Klinik für Anästhesiologie. Inotrope Therapie im OP: Risiko oder Benefit? Matthias Heringlake

Transkript

1 Inotrope Therapie im OP: Risiko oder Benefit? Matthias Heringlake

2 The Role of Oxygen Debt in the Development of Organ Failure Sepsis, and Death in High- Risk Surgical Patients. Shoemaker WC et al. Chest 1992;102;

3 und Intensivmedizin Mixed venous oxygen saturation predicts short- and long-term outcome after coronary artery bypass grafting surgery n = 2755 Holm et al. British Journal of Anaesthesia 107 (3): (2011)

4 Dobutamine Stress Echocardiography and Troponin T as a Marker of Myocardial Injury Pastor G et al. Rev Esp Cardiol 2002;55(5):469-73

5 Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery Deveraux et al. JAMA. 2012;307(21):

6 Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery Deveraux et al. JAMA. 2012;307(21):

7 Agenda Inotropika und Outcome im Allgemeinen Inotropika und Outcome bei zielgerichteter hämodynamischer Optimierung Könnte die Wahl des Inotropikums eine Rolle spielen? Perspektiven Schlussfolgerungen Potentielle Interessenskonflikte: Honorare und Forschungsunterstützung durch: Covidien-Medtronic, CAS Medical Systems, Orion Pharma, Tenax Pharma, Amomed Pharma

8 Agenda Inotropika und Outcome im Allgemeinen Inotropika und Outcome bei zielgerichteter hämodynamischer Optimierung Könnte die Wahl des Inotropikums eine Rolle spielen? Perspektiven Schlussfolgerungen

9 Differences between patients with a preserved and a depressed left ventricular function: a report from the EuroHeart Failure Survey Lenzen MJ et al. European Heart Journal (2004) 25,

10 In-Hospital Mortality in Patients With Acute Decompensated Heart Failure Requiring Intravenous Vasoactive Medications (ADHERE) 1,4 1,2 adjusted mortality Odds ratios 1 0,8 0,6 0,4 0,2 0 NTG vs. MIL NTG vs. DOB NES vs. MIL NES VS DOB DOB vs.mil Abraham WT et al. J Am Coll Cardiol 2005;46:57 64

11 Perioperative Use of Dobutamine in Cardiac Surgery and Adverse Cardiac Outcome. Fellahi JL et al Anesthesiology 2008; 108:979 87

12 Perioperative Use of Dobutamine in Cardiac Surgery and Adverse Cardiac Outcome. Fellahi JL et al Anesthesiology 2008; 108:979 87

13 Perioperative Use of Dobutamine in Cardiac Surgery and Adverse Cardiac Outcome. In conclusion, the perioperative use of dobutamine simply based on the clinical judgment of the attending anesthesiologists in low-risk patients undergoing elective cardiac surgery with CPB is associated with adverse postoperative cardiac outcome. Fellahi JL et al Anesthesiology 2008; 108:979 87

14 The relationship between inotrope exposure, sixhour postoperative physiological variables, hospital mortality and renal dysfunction in patients undergoing cardiac surgery Shahin et al. Critical Care 2011, 15:R162

15 The relationship between inotrope exposure, sixhour postoperative physiological variables, hospital mortality and renal dysfunction in patients undergoing cardiac surgery Hospital mortality stratified by oxygen delivery and mixed venous oxygen saturation at 6h after cardiac surgery. 22,5 17, ,5 10, ,5 3,5 0 DO2 375 ml/min/m2 DO2 < 375 ml/min/m2 0 SvO2 70% SvO2 < 70% no agents inotrope exposed Shahin et al. Critical Care 2011, 15:R162

16 The relationship between inotrope exposure, sixhour postoperative physiological variables, hospital mortality and renal dysfunction in patients undergoing cardiac surgery 5 adjusted Odds ratio 3,75 2,5 Multivariable analysis of association between inotrope exposure and hospital mortality 1,25 0 inotrope exposed IABP ReDo CPB duration Shahin et al. Critical Care 2011, 15:R162

17 und Intensivmedizin Health Outcomes with and without Use of Inotropic Therapy in Cardiac Surgery - Results of a Propensity Score matched Analysis. Anesthesiology 2014; 120:

19 A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients. Hamilton MA et al. Anesth Analg 2011

20 Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis Arulkumaran et al. British Journal of Anaesthesia 112 (4): (2014)

21 Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis Arulkumaran et al. British Journal of Anaesthesia 112 (4): (2014)

