CPB was performed under normothermia (>35.5☌) in all types of surgery, and myocardial protection was achieved by intermittent anterograde or combined (anterograde plus retrograde) warm blood cardioplegia, as previously described. Antifibrinolytic therapy, either tranexamic acid (15 mg/kg twice) or aprotinin (2 × 10 6KIU before CPB, 2 × 10 6KIU in prime, and 500,000 KIU/h during surgery), was routinely administered. 14,15The use of pulmonary artery catheter and/or transesophageal echocardiography was left to the discretion of each attending anesthesiologist. Standardized total intravenous anesthesia (target control propofol infusion, remifentanil and pancuronium bromide) and monitoring techniques (five-lead electrocardiogram with computerized analysis of ST segment, invasive arterial blood pressure, and central venous pressure) were used in all patients and complied with routine practice in our hospital. β-Blocking agents and statins were given until the day of surgery in chronically treated patients. Inotrope ManagementĪll patients were premedicated with oral lorazepam (2.5 mg the evening before surgery and on the morning of surgery). Patients with high risk of postoperative cardiac morbidity and mortality (emergency surgery ) were excluded from the study. Inclusion criteria were elective coronary artery bypass grafting, aortic or mitral valve replacement, and combined surgery (coronary artery bypass grafting plus aortic or mitral valve replacement). Because data were collected during routine care of patients which conformed to standard procedures currently used in our institution, authorization was granted to waive written informed consent. The study was approved by an institutional review board (Comité Consultatif pour la Protection des Personnes se prêtant à la Recherche Biomédicale Pitié-Salpêtrière, Paris, France). Preoperative patient characteristics as well as intraoperative variables were collected prospectively into a database for later analysis. The study was prospective, open-labeled, nonrandomized, and observational and was conducted under the auspices of a large quality assurance project evaluating clinical practices in cardiac surgery approved by all staff members of the Department of Anesthesiology. 13Ĭonsecutive adult patients undergoing cardiac surgery with CPB were enrolled from January 2003 to December 2004 at the Saint-Martin Hospital (Caen, France). Indeed, the simple clinical judgment of anesthesiologists may not always reflect the right judgment. 12Taken together, these data suggest an important variability in prescribing post-CPB inotropic agents among cardiac anesthesiologists and a possible inappropriate use of dobutamine for many patients. 12Moreover, no institutional guidelines or prespecified algorithms were used in 91% of cardiac centers. 11Despite this, the results of a recent French multicenter trial showed that catecholamine (mainly dobutamine) administration was simply based on mean arterial pressure value in more than 80% of patients. 9Cardiac monitoring has proved to be an important tool to guide inotropic use after cardiac surgery. 8–10Independently of the patient, identity of the attending anesthesiologist has been also reported as a strong predictor of inotropic support in a multivariate model analysis. Factors related to use of positive inotropic drugs, such as older age, decreased left ventricular function, emergency and/or redo surgery, combined surgery, or longer durations of CPB, have been well identified in coronary and valve surgery patients.
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