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Azem K, Novakovsky D, Krasulya B, Fein S, Iluz-Freundlich D, Uhanova J, Kornilov E, Eidelman LA, Kaptzon S, Gorfil D, Aravot D, Barac Y, Aranbitski R. Effect of nitric oxide delivery via cardiopulmonary bypass circuit on postoperative oxygenation in adults undergoing cardiac surgery (NOCARD trial): a randomised controlled trial. Eur J Anaesthesiol 2024; 41:677-686. [PMID: 39037709 DOI: 10.1097/eja.0000000000002022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
BACKGROUND Cardiac surgery involving cardiopulmonary bypass induces a significant systemic inflammatory response, contributing to various postoperative complications, including pulmonary dysfunction, myocardial and kidney injuries. OBJECTIVE To investigate the effect of Nitric Oxide delivery via the cardiopulmonary bypass circuit on various postoperative outcomes. DESIGN A prospective, single-centre, double-blinded, randomised controlled trial. SETTING Rabin Medical Centre, Beilinson Hospital, Israel. PATIENTS Adult patients scheduled for elective cardiac surgery were randomly allocated to one of the study groups. INTERVENTIONS For the treatment group, 40 ppm of nitric oxide was delivered via the cardiopulmonary bypass circuit. For the control group, nitric oxide was not delivered. OUTCOME MEASURES The primary outcome was the incidence of hypoxaemia, defined as a p a O2 /FiO 2 ratio less than 300 within 24 h postoperatively. The secondary outcomes were the incidences of low cardiac output syndrome and acute kidney injury within 72 h postoperatively. RESULTS Ninety-eight patients were included in the final analysis, with 47 patients allocated to the control group and 51 to the Nitric Oxide group. The Nitric Oxide group exhibited significantly lower hypoxaemia rates at admission to the cardiothoracic intensive care unit (47.1 vs. 68.1%), P = 0.043. This effect, however, varied in patients with or without baseline hypoxaemia. Patients with baseline hypoxaemia who received nitric oxide exhibited significantly lower hypoxaemia rates (61.1 vs. 93.8%), P = 0.042, and higher p a O2 /FiO 2 ratios at all time points, F (1,30) = 6.08, P = 0.019. Conversely, this benefit was not observed in patients without baseline hypoxaemia. No significant differences were observed in the incidence of low cardiac output syndrome or acute kidney injury. No substantial safety concerns were noted, and toxic methaemoglobin levels were not observed. CONCLUSIONS Patients with baseline hypoxaemia undergoing cardiac surgery and receiving nitric oxide exhibited lower hypoxaemia rates and higher p a O2 /FiO 2 ratios. No significant differences were found regarding postoperative pulmonary complications and overall outcomes. TRIAL REGISTRATION NCT04807413.
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Affiliation(s)
- Karam Azem
- From the Department of Anaesthesia (KA, DN, BK, SF, DI-F, EK, LAE, RA), Department of Cardiovascular and Thoracic Surgery, Rabin Medical Centre, Beilinson Hospital, Petah Tikva (SK, DG, DA, YB), Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba (JU), Department of Neurobiology, Weizmann Institute of Science, Rehovot (EK), and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (KA, DN, BK, SF, DI-F, EK, LAE, SK, DG, DA, YB, RA)
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Pan KC, Namachivayam SP, Chiletti R, Best D, Horton S, Butt W. Clinical Effects of Nitric Oxide Added to the Oxygenator of Children on Extracorporeal Membrane Oxygenation: Pre-Post Cohort Study. ASAIO J 2024; 70:698-703. [PMID: 38417432 DOI: 10.1097/mat.0000000000002164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
Nitric oxide (NO) can be safely delivered through the sweep gas to the oxygenator of an extracorporeal membrane oxygenation (ECMO) circuit. It has theoretical benefits such as preventing platelet adhesion to surfaces, mitigating inflammatory response and protection against ischemia-reperfusion injury. In this uncontrolled before-after study of children on ECMO, the outcomes of those who received NO were compared with those who did not. Among 393 ECMO runs (from 337 patients), 192 of 393 (49%) received NO and 201 of 393 (51%) did not. The use of NO was associated with a 37% reduction in circuit change (adjusted risk ratio [aRR]: 0.63, 95% confidence interval [CI]: 0.42-0.93). The aRR (95% CI) for risk of neurologic injury was 0.72 (0.47-1.11). We observed potential heterogeneity of treatment effect for the risk of neurologic injury in children who had cardiac surgery: the risk with NO was lower in those who had cardiac surgery (aRR: 0.50, 95% CI: 0.26-0.96). There was no difference in survival between the study groups. In children managed with NO delivered through the ECMO circuit, we report a reduction in observed rate of circuit change and lower risk of neurologic injury in children who underwent cardiac surgery. Nitric oxide therapy on ECMO warrants prospective evaluation in children.