22 Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis Early GDT using administration of fluid challenges and inotropes guided by haemodynamic monitoring does not result in an increased rate of cardiac events in this cohort of patients with limited cardiopulmonary reserve. GDT in high risk surgery is beneficial in reducing CVS events. This holds true irrespective of the choice of the monitored physiological parameter or haemodynamic monitor in use. Arulkumaran et al. British Journal of Anaesthesia 112 (4): (2014)

23 Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial IOP: Pulse rate (60 to 100 bpm), mean arterial pressure (60 to 100 mmhg), central venous pressure (CVP) (6 to 12 mmhg), urine output (> 25 ml/hr), haemoglobin (> 8 g/ dl), SpO2 (> 94%), temperature (36 to 37 C), serum base excess (-2 to +2 mmol/l) and partial pressure of arterial carbon dioxide (PaCO2 ; 35 to 45 mmhg). Jhanji et al. Critical Care 2010, 14:R151

24 Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial Jhanji et al. Critical Care 2010, 14:R151

25 Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial Jhanji et al. Critical Care 2010, 14:R151

26 Peri-operative troponin monitoring using a prototype highsensitivity cardiac troponin I (hs-ctni) assay: comparisons with hs-ctnt and contemporary ctni assays Lee GR et al. Annals of Clinical Biochemistry 2014, Vol. 51(2)

27 Peri-operative troponin monitoring using a prototype highsensitivity cardiac troponin I (hs-ctni) assay: comparisons with hs-ctnt and contemporary ctni assays Lee GR et al. Annals of Clinical Biochemistry 2014, Vol. 51(2)

28 Peri-operative troponin monitoring using a prototype highsensitivity cardiac troponin I (hs-ctni) assay: comparisons with hs-ctnt and contemporary ctni assays. when we considered the incidence of mortality within 28 days (10%) and 180 days (21%) of surgery, troponin concentrations > 99th percentile were associated with a significantly greater risk of mortality (but only for hs-ctni) measurements. Lee GR et al. Annals of Clinical Biochemistry 2014, Vol. 51(2)

30 und Intensivmedizin Triple pharmacological effects of levosimendan Increased cardiac contractility mediated by calcium sensitisation of troponin C Inotrope Cardio- and organ protection through opening of mitochondrial potassium channels in the cardiomyocytes Cardio- and organ protection Vasodilation through opening of potassium channels on the sarcolemma of smooth muscle cells in the vasculature Vasodilator Niemien S et al. Heart Lung Vessel. 2013;5:

31 und Intensivmedizin A Bayesian network meta-analysis on the effect of inodilatory agents on mortality (in cardiac surgical pts.) Greco T et al. British Journal of Anaesthesia 114 (5): (2015)

32 und Intensivmedizin A Bayesian network meta-analysis on the effect of inodilatory agents on mortality (in cardiac surgical pts.) Greco T et al. British Journal of Anaesthesia 114 (5): (2015)

33 Effect of Levosimendan on Survival and Adverse Events After Cardiac Surgery: A Meta-Analysis Harrison RW et al. J Cardiothoracic Vasc Anesthesia,2013; 27,

34 Levosimendan Versus Dobutamine in Myocardial Injury Patients with Septic Shock: A Randomized Controlled Trial n =38 Meng et al. Med Sci Monit, 2016; 22:

36 und Intensivmedizin Early levosimendan administration is associated with decreased mortality after cardiac surgery. Levosimendan administration was triggered by a) preoperative severely reduced left ventricular systolic function (LVEF <35%) and/or b) post- or perioperative signs of a LCOS - independent of the preoperative LVEF. n = 159 Treskatsch S et al. J Crit Care 2015

37 und Intensivmedizin Early levosimendan administration is associated with decreased mortality after cardiac surgery. Levosimendan administration was triggered by a) preoperative severely reduced left ventricular systolic function (LVEF <35%) and/or b) post- or perioperative signs of a LCOS - independent of the preoperative LVEF. Treskatsch S et al. J Crit Care 2015

39 Schlussfolgerungen Zielgerichtete hämodynamische Therapie >> häufig Bedarf für Inotropika Konventionelle Betamimetika sind zwar i.d.r. mit einer erhöhten Mortalität assoziiert Im Kontext der GDT: Keine Steigerung der kardiovaskulären Morbidität (nach klinischen Kriterien) + besseres Outcome Bei spezifischer Analyse mittels sensitiver myokardialer Nekrosemarker: Erhöhte Freisetzung von Troponin I (und höhere Mortalität?) Levosimendan ist diesbezüglich konventionellen Betamimetika überlegen Wirkungseintritt verzögert im Vergleich mit Betamimetika / PDE III-I >> Präemptive Therapie des Patienten at risk auch außerhalb der HCH?!

40 und Intensivmedizin Vielen Dank für Ihre Aufmerksamkeit