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Hensley NB, Colao JA, Zorrilla-Vaca A, Nanavati J, Lawton JS, Raphael J, Mazzeffi MA, Wierschke C, Kostibas MP, Cho BC, Frank SM, Grant MC. Ultrafiltration in cardiac surgery: Results of a systematic review and meta-analysis. Perfusion 2024; 39:743-751. [PMID: 36795704 DOI: 10.1177/02676591231157970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Background: Ultrafiltration is used with cardiopulmonary bypass to reduce the effects of hemodilution and restore electrolyte balance. We performed a systematic review and meta-analysis to analyze the effect of conventional and modified ultrafiltration on intraoperative blood transfusion.Methods: Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, we systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library to perform a meta-analysis of studies of randomized controlled trials (RCTs) and observational studies evaluating conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) on the primary outcome of intraoperative red cell transfusions.Results: A total of 7 RCTs (n = 928) were included, comparing modified ultrafiltration (n = 473 patients) to controls (n = 455 patients) and 2 observational studies (n = 47,007), comparing conventional ultrafiltration (n = 21,748) to controls (n = 25,427). Overall, MUF was associated with transfusion of fewer intraoperative red cell units per patient (n = 7); MD -0.73 units; 95% CI -1.12 to -0.35 p = 0.04; p for heterogeneity = 0.0001, I2 = 55%) compared to controls. CUF was no difference in intraoperative red cell transfusions compared to controls (n = 2); OR 3.09; 95% CI 0.26-36.59; p = 0.37; p for heterogeneity = 0.94, I2 = 0%. Review of the included observational studies revealed an association between larger volumes (>2.2 L in a 70 kg patient) of CUF and risk of acute kidney injury (AKI).Conclusion: The results of this systematic review and meta-analysis suggest that MUF is associated with fewer intraoperative red cell transfusions. Based on limited studies, CUF does not appear to be associated with a difference in intraoperative red cell transfusion.
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Affiliation(s)
- Nadia B Hensley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph A Colao
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Nanavati
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer S Lawton
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacob Raphael
- Sidney Kimmel Medical College, Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology, George Washington University Hospital, Washington, DC, USA
| | - Chad Wierschke
- Department of Surgery, Perfusion Division, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Megan P Kostibas
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Patel KP, Stammers AH, Tesdahl EA, Chores J, Beckmann SR, Baeza J, Petterson CM, Thompson T, Baginski A, Firstenberg M, Jacobs JP. Effect of geography on the use of ultrafiltration during cardiac surgery with cardiopulmonary bypass. Perfusion 2024:2676591241246080. [PMID: 38647100 DOI: 10.1177/02676591241246080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Ultrafiltration (UF) is a common practice during cardiopulmonary bypass (CPB) where it is used as a blood management strategy to reduce red blood cell (RBC) transfusion, minimize adverse effects of hemodilution, and reduce proinflammatory mediators. However, its clinical utilization has been shown to vary throughout the continents. PURPOSE The purpose of this investigation was to assess the distribution of UF use across the United States. DATA COLLECTION Data on UF use during cardiac surgery was obtained from a national (United States) perfusion database for adult cardiac procedures performed from January 2016 through December 2018. STUDY SAMPLE Four geographical regions were established: Northeast (NE), South (SO), Midwest (MW) and West (WE). The primary endpoint was the use of UF with secondary endpoints UF volume, CPB and anesthesia asanguineous volumes, intraoperative allogeneic RBC transfusion, nadir hematocrit and urine output (UO). 92,859 adult cardiac cases from 191 hospitals were reviewed. RESULTS The NE and the WE had similar usages of UF (59.9% and 59.7% respectively), which were higher than the MW and the SO (38.6% and 34.9%, p < .001). When UF was utilized, the median [IQR] volume removed was highest in the NE (1900 [1200-2800]mL), and similar in all other regions (WE 1500 [850-2400 mL, MW 1500 [900-2300]mL and SO 1500 [950-2200]mL, p < .001. Median total UO was lowest in the NE 400 [210,650]mL vs all other regions (p < .001), and remained so when indexed by patient weight and operative time (NE-0.8 [0.5, 1.3]mL/kg/hour, MW-1.1 [0.7, 1.8] mL/kg/hour, SO-1.3 [0.8, 2.0]mL/kg/hour, WE-1.1 [0.7, 1.3]mL/kg/hour, p < .001. Intraoperative RBC transfusion rate was highest in the SO (21.3%) and WE (20.5%), while similar rates seen in the NE (16.2%) and MW (17.6%), p < .001. CONCLUSIONS Across the United States there is geographic variation on the use of UF. Further research is warranted to investigate why these practice variations exist and to better understand and determine their reasons for use.
