A comparison of intraoperative goal-directed intravenous administration of crystalloid versus colloid solutions on the postoperative maximum N-terminal pro brain natriuretic peptide in patients undergoing moderate- to high-risk noncardiac surgery

Abstract

Background N-terminal pro brain natriuretic peptide (NT-proBNP) and troponin T are released during myocardial wall stress and/or ischemia and are strong predictors for postoperative cardiovascular complications. However, the relative effects of goal-directed, intravenous administration of crystalloid compared to colloid solutions on NT-proBNP and troponin T, especially in relatively healthy patients undergoing moderate- to high-risk noncardiac surgery, remains unclear. Thus, we evaluated in this sub-study the effect of a goal-directed crystalloid versus a goal-directed colloid fluid regimen on postoperative maximum NT-proBNP concentration. We further evaluated the incidence of myocardial injury after noncardiac surgery (MINS) between both study groups. Methods Thirty patients were randomly assigned to receive additional intravenous fluid boluses of 6% hydroxyethyl starch 130/0.4 and 30 patients to receive lactated Ringer’s solution. Intraoperative fluid management was guided by oesophageal Doppler-according to a previously published algorithm. The primary outcome were differences in postoperative maximum NT-proBNP (maxNT-proBNP) between both groups. As our secondary outcome we evaluated the incidence of MINS between both study groups. We defined maxNT-proBNP as the maximum value measured within 2 h after surgery and on the first and second postoperative day. Results In total 56 patients were analysed. There was no significant difference in postoperative maximum NT-proBNP between the colloid group (258.7 ng/L (IQR 199.4 to 782.1)) and the crystalloid group (440.3 ng/L (IQR 177.9 to 691.2)) during the first 2 postoperative days ( P = 0.29). Five patients in the colloid group and 7 patients in the crystalloid group developed MINS ( P = 0.75). Conclusions Based on this relatively small study goal-directed colloid administration did not decrease postoperative maxNT-proBNP concentration as compared to goal-directed crystalloid administration. Trial registration ClinicalTrials.gov ( NCT01195883 ) Registered on 6th September 2010.

Effect of perioperative levosimendan administration on postoperative N-terminal pro-B-type natriuretic peptide concentration in patients with increased cardiovascular risk factors undergoing non-cardiac surgery: protocol for the double-blind, randomised, placebo-controlled IMPROVE trial

“…In two of our previous trials, we observed a nearly fourfold increase in NT-pro-BNP concentration within the first 3 days after moderate-risk to high-risk major abdominal surgery in patients at-risk for cardiovascular complications and even more interestingly this significant increase was also observed in relatively healthy patients 7 21. It is known that postoperative maximum NT-pro-BNP concentration within the first three postoperative days is a strong predictor for postoperative cardiovascular events 1 22.…”

“…We will measure the extend of postoperative myocardial strain on the basis on the maximal rise in NT-pro-BNP concentration within the first 3 days 1. We have previously shown that NT-pro-BNP concentrations did not increase immediately after surgery, but within the first three postoperative days, which we assumed might be an indicator of myocardial strain 7 21…”

Perioperative Supplemental Oxygen and Postoperative Copeptin Concentrations in Cardiac-Risk Patients Undergoing Major Abdominal Surgery—A Secondary Analysis of a Randomized Clinical Trial

“…Troponin T and NT-proBNP concentrations in the first postoperative days are strong predictors for myocardial injury and myocardial strain [2,34]. In contrast to NT-proBNP and Troponin T, which increase approximately 48 h after major abdominal surgery [21,35], we observed that Copeptin concentrations peak within two hours after surgery. Nevertheless, only Copeptin concentrations on the first and third postoperative days were predictive for the development of MINS.…”

PerIoperative iNflammatory reSponse assessment In hiGH-risk patienTs undergoing non-cardiac surgery (INSIGHT): study protocol of a prospective non-interventional observational study

“…Even more relevant for our study, increased postoperative NT-proBNP concentrations are independently associated with adverse cardiac events after non-cardiac surgery 45. Interestingly, NT-proBNP concentrations increase up to fourfold during the first three postoperative days 43 46. While increased NT-proBNP might reflect subclinical heart failure, we believe that there might be an important inflammatory component.…”

“…Specifically, preoperative elevated high-sensitivity CRP is a strong predictor for postoperative cardiovascular complications 42. Interestingly, we know from previous studies that both inflammatory biomarkers steeply increase within the first 3 days and also cardiac biomarkers, for example, Troponin T and NT-proBNP rise immediately after surgery as well 6 43. To evaluate an overall trend, we added day 5 measurements as well.…”