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Affiliation(s)
- Kevin C Pan
- From the Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Siva P Namachivayam
- From the Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Roberto Chiletti
- From the Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Derek Best
- From the Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Stephen Horton
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Perfusion, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Warwick Butt
- From the Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
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Zhao M, Zhang Q, Lin Y, Chen Y, Cao H. Impact of nitric oxide via cardiopulmonary bypass on pediatric heart surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Surg 2024; 19:461. [PMID: 39030578 PMCID: PMC11258894 DOI: 10.1186/s13019-024-02953-y] [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] [Received: 09/03/2023] [Accepted: 06/30/2024] [Indexed: 07/21/2024] Open
Abstract
OBJECTIVE The impact of nitric oxide (NO) administered via cardiopulmonary bypass (CPB) on pediatric heart surgery remains controversial. The objective of this study is to conduct a comprehensive systematic review and meta-analysis to examine the impact of NO administered via CPB on pediatric heart surgery. METHODS This study searched 7 electronic databases to identify Randomized Controlled Trials (RCTs) on the impact of NO administration during CPB on postoperative outcomes in pediatric heart surgery. The searched databases included Embase, Medline (though PubMed), Cochrane Library, Web of Science, Wan Fang database, China National Knowledge Infrastructure (CNKI), and ClinicalTrials.gov from their inception to November 2, 2022. The included RCTs compared NO administration during CPB with standard CPB procedures or placebo gas treatment in pediatric heart surgery. fixed-effects models and/or random-effects models were used to estimate the effect size with 95% confidence interval (CI). Heterogeneity among studies was indicated by p-values and I2. All analyses were performed using Review Manager software (version 5.4) in this study. RESULTS A total of 6 RCTs including 1,739 children were identified in this study. The primary outcome was duration of postoperative mechanical ventilation, with the length of hospital and intensive care unit (ICU) stay as the second outcomes. Through a pooled analysis, we found that exogenous NO administered via CPB for pediatric heart surgery could not shorten the duration of postoperative mechanical ventilation when compared with the control group (standardized mean difference (SMD) -0.07, CI [-0.16, 0.02], I2 = 45%, P = 0.15). Additionally, there were also no difference between the two groups in terms of length of hospital stay (mean difference (MD) -0.29, CI [-1.03, 0.46], I2 = 32%, P = 0.45) and length of ICU stay (MD -0.22, CI [-0.49 to 0.05], I2 = 72%, P = 0.10). CONCLUSIONS This meta-analysis showed that exogenous NO administration via CBP had no benefits on the duration of mechanical ventilation, the length of postoperative hospital, and ICU stay after pediatric heart surgery.
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Affiliation(s)
- Minli Zhao
- Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350014, China
- Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), Fuzhou, 350000, China
| | - Qiuping Zhang
- Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350014, China
- Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), Fuzhou, 350000, China
| | - Yuan Lin
- Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350014, China
- Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), Fuzhou, 350000, China
| | - Yukun Chen
- Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350014, China
- Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), Fuzhou, 350000, China
| | - Hua Cao
- Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350014, China.
- Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350000, China.
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), Fuzhou, 350000, China.
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Yan Y, Zhao C, Niu J, Yan P, Li J, Wang D, Li G. Rationale and Design of the IMPROVE Trial: A Multicenter, Randomized, Controlled, Open-label, Blinded-endpoint Trial Assessing the Efficacy of Remote Ischemic Conditioning in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting. Adv Ther 2024; 41:3003-3012. [PMID: 38616242 DOI: 10.1007/s12325-024-02836-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/07/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Despite the appearance of off-pump coronary artery bypass grafting (CABG), ischemia-reperfusion injury (IRI) in the perioperative period still arouses concerns of clinicians. Remote ischemic conditioning (RIC) is the process of repeated ischemia and reperfusion in the peripheral vessels, which is proven to reduce IRI in vital organs. However, the effect of RIC in patients undergoing off-pump CABG is still unclear. METHODS This IMPROVE trial is a national, multicenter, randomized, controlled, open-label, blinded-endpoint clinical trial designed to assess whether RIC intervention can improve short-term prognosis of patients undergoing off-pump CABG. It plans to enroll 648 patients who will be randomly assigned into a RIC group or control group. Patients in the RIC group will receive four cycles of 5 min of pressurization (about 200 mmHg) and 5 min of rest in the 3 days before and 7 days after the surgery. PLANNED OUTCOMES The primary outcome is the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) within the 3-month follow-up. MACCE is defined as all-cause death, myocardial infarction, stroke, and coronary revascularization surgery. CLINICAL TRIAL REGISTRATION NCT06141525 (ClinicalTrials.gov).
