**6. Liver protection**

Hepatic injury in cardiac surgery is not frequent but is associated with significant morbidity and mortality. High index of suspicion postoperatively will lead to earlier treatment directed at eliminating or minimizing ongoing hepatic injury while preventing additional metabolic stress from ischemia, hemorrhage, or sepsis(93). Protection may be conferred by modulating the perfusion protocol during bypass and pharmacological interventions which modify the inflammatory response to surgery(104).

The principle underlying the protective ischemic preconditioning is a limitation to the exposure of the liver to ischemia, thus allowing the activation of natural defense mechanisms against subsequent injury(105). Several mechanisms of injury determined by a period of ischemia followed by reperfusion are known. These mechanisms, involving cytokines and oxygen free radicals, determine both local and systemic injury(106) and the nitric oxide plays a crucial role in protection. This effect can last for a few days(107). The possibility of remote (inter organ) preconditioning is a recent observation in which brief ischemia of one organ has been shown to confer protection on distant organs, such as liver, without direct stress to the organ(108), but effective clinical use of this resource needs additional studies.

Despite many advances in preoperative evaluation, technological, pharmacological, surgical, and anesthetic techniques, cardiac surgery continues to cause major organ derangement. There are many unanswered questions regarding perioperative organ protection and many promising therapies may continue to improve postoperative outcome. Considering the evolution of anesthetic and surgical techniques, patients are currently submitted to surgery with severe diseases and extreme ages. Anesthesiologists are often faced with patients who have heart disease or hemodynamic instability. The combination of anesthetic and postoperative sedation with appropriate cardioprotective anesthetics agents may contribute to the prevention of organ dysfunction and contribute to the reduction of perioperative morbidity and mortality.

#### **7. References**

100 Perioperative Considerations in Cardiac Surgery

Iodinated contrast has also been associated with AKI. Currently, N-Acetylcysteine and isotonic intravenous bicarbonate have been investigated, but the data supporting these interventions are controversial mainly due to methodological limitations(100). Atrial natriuretic peptide, statins and prostaglandin analogs are under study and there are some evidence of their benefit, but no large, adequately power study is present(100). Currently no grade IA recommendation exists regarding renal protection to iodinated contrasts. Prophylactic volume expansion without hydroxy-ethyl starch and sodium bicarbonate for emergency procedures appears to be beneficial in patients at risk of contrast

Pharmacological interventions, such as the use of fenoldopam, are currently under study, but large trials with adequate power are still needed in order to recommend the routine for prevention of renal failure. Atrial natriuretic peptide (ANP) is another drug implicated in renal protection, and low doses of ANP can provide better outcomes when used in low doses in the prevention of AKI and in the postsurgery management(96, 101). Inhalational and intravenous anesthetics can also have effects on renal protection(102). When comparing propofol and sevoflurane, propofol was associated with renal protection during an episode of ischemia and reperfusion in a swine model with lower levels of plasma creatinine(103). Also, lower neutrophil infiltrates, plasmatic cytokines, free radical production, lipid peroxidation and inducible nitric oxide synthase activity were found when propofol was

In conclusion, only a few recommendations exist regarding renal protection. Most of them are common sense based, maintaining adequate blood pressure, fluid therapy and avoiding

Hepatic injury in cardiac surgery is not frequent but is associated with significant morbidity and mortality. High index of suspicion postoperatively will lead to earlier treatment directed at eliminating or minimizing ongoing hepatic injury while preventing additional metabolic stress from ischemia, hemorrhage, or sepsis(93). Protection may be conferred by modulating the perfusion protocol during bypass and pharmacological interventions which

The principle underlying the protective ischemic preconditioning is a limitation to the exposure of the liver to ischemia, thus allowing the activation of natural defense mechanisms against subsequent injury(105). Several mechanisms of injury determined by a period of ischemia followed by reperfusion are known. These mechanisms, involving cytokines and oxygen free radicals, determine both local and systemic injury(106) and the nitric oxide plays a crucial role in protection. This effect can last for a few days(107). The possibility of remote (inter organ) preconditioning is a recent observation in which brief ischemia of one organ has been shown to confer protection on distant organs, such as liver, without direct stress to the organ(108), but effective clinical use of this resource needs

Despite many advances in preoperative evaluation, technological, pharmacological, surgical, and anesthetic techniques, cardiac surgery continues to cause major organ derangement. There are many unanswered questions regarding perioperative organ protection and many promising therapies may continue to improve postoperative outcome. Considering the evolution of anesthetic and surgical techniques, patients are currently

nephropathy(99).

used, suggesting a possible renal protection(103).

modify the inflammatory response to surgery(104).

the use of nephrotoxic drugs(99, 102).

**6. Liver protection** 

additional studies.


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