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High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass
Yuki Kotani1, Yuki Kataoka2,3,4,5, Junichi Izawa6,7
1Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan.
Insights
Maintaining a higher mean arterial pressure during cardiac surgery with cardiopulmonary bypass (CPB) showed little to no difference in patient outcomes like acute kidney injury and mortality. Further research is needed to confirm efficacy.
Area of Science:
- Cardiology
- Anesthesiology
- Critical Care Medicine
Background:
- Cardiac surgery frequently utilizes cardiopulmonary bypass (CPB), a procedure associated with potential morbidities.
- Patients undergoing cardiac surgery often have chronic hypertension, influencing blood pressure management.
- Maintaining adequate blood flow to vital organs requires careful consideration of blood pressure targets, especially in hypertensive individuals.
Purpose of the Study:
- To evaluate the benefits and harms of higher versus lower mean arterial pressure (MAP) targets during cardiac surgery performed with CPB.
- To assess the impact of different MAP targets on key patient outcomes.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted.
- Included RCTs compared higher MAP targets (≥65 mmHg) with lower MAP targets (<65 mmHg) in adults undergoing cardiac surgery with CPB.
- Primary outcomes assessed included acute kidney injury, cognitive deterioration, and all-cause mortality.
Main Results:
- Three RCTs involving 737 participants were analyzed.
- A higher MAP target showed little to no difference in acute kidney injury (low-certainty evidence), cognitive deterioration (low-certainty evidence), and all-cause mortality (low-certainty evidence).
- No significant differences were observed for most secondary outcomes, though a higher target may slightly increase hospital stay.
Conclusions:
- Current evidence suggests that a higher MAP target may not significantly alter patient outcomes such as acute kidney injury and mortality following cardiac surgery with CPB.
- The wide confidence intervals indicate a need for further high-quality RCTs to definitively establish the efficacy of higher MAP targets in this patient population.
Background:
Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB.
Objectives:
To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB.
Search Methods:
We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020.
Selection Criteria:
We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB.
Data Collection And Analysis:
We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence.
Main Results:
We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB.
Authors' Conclusions:
A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.
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