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Affiliation(s)
- Kirti P Patel
- Medical Department, SpecialtyCare, Brentwood, TN, USA
| | | | | | | | | | | | | | - Ty Thompson
- Medical School, California University of Science and Medicine, Colton, CA, USA
| | - Alexander Baginski
- Medical Department, SpecialtyCare, Brentwood, TN, USA
- Harrisburg Perfusion Team, SpecialtyCare, Harrisburg, PA, USA
| | | | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
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Gerami H, Sajedianfard J, Ghasemzadeh B, AnsariLari M. Is ultrafiltration volume a predictor of postoperative acute kidney injury in patients undergoing cardiopulmonary bypass? Perfusion 2024:2676591241246081. [PMID: 38590130 DOI: 10.1177/02676591241246081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Intraoperative ultrafiltration (UF) is a procedure used during cardiopulmonary bypass (CPB) to reduce haemodilution and prevent excessive blood transfusion. However, the effect of UF volume on acute kidney injury (AKI) is not well established, and the results are conflicting. Additionally, there are no set indications for applying UF during CPB. METHODS This retrospective study analysed 641 patients who underwent coronary artery bypass graft (CABG) surgery with CPB. Perioperative parameters were extracted from the patients' records, and the UF volume was recorded. Acute Kidney Injury Network classification was used to define AKI. Univariable and multivariable logistic regression models were used to predict AKI while controlling for confounding factors. RESULTS The study enrolled patients with a mean age of 58.8 ± 11.1 years, 39.2% of whom were female. AKI occurred in 22.5% of patients, with 16.1% (103) experiencing stage I and 6.4% (41) experiencing stage II. The results showed a significant association between UF volume and the risk of developing AKI, with higher UF volumes associated with a higher risk of AKI. In the multivariable analysis, the other predictors of AKI included age, lowest mean arterial pressure (MAP), and red blood cell (RBC) transfusion during CPB. CONCLUSION The predictors of postoperative AKI in coronary CABG patients were the volume of UF, age, MAP, and blood transfusion during CPB.
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Affiliation(s)
- Hamid Gerami
- Department of Basic Sciences, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Javad Sajedianfard
- Department of Basic Sciences, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Bahram Ghasemzadeh
- Department of Cardiac Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam AnsariLari
- Department of Food Hygiene and Public Health, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
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Milne B, Gilbey T, De Somer F, Kunst G. Adverse renal effects associated with cardiopulmonary bypass. Perfusion 2024; 39:452-468. [PMID: 36794518 PMCID: PMC10943608 DOI: 10.1177/02676591231157055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction, one of the most common complications of this surgical cohort. Acute kidney injury (AKI) is associated with increased short-term morbidity and mortality and has been the focus of much research. There is increasing recognition of the role of AKI as the key pathophysiological state leading to the disease entities acute and chronic kidney disease (AKD and CKD). In this narrative review, we will consider the epidemiology of renal dysfunction after cardiac surgery on CPB and the clinical manifestations across the spectrum of disease. We will discuss the transition between different states of injury and dysfunction, and, importantly, the relevance to clinicians. The specific facets of kidney injury on extracorporeal circulation will be described and the current evidence evaluated for the use of perfusion-based techniques to reduce the incidence and mitigate the complications of renal dysfunction after cardiac surgery.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Filip De Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London British Heart Foundation Centre of Excellence, London, UK
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Greco K, Varelmann D, Patel J. Anesthetic Management of a Jehovah's Witness Patient for Coronary Artery Bypass Grafting With Antiphospholipid Antibody Syndrome and Renal Transplant. Semin Cardiothorac Vasc Anesth 2024:10892532241236117. [PMID: 38400727 DOI: 10.1177/10892532241236117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
Anesthesia for cardiac surgical patients with antiphospholipid antibody syndrome (APLS) presents challenges with monitoring anticoagulation during cardiopulmonary bypass. Additionally, this condition is associated with other autoimmune diseases and comorbidities that need to be considered in caring for these patients, and there is minimal evidence for specific strategies during cardiac surgery. Separately, Jehovah's Witness (JW) patients typically do not consent to receiving blood products, presenting an additional challenge for resuscitation during cardiac surgery and especially in the context of APLS. We present our approach to the anesthetic management of a JW patient with systemic lupus erythematosus (SLE) complicated by APLS, thrombocytopenia, and renal failure with history of renal transplant who presented for coronary artery bypass surgery. Management strategies we recommend include administration of antifibrinolytics after heparinization to mitigate bleeding risk and interdisciplinary management with the perfusion, intensive care, surgical, and nephrology teams.
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Affiliation(s)
- Katherine Greco
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Dirk Varelmann
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonah Patel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Alfirevic A, Li Y, Kelava M, Grady P, Ball C, Wittenauer M, Soltesz EG, Duncan AE. Association of Conventional Ultrafiltration on Postoperative Pulmonary Complications. Ann Thorac Surg 2023; 116:164-171. [PMID: 36935030 DOI: 10.1016/j.athoracsur.2023.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Postoperative pulmonary complications increase mortality after cardiac surgery. Conventional ultrafiltration may reduce pulmonary complications by removing mediators of bypass-induced inflammation and countering hemodilution. We tested the primary hypothesis that conventional ultrafiltration reduces postoperative pulmonary complications, and secondarily, improves early pulmonary function assessed by the ratio of PaO2 to fractional inspired oxygen concentration. METHODS This retrospective analysis compared the incidence of postoperative pulmonary complications in adult patients who underwent cardiac surgery, with and without the use of conventional ultrafiltration, by using logistic regression with adjustment for confounding variables. The primary outcome was a composite of reintubation, prolonged ventilation, pneumonia, or pleural effusion. Secondarily, we examined early postoperative lung function using a quantile regression model. We also explored whether red blood cell transfusion differed between groups. RESULTS Of 8026 patients, 1043 (13%) received conventional ultrafiltration. After adjustment for confounding variables, the incidence of the composite primary outcome was higher in the conventional ultrafiltration group (12.1% vs 9.9%; P = .03), with an estimated odds ratio of 1.25 (95% CI, 1.02-1.53; P = .03). The median (quantiles) PaO2-to-fractional inspired oxygen concentration ratio was 373 (303-433) vs 368 (303-428), with the estimated adjusted difference in medians of 5 (95% CI, -5.9 to 16; P = .37). The estimated odds ratio of intraoperative transfusion was 1.38 (95% CI, 1.19-1.60; P < .0001) and for postoperative transfusion was 1.30 (95% CI, 1.14-1.49; P = .0001). CONCLUSIONS Use of conventional ultrafiltration was not associated with a reduction in the composite of postoperative pulmonary complications or improved early pulmonary function. We found no evidence of benefit from use of conventional ultrafiltration during cardiac surgery.
