Prophylactic corticosteroids for cardiopulmonary bypass in adults

Dieleman, Jan M.; Paassen, Judith van; Dijk, Diederik van; Arbous, M. Sesmu; Kalkman, Cor J.; Vandenbroucke, Jan P.; Heijden, Geert J. van der; Dekkers, Olaf M.

doi:10.1002/14651858.cd005566.pub3

Cited by 56 publications

(20 citation statements)

References 128 publications

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“…High doses of corticosteroids are often administered to attenuate the inflammatory response to cardiac surgery and cardiopulmonary bypass (CPB) [ 1 ]. Administration of a corticosteroid such as methylprednisolone or dexamethasone during cardiac surgery is associated with a reduced duration of postoperative mechanical ventilation and intensive care unit (ICU) and hospital stay, probably because of a lower risk of postoperative pulmonary complications [ 1 - 4 ]. Still, controversy regarding their use remains because of potential important adverse effects.…”

Section: Introductionmentioning

confidence: 99%

Effect of high-dose dexamethasone on perioperative lactate levels and glucose control: a randomized controlled trial

et al. 2015

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IntroductionBlood lactate levels are increasingly used to monitor patients. Steroids are frequently administered to critically ill patients. However, the effect of steroids on lactate levels has not been adequately investigated. We studied the effect of a single intraoperative high dose of dexamethasone on lactate and glucose levels in patients undergoing cardiac surgery.MethodsThe Dexamethasone for Cardiac Surgery (DECS) trial was a multicenter randomized trial on the effect of dexamethasone 1 mg/kg versus placebo on clinical outcomes after cardiac surgery in adults. Here we report a pre-planned secondary analysis of data from DECS trial participants included at the University Medical Center Groningen. The use of a computer-assisted glucose regulation protocol—Glucose Regulation for Intensive care Patients (GRIP)—was part of routine postoperative care. GRIP aimed at glucose levels of 4 to 8 mmol/L. Primary outcome parameters were area under the lactate and glucose curves over the first 15 hours of ICU stay (AUC15). ICU length of stay and mortality were observed as well.ResultsThe primary outcome could be determined in 497 patients of the 500 included patients. During the first 15 hours of ICU stay, lactate and glucose levels were significantly higher in the dexamethasone group than in the placebo group: lactate AUC15 25.8 (13.1) versus 19.9 (11.2) mmol/L × hour, P <0.001 and glucose AUC15 126.5 (13.0) versus 114.4 (13.9) mmol/L × hour, P <0.001. In this period, patients in the dexamethasone group required twice as much insulin compared with patients who had received placebo. Multivariate and cross-correlation analyses suggest that the effect of dexamethasone on lactate levels is related to preceding increased glucose levels. Patients in the placebo group were more likely to stay in the ICU for more than 24 hours (39.2%) compared with patients in the dexamethasone group (25.0%, P = 0.001), and 30-day mortality rates were 1.6% and 2.4%, respectively (P = 0.759).ConclusionsIntraoperative high-dose dexamethasone increased postoperative lactate and glucose levels in the first 15 hours of ICU stay. Still, patients in the dexamethasone group had a shorter ICU length of stay and similar mortality compared with controls.Trial registrationClinicalTrials.gov NCT00293592. Registered 16 February 2006.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0736-9) contains supplementary material, which is available to authorized users.

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Section: Introductionmentioning

confidence: 99%

Effect of high-dose dexamethasone on perioperative lactate levels and glucose control: a randomized controlled trial

et al. 2015

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“…Small trials and the meta-analyses that include these trials have suggested that steroids reduce the risk of new postoperative atrial fibrillation. [7][8][9] The authors' patient-level meta-analysis did not demonstrate a reduction of atrial fibrillation with steroid treatment, suggesting that the small, lower-quality trials had resulted in a spurious result. In fact, a recent study-level meta-analysis suggested publication bias for this outcome.…”

