Charlotte C McEwen1, Takhliq Amir2, Yuan Qiu2, Jack Young3, Kevin Kennedy4, Hilary P Grocott5, Hessam Kashani5, David Mazer6,7, Scott Brudney8, Morvarid Kavosh5, Eric Jacobsohn8, Anne Vedel9, Eugene Wang2, Richard P Whitlock10,11, Emilie P Belley-Coté11,12, Jessica Spence13,14. 1. Department of Surgery (Cardiac Surgery), McMaster University, Hamilton, ON, Canada. 2. Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. 3. Health Sciences Library, McMaster University, Hamilton, ON, Canada. 4. Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada. 5. Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada. 6. Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. 7. Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada. 8. Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada. 9. Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark. 10. Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada. 11. Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. 12. Departments of Medicine (Cardiology and Critical Care) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada. 13. Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. jessicaspence13@gmail.com. 14. Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada. jessicaspence13@gmail.com.
Abstract
PURPOSE: Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE: We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS: We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION: Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION: PROSPERO (CRD42020177376); registered: 5 July 2020.
PURPOSE: Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE: We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS: We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION: Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION: PROSPERO (CRD42020177376); registered: 5 July 2020.
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