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Affiliation(s)
- Andrej Alfirevic
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio.
| | - Yufei Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Marta Kelava
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Grady
- Department of Perfusion Services, Cleveland Clinic, Cleveland, Ohio
| | - Clifford Ball
- Department of Perfusion Services, Cleveland Clinic, Cleveland, Ohio
| | | | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Kramer RS, Kelting T. Is It Time To Do Away With Conventional Ultrafiltration? Ann Thorac Surg 2023; 116:172. [PMID: 36963647 DOI: 10.1016/j.athoracsur.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/11/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Robert S Kramer
- Department of Cardiovascular Services, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
| | - Tyler Kelting
- Department of Cardiovascular Services, Maine Medical Center, 22 Bramhall St, Portland, ME 04102
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Brown JK, Shaw AD, Mythen MG, Guzzi L, Reddy VS, Crisafi C, Engelman DT. Adult Cardiac Surgery-Associated Acute Kidney Injury: Joint Consensus Report. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00340-3. [PMID: 37355415 DOI: 10.1053/j.jvca.2023.05.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVES Acute kidney injury (AKI) is increasingly recognized as a source of poor patient outcomes after cardiac surgery. The purpose of the present report is to provide perioperative teams with expert recommendations specific to cardiac surgery-associated AKI (CSA-AKI). METHODS This report and consensus recommendations were developed during a joint, in-person, multidisciplinary conference with the Perioperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. Multinational practitioners with diverse expertise in all aspects of cardiac surgical perioperative care, including clinical backgrounds in anesthesiology, surgery and nursing, met from October 20 to 22, 2021, in Sacramento, California, and used a modified Delphi process and a comprehensive review of evidence to formulate recommendations. The quality of evidence and strength of each recommendation were established using the Grading of Recommendations Assessment, Development, and Evaluation methodology. A majority vote endorsed recommendations. RESULTS Based on available evidence and group consensus, a total of 13 recommendations were formulated (4 for the preoperative phase, 4 for the intraoperative phase, and 5 for the postoperative phase), and are reported here. CONCLUSIONS Because there are no reliable or effective treatment options for CSA-AKI, evidence-based practices that highlight prevention and early detection are paramount. Cardiac surgery-associated AKI incidence may be mitigated and postsurgical outcomes improved by focusing additional attention on presurgical kidney health status; implementing a specific cardiopulmonary bypass bundle; using strategies to maintain intravascular euvolemia; leveraging advanced tools such as the electronic medical record, point-of-care ultrasound, and biomarker testing; and using patient-specific, goal-directed therapy to prioritize oxygen delivery and end-organ perfusion over static physiologic metrics.
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Affiliation(s)
- Jessica K Brown
- Department of Anesthesiology and Perioperative Medicine, the University of Texas, MD Anderson Cancer Center, Houston, TX.
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
| | - Monty G Mythen
- University College London National Institute of Health Research Biomedical Research Center, London, United Kingdom
| | - Lou Guzzi
- Department of Critical Care Medicine, AdventHealth Medical Group, Orlando, Florida
| | | | - Cheryl Crisafi
- Heart & Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, MA
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Cowart C, Roberts SM. Pro: Modified Ultrafiltration Is Beneficial for Adults Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:1049-1052. [PMID: 36754730 DOI: 10.1053/j.jvca.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Affiliation(s)
- Christopher Cowart
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
| | - S Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA.
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10
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Milne B, Gilbey T, Kunst G. Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2022; 36:4460-4482. [PMID: 36241503 DOI: 10.1053/j.jvca.2022.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Tom Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, Faculty of Life Sciences and Medicine, London, United Kingdom.
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Phothikun A, Nawarawong W, Tantraworasin A, Tepsuwan T. The outcomes of ultrafiltration in on-pump versus off-pump coronary artery bypass grafting in patients with renal impairment. J Cardiothorac Surg 2022; 17:219. [PMID: 36045425 PMCID: PMC9429667 DOI: 10.1186/s13019-022-01976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE In chronic kidney disease (CKD), using cardiopulmonary bypass (CPB) may contribute to renal dysfunction. Off-pump coronary artery bypass grafting (OPCAB) is one technique that preserved renal function, but the procedure may not be possible in certain situations. The ultrafiltration (UF) can remove excess fluid and inflammatory mediators that result from exposure to the CPB. Coronary artery bypass grafting (CABG) with UF could be an alternative way to preserve renal function. METHOD A retrospective study of CKD patients who underwent CABG. The renal outcomes were compared between the patients who underwent CABG with UF and OPCAB. A repeated measure adjusted by propensity score was used for comparing the renal outcome. Univariable and multivariable logistic regression was used to identify the risk factors for acute renal failure (AKI) and adverse outcomes. RESULTS From January 2009 and June 2020, there were 220 CKD patients, 109 (49.55%) patients underwent CABG with UF, and 111 (50.45%) patients underwent OPCAB. There were statistically significant differences in the change of the average level of creatinine between CABG with UF (increased + 0.09 mg/dl) and OPCAB (decreased - 0.05 mg/dl) (p = 0.043). Also, patients who underwent CABG with UF had a significantly increased risk for AKI (OR 5.38, 95%CI 1.09, 26.5). CONCLUSION The UF adjunct technique in CABG with CPB tends to provide a lower protective effect for renal function and had a significantly higher incidence of post-cardiac surgery AKI when compared to OPCAB. If technically feasible, OPCAB would be a preferable choice for CKD patients. STUDY REGISTRATION NUMBER SUR-2562-06607/Research ID: 6607.
