Presentation is loading. Please wait.

Presentation is loading. Please wait.

Peri-operative cardiac protection Relatore:Dott. Giovanni Landoni Tutorial in General Anesthesia, Milano, 28 Marzo 2009 IRCCS Ospedale San Raffaele Milano.

Similar presentations


Presentation on theme: "Peri-operative cardiac protection Relatore:Dott. Giovanni Landoni Tutorial in General Anesthesia, Milano, 28 Marzo 2009 IRCCS Ospedale San Raffaele Milano."— Presentation transcript:

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

2 Volatile Anesthetics Cardioprotection & anaesthesia Volatile Anesthetics blockers recommended CStatinssuggested in selected pts 2 agonists may be considered in selected pts CCa ++ antagonistsmay be considered in selected pts CInsulinreasonable in hyperglycaemic pts CVolatile Anesthetics can be beneficial

3 REDUCING PERIOPERATIVE MYOCARDIAL INFARCTION zEPIDURAL ANESTHESIA (non-cardiac surgery) zBETA BLOCKERS (non-cardiac surgery) ??!! zVOLATILE AGENTS (cardiac surgery) zLEVOSIMENDAN (cardiac surgery)

4 REDUCING PERIOPERATIVE MORTALITY AND MYOCARDIAL INFARCTION zVOLATILE AGENTS (cardiac surgery) zLEVOSIMENDAN (cardiac surgery)

5 REDUCING PERIOPERATIVE MORTALITY zFENOLDOPAM zPEXELIZUMAB (cardiac surgery) zDOPEXAMINE zEARLY ENTERAL NUTRITION (intestinal surgery) zINSULINE !!?? zSTATINS

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

7 DESFLURANE versus PROPOFOL (fentanyl-based cardiac anesthesia)

8 RCT (382 PATIENTS) OFF-PUMP CABG (112 PATIENTS) ON-PUMP CABG (150 PATIENTS) MITRAL SURGERY (120 PATIENTS)

9

10

11

12 Peak TROPONIN I ng/ml OFF-PUMP CABG 1.2 ( ) versus 2.7 ( ) *P<0.001 ON-PUMP CABG 2.5 ( ) versus 5.5 ( ) *P<0.001 MITRAL SURGERY 11.0 ( ) versus 11.5 ( ) P=0.7

13 Troponin I after OFF-PUMP CABG

14 Troponin I after CABG (CPB)

15 Troponin I after MITRAL SURGERY

16 INOTROPES in ICU OFF-PUMP CABG 35.1% versus 56.4% *P=0.04 ON-PUMP CABG 32.0% versus 41.3% *P=0.04 MITRAL SURGERY 42.4% versus 54.1% P=0.3

17 NEW Q WAVES OFF-PUMP CABG 11% versus 17% P=0.8 ON-PUMP CABG 6.7% versus 18.7% *P=0.049 MITRAL SURGERY 1.7% Versus 1.6% P=0.7

18

19 I Meta-analysis and/or large randomized studies IIRandomized trials IIINon-randomized prospective trials IVRetrospective studies VCase reports and Expert Opinion VIAnimal / Laboratories Studies Evidence?

20

21 Volatile Anesthetics

22 META-ANALYSIS (cardiac anaesthesia) 422 randomized studies (15 CPB-CABG; 6 OP-CABG; 1 mitral valve surgery) patients (904 TIVA and 1018 DES or SEVO) 416 studies administered volatile anesthetics throughout all the procedure (6 studies for 5-30 minutes)

23 Mortality Evidence!

24 Mortality 74/977=0.4% v 14/872=1.6% 7NNT=84 7RRR=(1,6-0,4)/1,6=75% 7OR: 0.31( ) 7P=0.02 Evidence!

25 Mortality NNT=84 Treat 84 to save one

26 Myocardial infarction Evidence!

27 724/979=2.4% v 45/874=5.1% 7NNT=37 7RRR: ( )/5.1 = 53% 7OR: 0.51( ) 7p=0.008 Myocardial infarction Evidence!