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Affiliation(s)
- Yang Yan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
| | - Changying Zhao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jialan Niu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Pengyun Yan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jing Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Cardiovascular Surgery, People's Hospital of Qinghai Province, Xining, China
| | - Duolao Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
- Department of Neurology, Guangdong Key Laboratory of Age-Related Cardiac and Cerebral Diseases, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Kamenshchikov NO, Churilina EA, Korepanov VA, Rebrova TY, Sukhodolo IV, Kozlov BN. Effect of inhaled nitric oxide on intestinal integrity in cardiopulmonary bypass and circulatory arrest simulation: An experimental study. Indian J Anaesth 2024; 68:623-630. [PMID: 39081908 PMCID: PMC11285895 DOI: 10.4103/ija.ija_1267_23] [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: 12/28/2023] [Revised: 04/14/2024] [Accepted: 04/25/2024] [Indexed: 08/02/2024] Open
Abstract
Background and Aims Cardiopulmonary bypass (CPB) and circulatory arrest (CA) can induce intestinal injury and consequently lead to multiple organ dysfunction. Nitric oxide (NO) has protective effects, but its effect on the intestine has not been studied. The study aimed to investigate intestinal injury variables and prove the intestinal protective effects of exogenous nitric oxide when modelling CPB and CA in an experiment. Methods The study was performed on sheep (n = 24). There were four groups: CPB, CPB + NO, CPB + CA and CPB + CA + NO. Sheep in NO groups received intraoperative inhalation of NO at a dose of 80 ppm. Groups without NO underwent CPB and CA without NO delivery. Defaecation rate, dynamics of intestinal fatty acid binding protein (i-FABP), coefficient of microviscosity and polarity in the areas of lipid-lipid and protein-lipid interactions of erythrocyte membranes were assessed. One hour after CPB, the intestinal tissue was collected and assessed for tissue concentrations of adenosine triphosphate (ATP) and lactate. Results The defaecation rate after CPB was higher in the CPB + NO group than in the CPB group. The concentration of i-FABP after CPB was lower in the CPB + NO and CPB + CA + NO groups than in the CPB and CPB + CA groups. Erythrocyte deformability before and after CPB revealed no significant dynamics in groups with NO. The ATP concentration 1 h after CPB was higher in the CPB + NO group than in the CPB group. The morphological picture in groups with NO was better. Conclusion When modelling CPB and CA, NO had a positive effect on the functional and structural state of the intestine and also maintained erythrocyte deformability.
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Affiliation(s)
- Nikolay O. Kamenshchikov
- Laboratory of Critical Care Medicine, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russian Federation
| | - Elena A. Churilina
- Laboratory of Critical Care Medicine, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russian Federation
| | - Vyacheslav A. Korepanov
- Laboratory of Molecular and Cellular Pathology and Gene Diagnostics, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russian Federation
| | - Tatiana Y. Rebrova
- Laboratory of Molecular and Cellular Pathology and Gene Diagnostics, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russian Federation
| | - Irina V. Sukhodolo
- Department of Morphology and General Pathology, Siberian State Medical University, 2 Moskovsky trakt, Tomsk, 634050, Russian Federation
| | - Boris N. Kozlov
- Laboratory of Critical Care Medicine, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russian Federation
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Yan Y, Kamenshchikov N, Zheng Z, Lei C. Inhaled nitric oxide and postoperative outcomes in cardiac surgery with cardiopulmonary bypass: A systematic review and meta-analysis. Nitric Oxide 2024; 146:64-74. [PMID: 38556145 DOI: 10.1016/j.niox.2024.03.004] [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] [Received: 01/21/2024] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
Cardiac surgeries under cardiopulmonary bypass (CPB) are complex procedures with high incidence of complications, morbidity and mortality. The inhaled nitric oxide (iNO) has been frequently used as an important composite of perioperative management during cardiac surgery under CPB. We conducted a meta-analysis of published randomized clinical trials (RCTs) to assess the effects of iNO on reducing postoperative complications, including the duration of postoperative mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, mortality, hemodynamic improvement (the composite right ventricular failure, low cardiac output syndrome, pulmonary arterial pressure, and vasoactive inotropic score) and myocardial injury biomarker (postoperative troponin I levels). Subgroup analyses were performed to assess the effect of modification and interaction. These included iNO dosage, the timing and duration of iNO therapy, different populations (children and adults), and comparators (other vasodilators and placebo or standard care). A comprehensive search for iNO and cardiac surgery was performed on online databases. Twenty-seven studies were included after removing the duplicates and irrelevant articles. The results suggested that iNO could reduce the duration of mechanical ventilation, but had no significance in the ICU stay, hospital stay, and mortality. This may be attributed to the small sample size of the most included studies and heterogeneity in timing, dosage and duration of iNO administration. Well-designed, large-scale, multicenter clinical trials are needed to further explore the effect of iNO in improving postoperative prognosis in cardiovascular surgical patients.