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Affiliation(s)
- Amarit Phothikun
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| | - Weerachai Nawarawong
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Tantraworasin
- General Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| | - Thitipong Tepsuwan
- Cardiovascular and Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. .,Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand.
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12
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Kandil OA, Motawea KR, Darling E, Riley JB, Shah J, Elashhat MAM, Searles B, Aiash H. Ultrafiltration and cardiopulmonary bypass associated acute kidney injury: A systematic review and meta-analysis. Clin Cardiol 2021; 44:1700-1708. [PMID: 34837387 PMCID: PMC8715396 DOI: 10.1002/clc.23750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Cardiopulmonary bypass is known to raise the risk of acute kidney injury (AKI). Previous studies have identified numerous risk factors of cardiopulmonary bypass including the possible impact of perioperative ultrafiltration. However, the association between ultrafiltration (UF) and AKI remains conflicting. Thus, we conducted a meta-analysis to further examine the relationship between UF and AKI. HYPOTHESIS Ultrafiltration during cardiac surgery increases the risk of developping Acute kidney Injury. METHODS We searched PubMed, Web of Science, EBSCO, and SCOPUS through July 2021. The RevMan (version 5.4) software was used to calculate the pooled risk ratios (RRs) and mean differences along with their associated confidence intervals (95% CI). RESULTS We identified 12 studies with a total of 8005 patients. There was no statistically significant difference in the incidence of AKI between the group who underwent UF and the control group who did not (RR = 0.90, 95% CI = 0.64-1). Subgroup analysis on patients with previous renal insufficiency also yielded nonsignificant difference (RR = 0.84, 95% CI = 0.53 -1.33, p = .47). Subgroup analysis based on volume of ultrafiltrate removed (> or <2900 ml) was not significant and did not increase the AKI risk as predicted (RR = 0.82, 95% CI = 0.63 -1.07, p = .15). We also did subgroup analysis according to the type of UF and again no significant difference in AKI incidence between UF groups and controls was observed in either the conventional ultrafiltration (CUF), modified ultrafiltration (MUF), zero-balanced ultrafiltration (ZBUF), or combined MUF and CUF subgroups. CONCLUSION UF in cardiac surgery is not associated with increased AKI incidence and may be safely used even in baseline chronic injury patients.
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Affiliation(s)
- Omneya A Kandil
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Karam R Motawea
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Edward Darling
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jeffrey B Riley
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jaffer Shah
- Medical Research Center, Kateb University, Kabul, Afghanistan
| | | | - Bruce Searles
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Hani Aiash
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA.,Department of Family Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.,Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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13
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Heung M, Dickinson T, Wu X, Fitzgerald DC, DeLucia A, Paone G, Chores J, Nieter D, Grix D, Theurer P, Zhang M, Likosky DS. The Role of Race on Acute Kidney Injury Following Cardiac Surgery. Ann Thorac Surg 2021; 114:2188-2194. [PMID: 34838514 DOI: 10.1016/j.athoracsur.2021.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) frequently complicates cardiac surgery and is more common among Black patients. We evaluated determinants of race-based differences in AKI rates. METHODS Serum creatinine-based criteria was used to identify adult cardiac surgical patients developing post-operative AKI in the PERForm registry (7/1/2014-6/30/2019). Patient characteristics, operative details and outcomes were compared by race (Black versus White) after excluding patients with pre-operative dialysis, missing pre- or post-operative creatinine, or other races. A mixed effect model (adjusting for demographics, comorbidities, surgical factors) used hospital as a random effect to predict post-operative stage 2 or 3 AKI. Propensity score analyses were conducted to evaluate robustness of the primary analyses. RESULTS The study cohort included 34,520 patients (8% Black). More Black than White patients were female (43 versus 27%, p<.001), had hypertension (93 versus 87%, p<.001) and diabetes (51 versus 41%, p<.001). AKI >Stage 2 occurred among 1,780 (5%) patients, more often among Black than White patients (8 versus 5%, p<.001). Intra-operatively, Black patients had lower nadir hematocrits (23 versus 26, p<.001), and were more likely to be transfused (22 versus 14%, p<.001). After adjustment, Black (compared to White) race independently predicted odds for post-operative AKI (adjOR 1.50, 95% CI 1.26-1.78). The multivariable findings were similar in propensity score analyses. CONCLUSIONS Despite accounting for differences in risk factors and intra-operative practices, Black patients had a 50% increased odds for developing moderate-severe post-operative AKI compared to White patients. Additional evaluations are warranted to identify potential targets to address racial disparities in AKI outcomes.
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Affiliation(s)
- Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, MI.
| | | | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Alphonse DeLucia
- Department of Cardiac Surgery, Bronson Methodist Hospital, Kalamazoo, MI
| | - Gaetano Paone
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA
| | | | - Donald Nieter
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
| | - David Grix
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
| | - Patricia Theurer
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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14
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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15
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Zero-Balance Ultrafiltration during Cardiopulmonary Bypass Is Associated with Decreased Urine Output. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:27-37. [PMID: 33814603 DOI: 10.1182/ject-2000016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 01/06/2021] [Indexed: 11/20/2022]
Abstract
Zero-balance ultrafiltration (ZBUF) during cardiopulmonary bypass (CPB) has been purported to reduce pro-inflammatory mediators during cardiac surgery. However, its clinical benefit is equivocal and its effect on renal function unknown. The purpose of this study was to examine the effect of ZBUF on urine output in adult patients undergoing CPB. Following institutional review board approval, 98,953 records from a national registry of adult patients at 215 U.S. hospitals between January 2016 and September 2019 were reviewed. Groups were stratified according to ZBUF use. Anuric patients were excluded from the study as they were patients with missing data on urine output, ultrafiltration use, or ZBUF volume. The primary endpoint was intraoperative urine output normalized to body weight and procedure duration (total operative time). Final analysis of this endpoint was carried out using a linear mixed-effects regression model adjusting for patient and procedural characteristics, as well as practice patterns associated with surgeons and perfusionists. There was a significant 16.1% reduction in median urine output for ZBUF patients (.94 [.54, 1.47] mL/kg/h) vs. the non-ZBUF group (1.12 [.70,-1.73] mL/kg/h), p < .001. After statistically adjusting for patient and procedural characteristics, each liter of ZBUF volume was associated with an estimated change in intraoperative urine output of -.03 mL/kg/h (95% CI: [-.04 to -.02], p < .001). The median ZBUF volume was 1,550 [1,000, 2,600] mL, and when ZBUF was used, conventional ultrafiltration (CUF) was more likely to be used as well (88.4% vs. 44.8%, p < .001). ZBUF patients had median asanguineous volume and crystalloid cardioplegia nearly two times more than non-ZBUF patients, and had slightly higher red blood cell transfusions (17.6% vs. 16.3%, p < .05). The application of ZBUF during CPB was associated with patients having lower urine output and significantly higher use of CUF. Further research is required to determine if these results are reproducible in prospective clinical studies.
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16
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Manning MW, Li YJ, Linder D, Haney JC, Wu YH, Podgoreanu MV, Swaminathan M, Schroder JN, Milano CA, Welsby IJ, Stafford-Smith M, Ghadimi K. Conventional Ultrafiltration During Elective Cardiac Surgery and Postoperative Acute Kidney Injury. J Cardiothorac Vasc Anesth 2020; 35:1310-1318. [PMID: 33339661 DOI: 10.1053/j.jvca.2020.11.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/08/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Conventional ultrafiltration (CUF) during cardiopulmonary bypass (CPB) serves to hemoconcentrate blood volume to avoid allogeneic blood transfusions. Previous studies have determined CUF volumes as a continuous variable are associated with postoperative acute kidney injury (AKI) after cardiac surgery, but optimal weight-indexed volumes that predict AKI have not been described. DESIGN Retrospective cohort. SETTING Single-center university hospital. PARTICIPANTS A total of 1,641 consecutive patients who underwent elective cardiac surgery between June 2013 and December 2015. INTERVENTIONS The CUF volume was removed during CPB in all participants as part of routine practice. The authors investigated the association of dichotomized weight-indexed CUF volume removal with postoperative AKI development to provide pragmatic guidance for clinical practice at the authors' institution. MEASUREMENTS AND MAIN RESULTS Primary outcomes of postoperative AKI were defined by the Kidney Disease: Improving Global Outcomes staging criteria and dichotomized, weight-indexed CUF volumes (mL/kg) were defined by (1) extreme quartiles (<Q1 v >Q3) and (2) Youden's criterion that best predicted AKI development. Multivariate logistic regression models were developed to test the association of these dichotomized indices with AKI status. Postoperative AKI occurred in 827 patients (50.4%). Higher CUF volumes were associated with AKI development by quartiles (CUF >Q3 = 32.6 v CUF < Q1 = 10.4 mL/kg; odds ratio [OR] = 1.68, 95% CI: 1.19-2.3) and Youden's criterion (CUF ≥ 32.9 v CUF <32.9 mL/kg; OR = 1.60, 95% CI: 1.21-2.13). Despite similar intraoperative nadir hematocrits among groups (p = 0.8), higher CUF volumes were associated with more allogeneic blood transfusions (p = 0.002) and longer lengths of stay (p < 0.001). CONCLUSIONS Removal of weight-indexed CUF volumes > 32 mL/kg increased the risk for postoperative AKI development. Importantly, CUF volume removal of any amount did not mitigate allogeneic blood transfusion during elective cardiac surgery. Prospective studies are needed to validate these findings.
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Affiliation(s)
- Michael W Manning
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC.
| | - Yi-Ju Li
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Dean Linder
- Oschner Medical Center, Jefferson Parish, LA
| | - John C Haney
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Mihai V Podgoreanu
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Madhav Swaminathan
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Ian J Welsby
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Mark Stafford-Smith
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
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17
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020; 131:1383-1396. [PMID: 33079860 DOI: 10.1213/ane.0000000000005093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J Mauricio Del Rio
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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18
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Del Rio JM, Jake Abernathy J, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:22-34. [PMID: 33008722 DOI: 10.1053/j.jvca.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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19
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Ann Thorac Surg 2020; 110:1447-1460. [PMID: 33008569 DOI: 10.1016/j.athoracsur.2020.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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20
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Ong GS, Guim GS, Lim QX, Chay-Nancy HS, Jaafar NB, Lim CA, Clement CKH, Sazzad F, Kofidis T. Alternative technique of long acting cardioplegia delivery results in less hemodilution. Perfusion 2020; 36:365-373. [PMID: 32777980 DOI: 10.1177/0267659120946727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Preparation of del-Nido cardioplegia and its delivery technique can cause significant hemodilution. The resultant effects from hemodilution are largely proportionate to the use of a dual circuit. We opted for a custom-disposable single cardioplegia circuit instead of a dual circuit. METHODS We describe an alternative technique of del-Nido cardioplegia delivery and initial clinical experience with it at National University Hospital, Singapore. This is a retrospective analysis of data from January 2017 to April 2019, comprising of 177 patients of heart surgery and reflecting a single center database survey under the National Health Care Group. RESULTS Of the 177 patients who underwent surgery with del-Nido cardioplegia, 76 (42.9%) were valve-only procedures and 5 (2.8%) were coronary artery bypass graft-only procedures. Ultrafiltration was utilized in 132 (62.6%) patients, whereas filtrate volume was 2200 [150-9500] mL. The alternative technique of del-Nido cardioplegia delivery adopted by National University Hospital advocates for a single pump, single circuit system. The retrospective institutional data highlighted safe delivery of del-Nido cardioplegia using this technique in a range of procedures. CONCLUSION Besides the safe delivery of del-Nido cardioplegia, the National University Hospital Technique reduces hemodilution and provides other technical benefits including a steeper temperature gradient, modification of circuit configuration to deliver another cardioplegia while on bypass, as well as re-configuration of clamps to spike the base solution.
