 studies including infectious complications as secondary outcomes. 5 Given that no study has been suffi ciently powered to assess this outcome, there remains a theoretical increased susceptibility to infection and poor wound healing associated with hyperglycemia that has not been elucidated in the existing studies.…”

Section: Hyperglycemia and Infectious Complicationsmentioning

confidence: 99%

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Role of Corticosteroids during Cardiopulmonary Bypass

2014

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Corticosteroids are commonly used in the peri-operative setting for patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The infl ammatory response to CPB is associated with organ dysfunction and increased mortality. Corticosteroids reduce biochemical infl ammatory markers associated with CPB, however the impact on clinical outcomes is mixed. The purpose of this article is to evaluate the evidence of changes in clinical outcomes associated with the peri-operative administration of corticosteroids in patients undergoing cardiac surgery with CPB. Randomized, placebo-controlled trials and meta-analyses were reviewed for evidence evaluating the impact of corticosteroids on clinical outcomes including mortality, myocardial infarction, atrial fi brillation (AF), duration of intubation, length of intensive care unit (ICU) or hospital stay, hyperglycemia, and gastrointestinal complications. Most of the relevant studies are underpowered to assess major clinical outcomes. Although corticosteroids likely reduce the risk of AF, this needs to be evaluated when used in addition to or in lieu of other anti-arrhythmic agents. Evidence does not equivocally support the use of corticosteroids to improve clinical outcomes in cardiac surgery patients.

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“…Early studies by Chaney et al 184 did not find any significant benefit of steroid administration to patients undergoing coronary artery bypass graft surgery (CABG); however, Yared et al 185 in a study of 216 patients undergoing cardiothoracic surgery, found that dexamethasone administration perioperatively decreased the incidence of post-operative AF in the first few days after surgery.Inflammatory markers (i.e., CRP, IL-6, and so forth) were not measured in this study. Yared et al 186 reported on the outcome of 78 patients undergoing combined CABG and valve surgery who were randomized to receive either dexamethasone or placebo before surgery.…”

Section: Glucocorticoidsmentioning

confidence: 99%

Atrial Remodeling And Atrial Fibrillation: Mechanistic Interactions And Clinical Implications

Hassan¹,

Al‐Ghamdi²

2009

J.A.F.I.B

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Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. The prevalence of AF increases dramatically with age and is seen in as high as 9% of individuals by the age of 80 years. In high-risk patients, the thromboembolic stroke risk can be as high as 9% per year and is associated with a 2-fold increase in mortality. Although the pathophysiological mechanism underlying the genesis of AF has been the focus of many studies, it remains only partially understood. Conventional theories focused on the presence of multiple re-entrant circuits originating in the atria that are asynchronous and conducted at various velocities through tissues with various refractory periods. Recently, rapidly firing atrial activity in the muscular sleeves at the pulmonary veins ostia or inside the pulmonary veins have been described as potential mechanism,. AF results from a complex interaction between various initiating triggers and development of abnormal atrial tissue substrate. The development of AF leads to structural and electrical changes in the atria, a process known as remodeling. To have effective surgical or catheter ablation of AF good understanding of the possible mechanism(s) is crucial.Once initiated, AF alters atrial electrical and structural properties that promote its maintenance and recurrence. The role of atrial remodeling (AR) in the development and maintenance of AF has been the subject of many animal and human studies over the past 10-15 years. This review will discuss the mechanisms of AR, the structural, electrophysiologic, and neurohormonal changes associated with AR and it is role in initiating and maintaining AF. We will also discuss briefly the role of inflammation in AR and AF initiation and maintenance, as well as, the possible therapeutic interventions to prevent AR, and hence AF, based on the current understanding of the interaction between AF and AR.

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Effects of single dose, postinduction dexamethasone on recovery after cardiac surgery

Cited by 134 publications

References 17 publications

Inflammation of Atrium After Cardiac Surgery Is Associated With Inhomogeneity of Atrial Conduction and Atrial Fibrillation

Inflammation of Atrium After Cardiac Surgery Is Associated With Inhomogeneity of Atrial Conduction and Atrial Fibrillation

Role of Corticosteroids during Cardiopulmonary Bypass

Atrial Remodeling And Atrial Fibrillation: Mechanistic Interactions And Clinical Implications

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