Section: Discussionmentioning

confidence: 98%

“…5,6 Systematic reviews and meta-analyses of randomized controlled trials have evaluated the efficacy and safety of prophylactic steroids in patients undergoing cardiopulmonary bypass. [7][8][9][10] Even though systematic reviews have included over 50 trials, they lacked power for outcomes with lower incidence rates such as mortality.…”

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The Effect of Steroids in Patients Undergoing Cardiopulmonary Bypass: An Individual Patient Meta-Analysis of Two Randomized Trials

Whitlock

Dieleman

Belley‐Côté

et al. 2020

Journal of Cardiothoracic and Vascular Anesthesia

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“…are effective in attenuating the post-operative or post-trauma immune response and subsequently decrease the risk of mortality and morbidity [6][7][8]. Despite evidence of effect in reducing molecular inflammatory parameters [9,10], several meta-analysis's have shown that glucocorticoids have no significant effect on decreasing adverse events after injury [7,9,11]. In fact, glucocorticoids were found to be associated with increased risk of gastrointestinal bleeding [7] and myocardial injury [8].…”

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confidence: 99%

“…Despite evidence of effect in reducing molecular inflammatory parameters [9,10], several meta-analysis's have shown that glucocorticoids have no significant effect on decreasing adverse events after injury [7,9,11]. In fact, glucocorticoids were found to be associated with increased risk of gastrointestinal bleeding [7] and myocardial injury [8]. It has been proposed that the variation in immune response between patients may be partly responsible for the inconsistent effects of immunomodulation therapy [12].…”

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confidence: 99%

Immune capacity determines outcome following surgery or trauma: a systematic review and meta-analysis

Jia

Zhou

Tuttle

et al. 2019

Eur J Trauma Emerg Surg

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Purpose Immunological functions are altered following physical injury. The magnitude of the immunological response is dependent on the initial injury. However, variability in the immune response exists within and between patients where only some patients are at risk of developing complications such as systemic inflammatory response syndrome after injury. This systematic review and meta-analysis assessed whether lipopolysaccharide (LPS) induced cytokine production capacity of leucocytes can be used as a functional test to predict the risk of developing complications after injury. Methods Medline, Embase and Web of Science were systematically searched to identify articles that investigated the association between LPS induced cytokine production capacity in leucocytes and any clinical outcome after surgery or trauma. Where sufficient information was supplied, a meta-analysis was performed to determine the overall clinical outcomes. Results A total of 25 articles out of 6765 abstracts identified through the literature search were included in this review. Most articles described a positive association between cytokine production capacity and the development of inflammatory complications (n = 15/25). Coincidingly, the meta-analysis demonstrated that TNFα (Hedges g: 0.63, 95% CI 0.23, 1.03), IL-6 (Hedges g: 0.76, 95% CI 0.41, 1.11) and IL-8 (Hedges g: 0.93, 95% CI 0.46, 1.39) production capacity was significantly higher, one day after injury, in patients who developed inflammatory complications compared to patients who did not following trauma or surgical intervention. No significant difference was observed for IL-1β. Conclusion The associations of elevated LPS-induced cytokine production capacity with the risk of developing inflammatory complications are consistent with previous theories that proposed excessive inflammation is accompanied by antiinflammatory mechanisms that results in a period of immunosuppression and increased risk of secondary complications. However, immunological biomarkers for risk stratification is still a developing field of research where further investigations and validations are required.

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Prophylactic corticosteroids for cardiopulmonary bypass in adults

Cited by 56 publications

References 128 publications

Effect of high-dose dexamethasone on perioperative lactate levels and glucose control: a randomized controlled trial

Effect of high-dose dexamethasone on perioperative lactate levels and glucose control: a randomized controlled trial

The Effect of Steroids in Patients Undergoing Cardiopulmonary Bypass: An Individual Patient Meta-Analysis of Two Randomized Trials

Immune capacity determines outcome following surgery or trauma: a systematic review and meta-analysis

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