Dexamethasone for Cardiac Surgery-II Trial

High-dose corticosteroids attenuate the inflammatory response to surgery with CPB and are commonly used in some countries,but uncommonly in the US, Canada and Australia. Steroids can reliably attenuate activation of the complement pathways associated with cardiac surgery, but clinical trials have had mixed results. The current evidence is dominated by the results of two recent large randomized trials: DECS (n=4,494)6 and SIRS (n=7,507).

Both DECS and SIRS assigned patients undergoing cardiac surgery with CPB to receive either a high intraoperative dose of steroids (dexamethasone 1 mg/kg, or methylprednisolone 500 mg, respectively) or placebo. The point estimates of both trials suggested a possible reduction in serious complications and mortality. Planned subgroup analyses in the DECS trial steroids reduced the incidence of respiratory failure (3.0 % vs. 4.3%, P=0.02), infection (9.5% vs. 14.8%, P=0.009), and shortened hospital stay (median 8 \[7-13\] vs. 9 \[7-13\] days, P=0.009).6 Severe renal failure (need for RRT) was reduced, 0.4% vs. 1.0%, P=0.04.8 But SIRS found methylprednisolone was associated with a higher incidence of myocardial injury (as measured by elevation of CK-MB enzyme). Nether trial identified a higher risk of myocardial infarction (MI). The methylprednisolone-induced elevation of CK-MB may therefore be a class effect.

Another compelling finding in pre-planned subgroup analysis of patient age groups is that when limiting analysis to those aged less than 75 years in the DECS trial, dexamethasone reduced the risk of the primary composite endpoint, RR 0.74 (95% CI: 0.58-0.95), P=0.017; as well as respiratory failure RR 0.62 (95% CI: 0.42-0.91), P=0.014; and possibly mortality RR 0.53 (95% CI: 0.26-1.10), P=0.08.6 This age-interaction effect is supported by the demonstration of increased C-reactive protein concentrations in younger patients enrolled in the DECS trial.

Therefore, it is highly plausible that prophylactic steroids can suppress deregulated inflammation and thus improve outcomes in cardiac surgery, but only when used in a less elderly (i.e. <75 years) patient population.

In retrospect, the primary endpoints of both DECS and SIRS trials can be challenged, in that they used composites heavily weighted by thrombotic events (MI, stroke) and not specific to inflammation (respiratory failure, kidney injury, sepsis, prolonged ICU and hospital stay, mortality). We thus plan to re-evaluate dexamethasone in cardiac surgery, using a patient-centred, clinically important endpoint focused on enhanced recovery and earlier hospital discharge: "days alive and at home up to 30 days after surgery".

• Dexamethasone (Drug): Dexamethasone administered as a single IV injection after induction of anaesthesia, but before initiation of CPB. Prepare as a 20 mg/mL dexamethasone solution, made up with 0.9% saline to 10 ml.

Primary outcomes

• days at home up to 30 days after surgery [30 days from Start of Surgery]: Home is defined as a person's usual abode or that of a close relative, excluding any nursing facility (rehabilitation center or nursing home).

Secondary outcomes

• respiratory failure [30 days from Start of Surgery]: Uninterrupted postoperative mechanical ventilation for more than 48 hours from admission to ICU
• Infection [30 days from Start of Surgery]: Surgical site infection, pneumonia, or documented positive microbial culture from any site (including blood).
• Myocardial Infarction [30 days from Start of Surgery]: Postoperative myocardial infarction will be defined according to the third universal definition
• Stroke [30 days from Start of Surgery]: A new neurological deficit lasting more than 24 hours or leading to earlier death, and confirmed by medical imaging.
• Peak blood glucose [30 days from Start of Surgery]: The highest blood glucose measured in this same period
• Length of stay [30 days from Start of Surgery]: Time from postoperative ICU admission to ICU discharge (hours) and hospital discharge (days).
• Quick SOFA score [Each evening on days 1-3 after surgery]: Tachypnoea, altered mentation and/or hypotension

Sex: All, ages: 18 Years to 75 Years

Inclusion Criteria:

1. Males and females, age 18 to 75 years undergoing elective cardiac surgery with cardiopulmonary bypass
2. EuroScore-II estimated risk of 1.5% or higher

Exclusion Criteria:

1. Poor language (English or Dutch) comprehension
2. Type I diabetes
3. Endocarditis or other evidence of sepsis
4. Preoperative steroid therapy

• Results publication: Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev. 2024 Mar 20;3(3):CD005566. doi: 10.1002/14651858.CD005566.pub4. PMID 38506343
• Results publication: Myles PS, Dieleman JM, Forbes A, Heritier S, Smith JA. Dexamethasone for Cardiac Surgery trial (DECS-II): Rationale and a novel, practice preference-randomized consent design. Am Heart J. 2018 Oct;204:52-57. doi: 10.1016/j.ahj.2018.06.008. Epub 2018 Jun 21. PMID 30081275

• Paul S Myles, MBBS, MD, Principal investigator, Alfred Hospital, Monash University