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Affiliation(s)
- Yun Yan
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China; Department of Anesthesiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100029, China
| | - Nikolay Kamenshchikov
- Laboratory of Critical Care Medicine, Department of Anesthesiology and Intensive Care, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk, 634012, Russian Federation
| | - Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China.
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Kamenshchikov NO, Diakova ML, Podoksenov YK, Churilina EA, Rebrova TY, Akhmedov SD, Maslov LN, Mukhomedzyanov AV, Kim EB, Tokareva ES, Kravchenko IV, Boiko AM, Kozulin MS, Kozlov BN. Potential Mechanisms for Organoprotective Effects of Exogenous Nitric Oxide in an Experimental Study. Biomedicines 2024; 12:719. [PMID: 38672075 PMCID: PMC11048067 DOI: 10.3390/biomedicines12040719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 04/28/2024] Open
Abstract
Performing cardiac surgery under cardiopulmonary bypass (CPB) and circulatory arrest (CA) provokes the development of complications caused by tissue metabolism, microcirculatory disorders, and endogenous nitric oxide (NO) deficiency. This study aimed to investigate the potential mechanisms for systemic organoprotective effects of exogenous NO during CPB and CA based on the assessment of dynamic changes in glycocalyx degradation markers, deformation properties of erythrocytes, and tissue metabolism in the experiment. A single-center prospective randomized controlled study was conducted on sheep, n = 24, comprising four groups of six in each. In two groups, NO was delivered at a dose of 80 ppm during CPB ("CPB + NO" group) or CPB and CA ("CPB + CA + NO"). In the "CPB" and "CPB + CA" groups, NO supply was not carried out. NO therapy prevented the deterioration of erythrocyte deformability. It was associated with improved tissue metabolism, lower lactate levels, and higher ATP levels in myocardial and lung tissues. The degree of glycocalyx degradation and endothelial dysfunction, assessed by the concentration of heparan sulfate proteoglycan and asymmetric dimethylarginine, did not change when exogenous NO was supplied. Intraoperative delivery of NO provides systemic organoprotection, which results in reducing the damaging effects of CPB on erythrocyte deformability and maintaining normal functioning of tissue metabolism.
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Affiliation(s)
| | - Mariia L. Diakova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk 634012, Russia; (N.O.K.); (Y.K.P.); (E.A.C.); (T.Y.R.); (S.D.A.); (L.N.M.); (A.V.M.); (E.B.K.); (E.S.T.); (I.V.K.); (A.M.B.); (M.S.K.); (B.N.K.)
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Mathis BJ, Kato H, Matsuishi Y, Hiramatsu Y. Endogenous and exogenous protection from surgically induced reactive oxygen and nitrogen species. Surg Today 2024; 54:1-13. [PMID: 36348164 DOI: 10.1007/s00595-022-02612-6] [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] [Received: 06/26/2022] [Accepted: 10/11/2022] [Indexed: 11/09/2022]
Abstract
Surgical intervention creates reactive oxygen species through diverse molecular mechanisms, including direct stimulation of immune-mediated inflammation necessary for wound healing. However, dysregulation of redox homeostasis in surgical patients overwhelms the endogenous defense system, slowing the healing process and damaging organs. We broadly surveyed reactive oxygen species that result from surgical interventions and the endogenous and/or exogenous antioxidants that control them. This study assimilates current reports on surgical sources of reactive oxygen and nitrogen species along with literature reports on the effects of endogenous and exogenous antioxidants in human, animal, and clinical settings. Although exogenous antioxidants are generally beneficial, endogenous antioxidant systems account for over 80% of total activity, varying based on patient age, sex, and health or co-morbidity status, especially in smokers, the diabetic, and the obese. Supplementation of exogenous compounds for support in surgical patients is thus theoretically beneficial, but a lack of persuasive clinical evidence has left this potential patient support strategy without clear guidelines. A more thorough understanding of the mechanisms of exogenous antioxidants in patients with compromised health statuses and pharmacokinetic profiling may increase the utility of such support in both the operating and recovery rooms.
