Target blood pressure management during cardiopulmonary bypass improves lactate levels after cardiac surgery: a randomized controlled trial

Miao, Qing; Dong, Wei; Chen, Zhanghua; Xu, Mengdan; Sun, Lin; Guo, Zhen; He, Bin; Wu, Jingxiang

doi:10.1186/s12871-021-01537-w

Cited by 8 publications

(6 citation statements)

References 22 publications

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“…In that study, 28 the investigators used a lower norepinephrine infusion rate than in our study (0.03-1 µg/kg/min in conjunction with rescue phenylephrine boluses versus combined norepinephrine rescue boluses and infusion rate of 0.05-0.2 µg/kg/min in the norepinephrine group in our study). That study 28 started earlier than the present study, but it included few patients undergoing heart valve surgery (only 20 patients in each study group). One of the most important hemodynamic parameters which was not mentioned in that study 27 is the SVRI which in our opinion was very important to be measured in a study discussing vasoplegia and vasopressor infusion in cardiac surgery.…”

Section: Discussionmentioning

confidence: 81%

“…Contradictory to our results, compared to maintaining low MAP at 50–60 mmHg during the CPB, Miao et al 28 reported lower blood lactate levels for the first one hour after surgery with maintaining MAP from 70 to 80 mmHg. In that study, 28 the investigators used a lower norepinephrine infusion rate than in our study (0.03–1 µg/kg/min in conjunction with rescue phenylephrine boluses versus combined norepinephrine rescue boluses and infusion rate of 0.05–0.2 µg/kg/min in the norepinephrine group in our study). That study 28 started earlier than the present study, but it included few patients undergoing heart valve surgery (only 20 patients in each study group).…”

Section: Discussionmentioning

confidence: 95%

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Effects of norepinephrine infusion during cardiopulmonary bypass on perioperative changes in lactic acid level (Norcal)

et al. 2022

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Introduction Hyperlactatemia, a problem reported in up to 30% of cardiac surgery patients, results from excessive production of or decreased clearance of lactate. It is typically a symptom of tissue hypoperfusion and may be associated with the prevalence of postoperative acute mesenteric ischemia and renal failure, or prolonged intensive care unit (ICU) and hospital stay, and increased 30-day mortality. Methods and measurements Eighty cardiac surgery patients using cardiopulmonary bypass (CPB) were randomly assigned into either a placebo (n = 39) or norepinephrine 0.05–0.2 µg/kg/min (n = 41) as well as norepinephrine boluses during CPB to maintain mean arterial blood pressure (MAP) at 65 to 80 mm Hg. Patient assignments were done after receiving ethical approval to proceed. The primary result was the perioperative changes in lactic acid level. Secondary findings were also recorded, including hemodynamic variables, the incidence of vasoplegia, intraoperative hypotension, myocardial ischemia, the need for vasopressor support, postoperative complications, and mortality. Results The peak levels and perioperative changes in blood lactate during the first 24 postoperative hours, the number of patients who experienced early hyperlactatemia on admission to the ICU (Placebo: 46.2%, Norepinephrine: 51.2%, p = .650), vasoplegia, hemodynamic changes, incidences of intraoperative hypotension, myocardial ischemia, postoperative complications, and mortality rates were similar in the two groups. Patients in the norepinephrine group received lower intraoperative rescue norepinephrine boluses to maintain the target MAP (p = .039) and had higher MAP values during the CPB and intraoperative blood loss [mean difference [95% confidence interval]; 177 [20.9–334.3] ml, p = .027]. Conclusion norepinephrine and placebo infusions during the CPB with the maintenance of MAP from 65 to 80 mmHg had comparative effects on the changes in blood lactate and incidence of vasoplegia after cardiac surgery. Norepinephrine infusion maintained higher MAP values during the CPB.