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Affiliation(s)
- Geok Seen Ong
- NUH Perfusion Services, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Goh Si Guim
- NUH Perfusion Services, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Qi Xuan Lim
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore.,National University Health System, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Huang Shoo Chay-Nancy
- NUH Perfusion Services, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Nurdiyana Binte Jaafar
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore.,National University Health System, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Clara Anne Lim
- NUH Perfusion Services, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Chew Kai Hong Clement
- NUH Perfusion Services, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Faizus Sazzad
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore.,National University Health System, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore.,National University Health System, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
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21
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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22
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The Effect of Standardizing Autologous Prime Techniques in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 51:227-237. [PMID: 31915406 DOI: 10.1182/ject-1900016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 11/27/2019] [Indexed: 11/20/2022]
Abstract
Autologous priming (AP) of the extracorporeal circuit has been used as a technique to reduce iatrogenic anemia in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The purpose of this study was to review the results of standardizing AP techniques to reduce variation among clinicians and its effect on clinical outcomes. Standardized goal-directed protocols for AP were established by the cardiac team and applied to all adult cardiac surgical patients where CPB was used. Following Institutional Review Board approval, data were analyzed for two sequential groups of patients: Non-standardized AP (NST-AP) and standardized AP (ST-AP). Exclusion criteria included pre-CPB hemodynamic instability and preoperative hematocrit (Hct) values less than 30%. The primary end point was the transfusion of red blood cells (RBCs), whereas secondary end points included Hct change and other perioperative allogeneic blood product transfusions. Data are presented as mean and SD. Of the 192 patients evaluated, 82 were in the NST-AP group and 110 in the ST-AP group. There were no preoperative demographic differences across groups. Total AP volume was lower in the NST-AP group than in the ST-AP patients (486.8 ± 259.6 mL vs. 1,048.2 ± 218.7 mL, p < .001). Whereas pre-CPB Hct values were identical between the groups, the first on-CPB (25.7% ± 4.5% vs. 27.9% ± 4.2%, p < .001), high CPB (27.7% ± 3.5% vs. 29.1% ± 3.6%, p < .008), and first postoperative (32.5% ± 4.0% vs. 34.3% ± 3.9%, p < .003) were all significantly higher in ST-AP patients. Perioperative transfusion rate was higher in NST-AP patients (63.6%) vs. ST-AP (44.6%), p < .01. There was no difference in intraoperative RBC transfusion, but postoperatively, more patients in the NST-AP group received RBCs than those in the ST-AP group (51.2% vs. 28.2%, p < .01). The application of an ST-AP protocol was effective in reducing hemodilution, which was associated within higher Hcts and lower postoperative transfusion rates.
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Mongero LB, Tesdahl EA, Stammers A, Weinstein S. The influence of ultrafiltration on red blood cell transfusion during cardiopulmonary bypass. Perfusion 2018; 34:303-309. [DOI: 10.1177/0267659118821026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Ultrafiltration during cardiopulmonary bypass (CPB) reduces fluid overload and inflammatory mediators in open-heart surgery and is thought to reduce the risk of red blood cell (RBC) transfusion. We evaluated its effectiveness in reducing RBC transfusions in a large population undergoing cardiac surgery, among patients in general as well as by gender. Methods: We analyzed 40,650 propensity-matched adult cardiac surgery cases conducted over a 61-month period at 195 hospitals. We assessed the risk of intraoperative transfusion (⩾1 unit RBC) according to body surface area (BSA)-normalized ultrafiltration volume via mixed-effects binary logistic regression. Our statistical model controlled for 12 demographic and operative variables as well as for center level tendencies in ultrafiltration use and intraoperative RBC transfusion. In light of recent findings on gender and risk of transfusion, we also included an interaction effect between gender and ultrafiltration volume (UV). Results: Ultrafiltration was associated with an increased crude rate of RBC transfusion (32.1% vs. 28.1%, p<0.001), but equivalent crude median hematocrit change from first in operating room to nadir on bypass (−11% in both groups, p = 0.133). After controlling for patient, operative and site-level characteristics, we found no statistically significant effect on transfusion rate by volume of ultrafiltrate removed nor did we find statistical support for any gender-specific effect of ultrafiltration. Conclusions: Ultrafiltration is not associated with a reduction of risk of RBC transfusion during cardiac surgery. The use of ultrafiltration as a method for reducing intraoperative RBC transfusion warrants further study.
