Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients: A Nested Randomized Clinical Trial
| Autor: | Daijiro Hori, Charles W. Hogue, Atsushi Yamaguchi, Kenton J. Zehr, Charles H. Brown, Andrew Laflam, Michael A. Kraut, John V. Conte, Karin J. Neufeld, O. Joseph Bienvenu, Kaushik Mandal, Ashish S. Shah, Rebecca F. Gottesman, Laura Max, Yohei Nomura, Duke E. Cameron, Kenneth Dale Brady, Jing Tian, Julia Probert |
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| Rok vydání: | 2019 |
| Předmět: |
Male
Mean arterial pressure 030230 surgery Cerebral autoregulation Severity of Illness Index law.invention 03 medical and health sciences 0302 clinical medicine Postoperative Complications Sex Factors Randomized controlled trial law Reference Values Monitoring Intraoperative medicine Homeostasis Humans Autoregulation Arterial Pressure Prospective Studies Cerebral perfusion pressure Prospective cohort study Geriatric Assessment Aged Academic Medical Centers Cardiopulmonary Bypass business.industry Incidence Age Factors Delirium Middle Aged Cerebral blood flow 030220 oncology & carcinogenesis Anesthesia Cerebrovascular Circulation Surgery Female medicine.symptom business |
| Zdroj: | JAMA surgery. 154(9) |
| ISSN: | 2168-6262 |
| Popis: | Importance Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. Objective To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. Design, Setting, and Participants This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. Intervention In the intervention group, the patient’s lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient’s mean arterial pressure was targeted to be greater than that patient’s lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. Main Outcomes and Measures The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Results Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97;P = .04). Conclusions and Relevance The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient’s lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. Trial Registration ClinicalTrials.gov identifier:NCT00981474 |
| Databáze: | OpenAIRE |
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