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Section: Discussionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 95%

Effects of norepinephrine infusion during cardiopulmonary bypass on perioperative changes in lactic acid level (Norcal)

et al. 2022

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“…Because these indices are more accessible, economical, and can be converted into visual dynamic indicators that can be monitored by clinicians in real time with simple sensors. Over the past decade, there have been many large-scale studies [ 22 – 25 ] exploring the relationship between different pressure indexes and the prognosis of sepsis patients, such as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and MAP. Sepsis patients can develop tissue and organ hypoperfusion early and progress rapidly to multi-organ failure.…”

Section: Discussionmentioning

confidence: 99%

Association between different MAP levels and 30-day mortality in sepsis patients: a propensity-score-matched, retrospective cohort study

Zhong

Chen

et al. 2023

BMC Anesthesiol

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Background Sepsis is a life-threatening organ dysfunction caused by the infection-related host response disorder. Adequate mean arterial pressure is an important prerequisite of tissue and organ perfusion, which runs through the treatment of sepsis patients, and an appropriate mean arterial pressure titration in the early-stage correlates to the positive outcome of the treatment. Therefore, in the present study, we aimed to elucidate the relationship between early mean arterial pressure levels and short-term mortality in sepsis patients. Methods We included all suspected sepsis patients from MIMIC-III database with average mean arterial pressure ≥ 60 mmHg on the first day of intensive care unit stay. Those patients were then divided into a permissive low-mean arterial pressure group (60–65 mmHg) and a high-mean arterial pressure group (> 65 mmHg). Multivariate Cox regression analysis was conducted to analyze the relationship between MAP level and 30-day, 60-day, and 100-day mortality of suspected sepsis patients in the two groups. Propensity score matching, inverse probability of treatment weighing, standardized mortality ratio weighting, PA weighting, overlap weighting, and doubly robust analysis were used to verify our results. Results A total of 14,031 suspected sepsis patients were eligible for inclusion in our study, among which 1305 (9.3%) had an average first-day mean arterial pressure of 60–65 mmHg, and the remaining 12,726 patients had an average first-day mean arterial pressure of more than 65 mmHg. The risk of 30-day mortality was reduced in the high mean arterial pressure group compared with the permissive low-mean arterial pressure group (HR 0.67 (95% CI 0.60–0.75; p < 0.001)). The higher mean arterial pressure was also associated with lower 60-day and 100-day in-hospital mortality as well as with shorter duration of intensive care unit stay. Patients in the high-mean arterial pressure group also had more urine output on the first and second days of intensive care unit admission. Conclusions After risk adjustment, the initial mean arterial pressure of above 65 mmHg was associated with reduced short-term mortality, shorter intensive care unit stay, and higher urine volume in the first two days among patients with sepsis.

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“…According to the 2019 European Adult Cardiac Surgery Guidelines for CPB, it is safe to maintain MAP targets between 50 and 70 mm Hg during CPB. 55 However, studies have shown that higher MAP targets during CPB were associated with lower post-bypass lactate levels, 56 lower incidence of stroke, 13 and decreased risk of AKI. 53 It may be prudent to add monitors of cerebral perfusion and oxygenation in patients undergoing cardiac surgery, particularly in those with a history of a cerebrovascular event.…”

Section: Using Intraoperative Data To Guide Blood Pressure Management...mentioning

confidence: 99%

Blood Pressure Goals in Critically Ill Patients

Rajkumar¹,

Hicks²,

Marchant

et al. 2023

Methodist DeBakey Cardiovascular Journal

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Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.

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Target blood pressure management during cardiopulmonary bypass improves lactate levels after cardiac surgery: a randomized controlled trial

Cited by 8 publications

References 22 publications

Effects of norepinephrine infusion during cardiopulmonary bypass on perioperative changes in lactic acid level (Norcal)

Effects of norepinephrine infusion during cardiopulmonary bypass on perioperative changes in lactic acid level (Norcal)

Association between different MAP levels and 30-day mortality in sepsis patients: a propensity-score-matched, retrospective cohort study

Blood Pressure Goals in Critically Ill Patients

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