Whitlock RP, Chan S, Devereaux PJ, et al. Clinical benefit of steroid use in patients undergoing cardiopulmonary bypass: a meta-analysis of randomized trials

Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada.
European Heart Journal (Impact Factor: 15.2). 08/2008; 29(21):2592-600. DOI: 10.1093/eurheartj/ehn333
Source: PubMed


We sought to establish the efficacy and safety of prophylactic steroids in adult patients undergoing cardiopulmonary bypass (CPB). We performed a meta-analysis of randomized trials reporting the effects of prophylactic steroids on clinical outcomes after CPB. Outcomes examined were mortality, myocardial infarction, neurological events, new onset atrial fibrillation, transfusion requirements, postoperative bleeding, duration of ventilation, intensive care unit (ICU) stay, hospital stay, wound complications, gastrointestinal complications, and infectious complications. We included 44 trials randomizing 3205 patients. Steroids reduced new onset atrial fibrillation [relative risk (RR) 0.71, 95% confidence interval (CI) 0.59 to 0.87], postoperative bleeding [weighted mean difference (WMD) -99.6 mL, 95% CI -149.8 to -49.3], and duration of ICU stay (WMD -0.23 days, 95% CI -0.40 to -0.07). Length of hospital stay was also reduced (WMD -0.59 days, 95% CI -1.17 to -0.02), but this result was less robust. A trend towards reduction in mortality was observed (RR 0.73, 95% CI 0.45 to 1.18). Randomized trials suggest that perioperative steroids have significant clinical benefit in CPB patients by decreasing the risk of new onset atrial fibrillation, while results are encouraging for reducing bleeding, length of stay, and mortality. These data do not raise major safety concerns, however, a sufficiently powered trial is warranted to confirm or refute these findings.

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    • "Multiple different clinical trials investigated the impact of steroids administration on POAF and showed that it can significantly reduce pro-inflammatory responses and the incidence of POAF (Viviano et al., 2014). Two meta-analysis of randomised clinical trials demonstrated that corticosteroid prophylaxis can significantly reduce the risk of POAF and length of stay in the ICU, postoperative bleeding and major wound infection compared with placebo (Whitlock et al., 2008; Ho & Tan, 2009). "
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    ABSTRACT: Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery that occurs in up to 60% of patients. POAF is associated with increased risk of cardiovascular mortality, stroke and other arrhythmias that can impact on early and long term clinical outcomes and health economics. Many factors such as disease-induced cardiac remodelling, operative trauma, changes in atrial pressure and chemical stimulation and reflex sympathetic/ parasympathetic activation have been implicated in the development of POAF. There is mounting evidence to support a major role for inflammation and oxidative stress in the pathogenesis of POAF. Both are consequences of using cardiopulmonary bypass and reperfusion following ischaemic cardioplegic arrest. Subsequently, several anti-inflammatory and antioxidant drugs have been tested in an attempt to reduce the incidence of POAF. However, prevention remains suboptimal and thus far none of the tested drugs has provided sufficient efficacy to be widely introduced in clinical practice. A better understanding of the cellular and molecular mechanisms responsible for the onset and persistence of POAF is needed to develop more effective prediction and interventions. Copyright © 2015. Published by Elsevier Inc.
    Pharmacology [?] Therapeutics 06/2015; 93. DOI:10.1016/j.pharmthera.2015.06.009 · 9.72 Impact Factor
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    • "Ulinastatin also significantly decreased the postoperative levels of cTnI. Normally, it has been shown that surgical procedures as well as CPB during cardiac surgery induce a systemic acute inflammatory response and regional myocardial I/R injury leading to increased endothelial permeability and free radical damage to vessels and parenchyma with coincident myocardial damage [63]. Both cTnI and CK-MB are predictive factors which reflect myocardial injury where cTnI is the most sensitive indicator of minor myocardial damage with superior cardiac specificity when compared with CK-MB [64] [65] [66]. "
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    ABSTRACT: Introduction: The systematic meta-analysis of randomized controlled trials (RCTs) evaluated the effects of intraoperative ulinastatin on early-postoperative recovery in patients undergoing cardiac surgery. Methods: RCTs comparing intraoperative ulinastatin with placebo in cardiac surgery were searched through PubMed, Cochrane databases, Medline, SinoMed, and the China National Knowledge Infrastructure (1966 to May 20th, 2013). The primary endpoints included hospital mortality, postoperative complication rate, length of stay in intensive care unit, and extubation time. The physiological and biochemical parameters illustrating postoperative cardiac and pulmonary function as well as inflammation response were considered as secondary endpoints. Results: Fifteen RCTs (509 patients) met the inclusion criteria. Ulinastatin did not affect hospital mortality, postoperative complication rate, or ICU length of stay but reduced extubation time. Ulinastatin also increased the oxygenation index on postoperative day 1 and reduced the plasma level of cardiac troponin-I. Additionally, ulinastatin inhibited the increased level of tumor necrosis factor-alpha, polymorphonuclear neutrophil elastase, interleukin-6, and interleukin-8 associated with cardiac surgery. Conclusion: Ulinastatin may be of value for the inhibition of postoperative increased inflammatory agents and most likely provided pulmonary protective effects in cardiac surgery. However, larger adequately powered RCTs are required to define the clinical effect of ulinastatin on postoperative outcomes in cardiac surgery.
    03/2014; 2014:630835. DOI:10.1155/2014/630835
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    • "In adult heart surgery with CPB, the outcome effects of preemptive steroid therapy have been systematically evaluated initially by multiple randomized clinical trials and more recently by serial meta-analyses [6,7,8,9,10]. This cumulative evidence base strongly suggests that dampening of the CPB-induced inflammatory response with steroids significantly reduces major morbidity end-points. "
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    ABSTRACT: The past year has witnessed major advances in of cardiovascular anesthesia and intensive care. Perioperative interventions such as anesthetic design, inotrope choice, glycemic therapy, blood management, and noninvasive ventilation have significant potential to enhance perioperative outcomes even further. The major theme for 2011 is the international consensus conference that focused on ancillary interventions likely to reduce mortality in cardiac anesthesia and intensive care. This landmark conference prioritized volatile anesthetics, levosimendan, and insulin therapy for their promising life-saving perioperative potential. Although extensive evidence has demonstrated the cardioprotective effects of volatile anesthetics, levosimendan as well as glucose, insulin and potassium therapy, the clinical relevance of these beneficial effects remains to be fully elucidated. Furthermore, controversy still persists about how tight perioperative glucose control should be in adult cardiac surgery because of the risk of hypoglycemia. A second major theme in 2011 has been perioperative hemostasis with the release of multispecialty guidelines. Furthermore, hemostatic agents such as recombinant factor VIIa and tranexamic acid have been studied intensively, even in the setting of major non-cardiac surgery. This review then highlights the remaining two major themes for 2011, namely the expanding role of noninvasive ventilation in our specialty and the formation of the Roland Hetzer International Cardiothoracic and Vascular Surgery Society. In conclusion, it is time for large adequately powered multicenter trials to test whether prioritized perioperative interventions truly reduce mortality and morbidity in cardiac surgical patients. This essential paradigm shift represents a major clinical opportunity for the global cardiovascular anesthesia and critical care community.
    03/2013; 5(1):9-16.
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