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Hypothermia to reduce neurological damage following coronary artery bypass surgery
K Rees1, M Beranek-Stanley, M Burke
1Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR. Karen.Rees@bristol.ac.uk
Insights
Hypothermia during coronary artery bypass surgery (CABG) shows a trend toward reducing strokes but increases risks of death and heart damage. More research is needed on mild hypothermia and subtle neurological deficits.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Critical Care Medicine
Background:
- Coronary artery bypass surgery (CABG) can lead to neurological damage and cognitive impairment.
- Hypothermia during cardiopulmonary bypass (CPB) is employed as a neuroprotective strategy.
Purpose of the Study:
- To evaluate the efficacy of hypothermia during CABG in mitigating neurological damage and cognitive decline.
- To synthesize evidence from randomized controlled trials (RCTs) on hypothermia's neuroprotective effects in CABG patients.
Main Methods:
- Systematic review and meta-analysis of RCTs identified through comprehensive database searches (Cochrane, MEDLINE, EMBASE) up to December 1999.
- Inclusion criteria encompassed all CABG procedures and any hypothermia protocol, focusing solely on trials reporting neurological outcomes.
- Data extraction and study selection were performed independently by two reviewers, with author contact for clarification and meta-regression to address heterogeneity.
Main Results:
- A trend suggested a reduction in non-fatal strokes with hypothermia (OR 0.68), but also a trend towards increased non-stroke related perioperative deaths (OR 1.46).
- Hypothermia did not significantly impact non-fatal myocardial infarction (OR 1.05) but was associated with a higher incidence of low output syndrome (OR 1.21).
- Overall analysis of adverse outcomes (stroke, death, myocardial infarction, low output syndrome, IABP use) showed no significant benefit of hypothermia over normothermia (OR 1.07).
Conclusions:
- Current evidence does not demonstrate a definitive advantage of hypothermia over normothermia in terms of clinical events during CABG.
- While hypothermia may reduce stroke rates, this benefit is counterbalanced by increased risks of perioperative mortality and myocardial damage.
- Insufficient data exists to conclude on the effects of mild hypothermia or temperature management during CPB on subtle neurological deficits, necessitating further trials.
Background:
Coronary artery bypass surgery (CABG) may be life saving, but known side effects include neurological damage and cognitive impairment. The temperature used during cardiopulmonary bypass (CPB) may be important with regard to these adverse outcomes, where hypothermia is used as a means of neuroprotection.
Objectives:
To assess the effectiveness of hypothermia during CABG in reducing neurological damage and subsequent cognitive deficits.
Search Strategy:
The Cochrane Controlled Trials Register was searched for randomised controlled trials (RCT) and this was updated by searching MEDLINE and EMBASE to December 1999 using database specific RCT filters. Reference lists of retrieved articles were searched and experts in the field were contacted.
Selection Criteria:
Only RCTs were considered. All patients undergoing CABG, either first time or revisions, elective or emergency procedures, were included. Any hypothermia protocol was considered. Only trials reporting neurological outcomes were included.
Data Collection And Analysis:
Studies were selected independently and data were extracted from the source papers independently by two reviewers. Authors were contacted for further information. Studies were combined with meta-analysis where appropriate, and meta-regression was used to explore heterogeneity.
Main Results:
There was a trend towards a reduction in the incidence of non fatal strokes in the hypothermic group (OR 0.68 (0.43, 1.05)). Conversely, there was a trend for the number of non stroke related perioperative deaths to be higher in the hypothermic group (OR 1.46 (0.9, 2.37)). Hypothermia had no effect on the incidence of non fatal myocardial infarction (OR 1.05 (0.81, 1.37)), but the incidence of another marker of myocardial damage, low output syndrome, was higher in the hypothermic group (OR 1.21 (0.99, 1.48). When pooling all "bad" outcomes (stroke, perioperative death, myocardial infarction, low output syndrome, intra aortic balloon pump use) there was no significant advantage of either hypothermia or normothermia (OR 1.07 (0.92, 1.24)). Only 4 of 17 trials reported neuropsychological function as an outcome.
Reviewer'S Conclusions:
This review could find no definite advantage of hypothermia over normothermia in the incidence of clinical events. Hypothermia was associated with a reduced stroke rate, but this is off set by a trend towards an increase in non stroke related perioperative mortality and myocardial damage. There is insufficient data to date to draw any conclusions about the use of mild hypothermia. Similarly, there is insufficient data to date to comment on the effect of temperature during CPB on subtle neurological deficits, and further trials are needed in these areas.