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Fierro MA, Ehieli EI, Cooter M, Traylor A, Stafford-Smith M, Swaminathan M. Renal Angina Is a Sensitive, but Nonspecific Identifier of Postcardiac Surgery Acute Kidney Injury. J Cardiothorac Vasc Anesth 2018; 33:357-364. [PMID: 30243866 DOI: 10.1053/j.jvca.2018.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a common complication of cardiac surgery, and early detection is difficult. This study was performed to determine the sensitivity, specificity, positive predictive value, negative predictive value, and statistical performance of renal angina (RA) as an early predictor of AKI in an adult cardiac surgical patient population. DESIGN Retrospective, nonrandomized, observational study. SETTING A single, university-affiliated, quaternary medical center. PARTICIPANTS The study comprised 324 consecutive patients undergoing coronary artery bypass grafting or cardiac valvular surgery from February 1 through July 30, 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred-seven patients at moderate or high risk of developing postoperative renal injury were identified, 82 of whom met criteria for RA. The occurrence of RA was found to have an 80.9% sensitivity and 30.8% specificity for the prediction of AKI using Acute Kidney Injury Network criteria and 89.3% sensitivity and 27.8% specificity when paired with the Risk, Injury, Failure, Loss, End Stage Renal Disease criteria. A receiver operating characteristic area under the curve analysis revealed a nonsignificant predictive ability of 55.8% (95% confidence interval 0.47-0.65) when RA was paired with Acute Kidney Injury Network criteria; however, the receiver operating characteristic area under the curve was significant when paired with Risk, Injury, Failure, Loss, End Stage Renal Disease criteria, with a predictive ability of 0.586 (0.509-0.662). CONCLUSIONS RA is a sensitive, but nonspecific, predictor of postcardiac surgery AKI, with clinical utility most suited as a screening tool.
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Affiliation(s)
- Michael A Fierro
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Eric I Ehieli
- Community Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Mary Cooter
- Division of Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Austin Traylor
- Division of Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Mark Stafford-Smith
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, Gasparovic V, Herzog CA, Kashani K, Katz N, Liu KD, Mehta RL, Ostermann M, Pannu N, Pickkers P, Price S, Ricci Z, Rich JB, Sajja LR, Weaver FA, Zarbock A, Ronco C, Kellum JA. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7:JAHA.118.008834. [PMID: 29858368 PMCID: PMC6015369 DOI: 10.1161/jaha.118.008834] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology & Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, United Kingdom.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL
| | - Charles Hobson
- Division of Surgical Critical Care, Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, IL
| | - Andrew Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - George J Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daniel T Engelman
- Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro, Zagreb, Croatia
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Kianoush Kashani
- Division of Nephrology & Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nevin Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, CA
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Susanna Price
- Adult Intensive Care Unit, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Roma, Italy
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lokeswara R Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital International Renal Research Institute of Vicenza, Italy
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA
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Mongero L, Stammers A, Tesdahl E, Stasko A, Weinstein S. The effect of ultrafiltration on end-cardiopulmonary bypass hematocrit during cardiac surgery. Perfusion 2018; 33:367-374. [PMID: 29301459 DOI: 10.1177/0267659117747046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Ultrafiltration (UF) during cardiopulmonary bypass (CPB) is a well-accepted method for hemoconcentration to reduce excess fluid and increase hematocrit, platelet count and plasma constituents. The efficacy of this technique may confer specific benefit to certain patients presenting with acquired cardiac defects. The purpose of this study was to retrospectively evaluate the effect of UF on end-CPB hematocrit by cardiac surgical procedure type. METHODS A review of 73,506 cardiac procedures from a national registry (SCOPE) was conducted between April 2012 and October 2016 at 197 institutions. Cases included in this analysis were those completed without intraoperative red blood cell transfusion and where zero-balance UF was not used. The primary end point was the last hematocrit reading taken before the end of CPB, with a secondary end point of urine output during CPB. In order to isolate the effect of the UF volume removed, we controlled for a number of confounding factors, including: first hematocrit on CPB, total asanguineous volume, estimated circulating blood volume, CPB urine output, total volume of crystalloid cardioplegia, total volume of other asanguineous fluids administered by both perfusion and anesthesia, type of cardiac procedure, acuity, gender, age and total time on CPB. Descriptive statistics were calculated among five subgroups according to the UF volume removed: no volume removed and quartiles across the range of UF volume removed. The effect of UF volume on primary and secondary end points was modeled using ordinary least squares and restricted cubic splines in order to assess possible non-linearity in the effect of the UF volume while controlling for the above-named confounding factors. An interaction term was included in each model to account for possible differences by procedure type. RESULTS The study found a statistically significant non-linear pattern in the relationship between the UF volume removed and the last hematocrit on bypass (X2 = 172.5, df=24, p<0.001). For most procedure types, UF was most effective at increasing the last hematocrit on CPB, from 1 mL to approximately 2.5 L, with continued improvements in hematocrit coming more slowly as the UF volume was increased above 2.5 L. There were statistically significant interactions between UF and procedure type (X2 = 78.5, df=24, p<0.0001) as well as UF and starting hematocrit on CPB (X2 = 234.0, df=4, p<0.0001). In a secondary end-point model, there was a statistically significant relationship between the ultrafiltration volume removed and urine output on bypass (X2 = 598.9, df=28, p<0.001). CONCLUSION The use of UF during CPB resulted in significant increases in end-hematocrit, with the greatest benefit shown when volumes were under 2.5 L. We saw a positive linear benefit up to 2.5 L removed and, thereafter, in most procedures, the benefit leveled off. However, of note is markedly decreased urine output on bypass as the ultrafiltration volumes increase.
