Hill Aileen, Bergmann Deborah, Schulte Janin, Zayat Rashad, Marx Gernot, Simon Tim-Philipp, Mossanen Jana, Brücken Anne, Stoppe Christian
Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany.
Department of Anesthesiology, Medical Faculty RWTH Aachen, Aachen, Germany.
Front Cardiovasc Med. 2023 Jan 23;9:1017867. doi: 10.3389/fcvm.2022.1017867. eCollection 2022.
Various clinical scores have been developed to predict organ dysfunction and mortality in patients undergoing cardiac surgery, but outcome prediction may be inaccurate for some patient groups. Proenkephalin A (penKid) and bioactive adrenomedullin (bio-ADM) have emerged as promising biomarkers correlating with shock and organ dysfunction. This imposes the question of whether they can be used as prognostic biomarkers for risk stratification in the perioperative setting of cardiac surgery.
Patients undergoing cardiac surgery were prospectively enrolled in this observational study. PenKid and bio-ADM plasma levels, as well as markers evaluating inflammation and organ dysfunction, were measured at five perioperative time points from before the induction of anesthesia to up to 48 h postoperatively. Clinical data regarding organ dysfunction and patient outcomes were recorded during the intensive care unit (ICU)-stay with a special focus on acute kidney injury (AKI).
In 136 patients undergoing cardiac surgery, the bio-ADM levels increased and the penKid levels decreased significantly over time. PenKid was associated with chronic kidney disease (CKD), the incidence of AKI, and renal replacement therapy (RRT). Bio-ADM was associated with lactate and the need for vasopressors. PenKid was useful to predict an ICU-length of stay (LOS)>1 day and added prognostic value to the European System for Cardiac Operative Risk Evaluation Score (EuroSCORE) II when measured after the end of cardiopulmonary bypass and 24 h after cardiac surgery. For bio-ADM, the same was true when measured 24 h after surgery. PenKid also added prognostic value to the EuroSCORE II for the combined outcome "ICU length of stay >1 day and in-hospital mortality."
The combination of preoperative EuroSCORE II and intraoperative measurement of penKid may be more useful to predict a prolonged ICU LOS and increased mortality than EuroSCORE II alone. Bio-ADM correlates with markers of shock. More research is encouraged for early risk stratification and validation of penKid and bio-ADM as a tool involved in clinical decisions, which may enable the early initiation of organ protective strategies.
已经开发出各种临床评分系统来预测心脏手术患者的器官功能障碍和死亡率，但对于某些患者群体，结局预测可能不准确。前脑啡肽A（penKid）和生物活性肾上腺髓质素（bio-ADM）已成为与休克和器官功能障碍相关的有前景的生物标志物。这就提出了一个问题，即它们是否可以用作心脏手术围手术期风险分层的预后生物标志物。
前瞻性纳入接受心脏手术的患者进行这项观察性研究。在围手术期的五个时间点，即从麻醉诱导前到术后48小时，测量penKid和bio-ADM血浆水平，以及评估炎症和器官功能障碍的标志物。在重症监护病房（ICU）住院期间记录有关器官功能障碍和患者结局的临床数据，特别关注急性肾损伤（AKI）。
在136例接受心脏手术的患者中，随着时间的推移，bio-ADM水平升高而penKid水平显著降低。PenKid与慢性肾脏病（CKD）、AKI的发生率和肾脏替代治疗（RRT）相关。Bio-ADM与乳酸水平和血管升压药的使用需求相关。PenKid有助于预测ICU住院时间（LOS）>1天，并且在体外循环结束后和心脏手术后24小时测量时，对欧洲心脏手术风险评估系统评分（EuroSCORE）II增加了预后价值。对于bio-ADM，在术后24小时测量时也是如此。PenKid对于“ICU住院时间>1天和院内死亡率”的综合结局，对EuroSCORE II也增加了预后价值。
术前EuroSCORE II与术中penKid测量相结合，可能比单独使用EuroSCORE II更有助于预测延长的ICU LOS和增加的死亡率。Bio-ADM与休克标志物相关。鼓励更多研究将penKid和bio-ADM作为临床决策工具进行早期风险分层和验证，这可能有助于早期启动器官保护策略。