28 Myocardial infarction NNT=37 Treat 37 to save one

29 PEAK CARDIAC TROPONIN I Evidence! WMD ng/dL [-3.09,-1.60], p<

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

31 Mechanical ventilation Evidence! WMD hours [-0.97,-0.02], p = 0.4

32 ICU STAY Evidence! WMD hours [-11.47,-2.73], p < 0.001

33 HOSPITAL STAY Evidence! WMD days [-3.83,-0.68], p = 0.005

34

35

36 Name of the Hospital % mortality at 30 days CLINICA SAN ROCCO - BRESCIA 0,26% OSPEDALE SAN RAFFAELE MILANO 0,36% PRESIDIO OSPEDALIERO "C. POMA" MANTOVA 0,48% OSPEDALE CIVILE LEGNANO - MI 0,67% OSPEDALE SANTA CROCE E CARLE CUNEO 1,15% OSPEDALE S. CHIARA TRENTO 1,16% NUOVO POLO CARDIOLOGICO - TRIESTE 1,22% HESPARIA HOSPITAL S.R.L. MODENA 1,32%

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

38 Have we forgotten about noncardiac surgery?

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

40 4281 citations retrieved from database searches 3936 titles/abstracts excluded because non-relevant 344 studies assessed according to the selection criteria 79 Randomised Controlled Trials finally included in the systematic review 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 A meta-analysis in noncardiac surgery Evidence?

41 Total79 Anesth analg 20 BJA14 EJA11 Acta anaesthesiol scand8 Anaesthesia5 J Anesth4 Anesthesiology3 Minerva anestesiol2 Altri13 A meta-analysis in noncardiac surgery Evidence?

42 4400 authors 4240 reviewers 490 editors 0 deaths 0 myocardial infarctions A meta-analysis in noncardiac surgery Evidence?

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

44

45

46 WHATS NEXT

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

48 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 P = 0,4 vs Landoni et al. JCVA 2008

49 Take home message 4RCTs should confirm the promising results of volatile anesthetics in noncardiac surgery 4Cardiac Troponin I could be an excellent intermediate (surrogate?) outcome in cardiac and non-cardiac high risk surgical patients

50 Epidural analgesia Cardioprotection & anaesthesia Epidural analgesia

51 CLINICAL IMPLICATIONS AND RISKS The risk of epidural haematoma or other serious complications ( before systemic heparitation) is 1:4500 Ruppen W et al, BMC Anesthesiol. 2006;6:10 No epidural haematoma has ever been described in a randomized setting Two case reports have been recently published Sharma S et al, J Cardiothorac Vasc Anesth. 2004;18: Rosen DA et al, Anesth Analg 2004;98:

52 Epidural analgesia Our response to the issues: A meta-analysis of 33 trials randomized 2366 patients ( 1231 receiving general anaesthesia and 1135 receiving epidural anaesthesia)

53 Epidural analgesia Results 1 EPIDURAL ANESTHESIA REDUCES THE RISK OF PERIOPERATIVE MYOCARDIAL INFARCTION 15/987 ( 1.5%) vs 30/1109 (2.7%) OR= 0.53 ( ) P for effect = 0.04 P for heterogeneity = 0.56 Number to treat (NNT) = 84

54 Epidural analgesia Results 2 EPIDURAL ANESTHESIA REDUCES THE RISK OF ACUTE RENAL FAILURE 8/426 ( 1.9%) vs 21/440 (4.8%) OR= 0.43 P for effect = 0.03 P for heterogeneity = 0.8 Number to treat (NNT) = 35

55 Epidural analgesia Results 3 EPIDURAL ANESTHESIA REDUCES THE TIME OF MECHANICAL VENTILATION P for effect < P for heterogeneity <0.001

56 Epidural analgesia Results 4 MORTALITY 8/975 ( 0.8%) vs 12/1071 (1.1%) OR = 0.69 P for effect = 0.4 P for heterogeneity = 0.4

57 THIS IS THE FIRST TIME THAT LOCOREGIONAL ANAESTHESIA IS SHOWN TO HAVE AN IMPACT ON CLINICALLY RELEVANT ENDPOINTS FOLLOWING CARDIAC SURGERY This analysis suggests that epidural analgesia reduces perioperative myocardial infarction in low risk patients undergoing cardiac surgery While awaiting the results of large randomized controlled studies in high risk patients Epidural analgesia Conclusions