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Acute Kidney Injury After Pediatric Cardiac Surgery: A Secondary Analysis of the Safe Pediatric Euglycemia After Cardiac Surgery Trial. Pediatr Crit Care Med 2017; 18:638-646. [PMID: 28492399 PMCID: PMC5503840 DOI: 10.1097/pcc.0000000000001185] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To understand the effect of tight glycemic control on cardiac surgery-associated acute kidney injury. DESIGN Secondary analysis of data from the Safe Pediatric Euglycemia after Cardiac Surgery trial of tight glycemic control versus standard care. SETTING Pediatric cardiac ICUs at University of Michigan, C.S. Mott Children's Hospital, and Boston Children's Hospital. PATIENTS Children 0-36 months old undergoing congenital cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cardiac surgery-associated acute kidney injury was assigned using the Acute Kidney Injury Network criteria with the modification that a greater than 0.1 mg/dL increase in serum creatinine was required to assign cardiac surgery-associated acute kidney injury. We explored associations between cardiac surgery-associated acute kidney injury and tight glycemic control and clinical outcomes. Of 799 patients studied, cardiac surgery-associated acute kidney injury occurred in 289 patients (36%), most of whom had stage II or III disease (72%). Cardiac surgery-associated acute kidney injury rates were similar between treatment groups (36% vs 36%; p = 0.99). Multivariable modeling showed that patients with cardiac surgery-associated acute kidney injury were younger (p = 0.002), underwent more complex surgery (p = 0.005), and had longer cardiopulmonary bypass times (p = 0.002). Cardiac surgery-associated acute kidney injury was associated with longer mechanical ventilation and ICU and hospital stays and increased mortality. Patients at University of Michigan had higher rates of cardiac surgery-associated acute kidney injury compared with Boston Children's Hospital patients (66% vs 15%; p < 0.001), but University of Michigan patients with cardiac surgery-associated acute kidney injury had shorter time to extubation and ICU and hospital stays compared with Boston Children's Hospital patients. CONCLUSIONS Tight glycemic control did not reduce the cardiac surgery-associated acute kidney injury rate in this trial cohort. We observed significant differences in cardiac surgery-associated acute kidney injury rates between the two study sites, and there was a differential effect of cardiac surgery-associated acute kidney injury on clinical outcomes by site. These findings warrant further investigation to identify causal variation in perioperative practices that affect cardiac surgery-associated acute kidney injury epidemiology.
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To beat acute kidney injury, you need to keep your eye on the goal. J Thorac Cardiovasc Surg 2017; 153:126-127. [DOI: 10.1016/j.jtcvs.2016.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 09/16/2016] [Indexed: 11/18/2022]
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A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg 2016; 153:118-125.e1. [PMID: 27832832 DOI: 10.1016/j.jtcvs.2016.09.016] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 09/03/2016] [Accepted: 09/07/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND We sought to determine whether a pilot goal-directed perfusion initiative could reduce the incidence of acute kidney injury after cardiac surgery. METHODS On the basis of the available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery >300 mL O2/min/m2 and reduction in vasopressor use) that were combined into a goal-directed perfusion initiative and implemented as a quality improvement measure in patients undergoing cardiac surgery at Johns Hopkins during 2015. Goal-directed perfusion initiative patients were matched to controls who underwent cardiac surgery between 2010 and 2015 using propensity scoring across 15 variables. The primary and secondary outcomes were the incidence of acute kidney injury and the mean increase in serum creatinine within the first 72 hours after cardiac surgery. RESULTS We used the goal-directed perfusion initiative in 88 patients and matched these to 88 control patients who were similar across all variables, including mean age (61 years in controls vs 64 years in goal-directed perfusion initiative patients, P = .12) and preoperative glomerular filtration rate (90 vs 83 mL/min, P = .34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs 1.4 mg, P < .001) and had lower nadir oxygen delivery (mean 241 vs 301 mL O2/min/m2, P < .001). Acute kidney injury incidence was 23.9% in controls and 9.1% in goal-directed perfusion initiative patients (P = .008); incidences of acute kidney injury stage 1, 2, and 3 were 19.3%, 3.4%, and 1.1% in controls, and 5.7%, 3.4%, and 0% in goal-directed perfusion initiative patients, respectively. Control patients exhibited a larger median percent increase in creatinine from baseline (27% vs 10%, P < .001). CONCLUSIONS The goal-directed perfusion initiative was associated with reduced acute kidney injury incidence after cardiac surgery in this pilot study.
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Huang PM, Kuo SW, Chen JS, Lee JM. Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience. Ann Thorac Surg 2016; 101:1921-7. [PMID: 26897323 DOI: 10.1016/j.athoracsur.2015.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 10/05/2015] [Accepted: 11/09/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND The objective was to analyze the outcomes of thoracoscopic mesh repair for hepatic hydrothorax (HH) at our institution during the past 10 years. METHODS A total of 63 patients with refractory HH who underwent thoracoscopic mesh onlay reinforcement to repair diaphragmatic defects from January 2005 to December 2014 were included in the study. Mesh covering alone was used in 47 patients and mesh with suturing was used in 16 patients. Patient demographics, Child-Pugh class, and model for end-stage liver disease (MELD) score were evaluated to predict morbidity and mortality. RESULTS Of the patients (mean age, 60.4 ± 15 years; 31 men and 32 women), 14.3% had concomitant underlying diseases of renal insufficiency, 34.9% had diabetes mellitus, and 4.8% had pneumonia. Diaphragmatic blebs were the most common diaphragmatic defects (29 of 63 [46%]). After a median 20.5 months of follow-up examinations, 4 patients experienced recurrence. The 1-month mortality rate was 9.5% (6 of 63 patients). On multivariable analysis, underlying impaired renal function (p = 0.039) and MELD scores (p = 0.048) were associated with increased 3-month mortality in 16 patients. Contrary to the rising Child-Pugh score (p = 0.058), rising MELD scores represented an increase in kidney or liver failure and mortality. The main causes of 3-month mortality were septic shock (n = 6), acute renal insufficiency (n = 4), gastrointestinal bleeding (n = 4), hepatic encephalopathy (n = 1), and ischemic bowel (n = 1). CONCLUSIONS Thoracoscopic mesh repair for refractory HH improves symptoms and lowers the recurrence rate.
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Affiliation(s)
- Pei-Ming Huang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Shuenn-Wen Kuo
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Shing Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jang-Ming Lee
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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