Intraoperative High-Dose Dexamethasone for Cardiac Surgery A Randomized Controlled Trial

JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 11/2012; 308(17):1761-1767. DOI: 10.1001/jama.2012.14144
Source: PubMed


CONTEXT Prophylactic corticosteroids are often administered during cardiac surgery to attenuate the inflammatory response to cardiopulmonary bypass and surgical trauma; however, evidence that routine corticosteroid use can prevent major adverse events is lacking. OBJECTIVE To quantify the effect of intraoperative high-dose dexamethasone on the incidence of major adverse events in patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized, double-blind, placebo-controlled trial of 4494 patients aged 18 years or older undergoing cardiac surgery with cardiopulmonary bypass at 8 cardiac surgical centers in the Netherlands enrolled between April 13, 2006, and November 23, 2011. INTERVENTION Patients were randomly assigned to receive a single intraoperative dose of 1 mg/kg dexamethasone (n = 2239) or placebo (n = 2255). MAIN OUTCOME MEASURES A composite of death, myocardial infarction, stroke, renal failure, or respiratory failure, within 30 days of randomization. RESULTS Of the 4494 patients who underwent randomization, 4482 (99.7%) could be evaluated for the primary outcome. A total of 157 patients (7.0%) in the dexamethasone group and 191 patients (8.5%) in the placebo group reached the primary study end point (relative risk, 0.83; 95% CI, 0.67-1.01; absolute risk reduction, -1.5%; 95% CI, -3.0% to 0.1%; P = .07). Dexamethasone was associated with reductions in postoperative infection, duration of postoperative mechanical ventilation, and lengths of intensive care unit and hospital stays. In contrast, dexamethasone was associated with higher postoperative glucose levels. CONCLUSION In our trial of adults undergoing cardiac surgery, the use of intraoperative dexamethasone did not reduce the 30-day incidence of major adverse events compared with placebo. TRIAL REGISTRATION Identifier: NCT00293592.

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Available from: Peter Rosseel, Oct 05, 2015
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    • "While a reduction in the risk of infections, length of ICU, and hospital stay was demonstrated in the dexamethasone group, no decrease in risk was observed with respect to stroke and postoperative mortality. In addition, dexamethasone was related to elevated postoperative glucose levels (P < 0.001) [55]. "
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    ABSTRACT: With more than a third of patients expected to endure the arrhythmia at any given time point, atrial fibrillation after cardiac surgery becomes a vexing problem in the postoperative care of cardiac surgery patients. The impact on patient care covers a spectrum from the more common clinically insignificant sequelae to debilitating embolic events. Despite this, postoperative atrial fibrillation generally masquerades as being insignificant, or at most as an anticipated inherent risk, merely extending one's hospital stay by a few days. As an independent risk factor for stroke, early and late mortality, and being a multibillion dollar strain on the healthcare system annually, postoperative atrial fibrillation is far more flagrant than a mere inherent risk. It is a serious medical quandary, which is not recognized as such. Though complete prevention is unrealistic, a step-wise treatment strategy that incorporates multiple preventative modalities can significantly reduce the impact of postoperative atrial fibrillation on patient care. The aims of this review are to present a brief overview of the arrhythmia's etiology, risk factors, and preventative strategies to reduce associated morbidities. Newer anticoagulants and the potential role of these drugs on future treatment paradigms are also discussed.
    12/2013; 2013(1):637482. DOI:10.1155/2013/637482
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    • "Exposure to dexamethasone did not significantly reduce the risk of the primary endpoint (relative risk 0.83; 95% confidence interval 0.67-1.01; P=0.07) [11]. Despite this non-significant trend of the primary endpoint, dexamethasone prophylaxis did significantly reduce the risk of the following secondary endpoints: duration of postoperative mechanical ventilation (P<0.001); "
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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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    Critical Care 03/2013; 17(Suppl 2):P396-P396. DOI:10.1186/cc12334 · 4.48 Impact Factor
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