58

59 NT-proBNP in the 46 patients with epidural anaesthesia (median, interquartile and range values in a logarithmic scale) compared to the 46 patients who received standard general anaesthesia

60 β-blockersand Non-cardiac surgery β-blockers and Non-cardiac surgery Cβ blockers recommended Pro Pro Cons

61 β-blockersand Non-cardiac surgery β-blockers and Non-cardiac surgeryPro Cons Cons: POISE trial

62 β-blockersand Non-cardiac surgery β-blockers and Non-cardiac surgery Perioperative βblock was associated to increased mortality following stroke CONS..

63 Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgeryInterventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery E Crystal, MS Garfinkle, SS Connolly, TT Ginger, K Sleik, SS Yusuf Cochrane Database of Systematic Reviews 2004 in Issue 4, 2004 β-blockersand Cardiac surgery β-blockers and Cardiac surgery..the lack of evidence for a possible negative inotropic effect has limited the use of β block in cardiac surgery.

64 RIDUZIONE ISCHEMIA Ischemia5/55 (9%) (9%) 12/ 51 (23%) 0.01 β-blockers: Our reviews on esmolol

65 ESMOLOLO IN NON - CARDIOCHIRURGIA Non riportata mortalità ed infarto nei due gruppi (34 studi, 1739 pazienti) EsmololoControlloP value Morte Infarto β-blockers: Our reviews on esmolol

66 β-blockers: Our reviews on esmolol ESMOLOL IN CARDIAC SURGERY. A META-ANALYSIS OF RANDOMISED CONTROLLED STUDIES JCVA 2009, IN PRESS

67 β-blockers: Our reviews on esmolol 23 studies 979 patients All mono-center studies Analysis with Review Manager 4.2 We tried to contact all the corresponding authors to know if they had new data

68 β-blockers: Our reviews on esmolol Non differenze per mortalità ed infarto

69 β-blockers: Our reviews on esmolol RIDUZIONE ISCHEMIA Ischemia15/122 (12%)36/140 (27%)0.009

70 β-blockers: Our reviews on esmolol RIDUZIONE INOTROPI Inotropi29/153 (18%) 48/146 (32%) 0.002

71 ESMOLOLO IN CEC Studio randomizzato 200 pazienti (100 esmololo-100 placebo) DTD>60%, FE< 50% Bolo esmololo in CEC (circa 3mg/kg durante cardioplegia) Incidenza di FV in uscita CEC Valutazione danno miocardico, degenza

72 LEVOSIMENDAN VS CONTROL Mortality in cardiac surgery 711/235=4.7% v 26/205=12.7% 7P=0.007 Evidence!

73 LEVOSIMENDAN VS CONTROL Myocardial Infarction in cardiac surgery 72/183=1.1% v 9/153=5.9% 7P=0.04 Evidence!

74 PERCHE NON SIAM POPOLO PERCHE SIAM DIVISI MAMELI

75 ITACTA ONGOING RCTs TOPICSHOSPITALSPATIENTS GRANTS zVOLATILE ANESTHETICS zFENOLDOPAM zDESMOPRESSIN zESMOLOL zLEVOSIMENDAN zVALVOLE PERCUTANEE z 4200AIFA 2006 z MINISTRY 2008 z 3200 z z 3150

76 GRUPPI DI INTERESSE ITACTA (COORDINATI DA ANESTESISTI UNDER 40) Gruppi esistenti ad oggi (per piu informazioni aperti ad iscrizioni z1. Sostituzioni valvolari percutanee z2. Monitoraggio emodinamico mini-invasivo z3. Statistica in anestesia e terapia intensiva z4. Analgesia selettiva in chirurgia toracica

77 For these and further slides on these topics please feel free to visit the metcardio.org website:


Download ppt "Peri-operative cardiac protection Relatore:Dott. Giovanni Landoni Tutorial in General Anesthesia, Milano, 28 Marzo 2009 IRCCS Ospedale San Raffaele Milano."

Similar presentations


Ads by Google