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Affiliation(s)
- Bryan J Mathis
- International Medical Center, University of Tsukuba Affiliated Hospital, 2-1-1 Amakubo, Tsukuba, 305-8576, Ibaraki, Japan.
| | - Hideyuki Kato
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yujiro Matsuishi
- Department of Neuroscience Nursing, St. Luke's International University, Tokyo, Japan
| | - Yuji Hiramatsu
- Department of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Ferreira LO, Vasconcelos VW, Lima JDS, Vieira Neto JR, da Costa GE, Esteves JDC, de Sousa SC, Moura JA, Santos FRS, Leitão Filho JM, Protásio MR, Araújo PS, Lemos CJDS, Resende KD, Lopes DCF. Biochemical Changes in Cardiopulmonary Bypass in Cardiac Surgery: New Insights. J Pers Med 2023; 13:1506. [PMID: 37888117 PMCID: PMC10608001 DOI: 10.3390/jpm13101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 10/28/2023] Open
Abstract
Patients undergoing coronary revascularization with extracorporeal circulation or cardiopulmonary bypass (CPB) may develop several biochemical changes in the microcirculation that lead to a systemic inflammatory response. Surgical incision, post-CPB reperfusion injury and blood contact with non-endothelial membranes can activate inflammatory signaling pathways that lead to the production and activation of inflammatory cells, with cytokine production and oxidative stress. This inflammatory storm can cause damage to vital organs, especially the heart, and thus lead to complications in the postoperative period. In addition to the organic pathophysiology during and after the period of exposure to extracorporeal circulation, this review addresses new perspectives for intraoperative treatment and management that may lead to a reduction in this inflammatory storm and thereby improve the prognosis and possibly reduce the mortality of these patients.
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Affiliation(s)
- Luan Oliveira Ferreira
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
- Laboratory of Experimental Neuropathology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil
| | - Victoria Winkler Vasconcelos
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Janielle de Sousa Lima
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jaime Rodrigues Vieira Neto
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Giovana Escribano da Costa
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jordana de Castro Esteves
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Sallatiel Cabral de Sousa
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jonathan Almeida Moura
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Felipe Ruda Silva Santos
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - João Monteiro Leitão Filho
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | | | - Pollyana Sousa Araújo
- Department of Cardiovascular Anesthesiology, Hospital Clínicas Gaspar Vianna, Belém 66083-106, Brazil; (P.S.A.); (C.J.d.S.L.)
| | - Cláudio José da Silva Lemos
- Department of Cardiovascular Anesthesiology, Hospital Clínicas Gaspar Vianna, Belém 66083-106, Brazil; (P.S.A.); (C.J.d.S.L.)
| | - Karina Dias Resende
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Dielly Catrina Favacho Lopes
- Laboratory of Experimental Neuropathology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil
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10
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Kamenshchikov NO, Duong N, Berra L. Nitric Oxide in Cardiac Surgery: A Review Article. Biomedicines 2023; 11:biomedicines11041085. [PMID: 37189703 DOI: 10.3390/biomedicines11041085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Perioperative organ injury remains a medical, social and economic problem in cardiac surgery. Patients with postoperative organ dysfunction have increases in morbidity, length of stay, long-term mortality, treatment costs and rehabilitation time. Currently, there are no pharmaceutical technologies or non-pharmacological interventions that can mitigate the continuum of multiple organ dysfunction and improve the outcomes of cardiac surgery. It is essential to identify agents that trigger or mediate an organ-protective phenotype during cardiac surgery. The authors highlight nitric oxide (NO) ability to act as an agent for perioperative protection of organs and tissues, especially in the heart-kidney axis. NO has been delivered in clinical practice at an acceptable cost, and the side effects of its use are known, predictable, reversible and relatively rare. This review presents basic data, physiological research and literature on the clinical application of NO in cardiac surgery. Results support the use of NO as a safe and promising approach in perioperative patient management. Further clinical research is required to define the role of NO as an adjunct therapy that can improve outcomes in cardiac surgery. Clinicians also have to identify cohorts of responders for perioperative NO therapy and the optimal modes for this technology.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
| | - Nicolette Duong
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
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11
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Lima Neto AVD, Silva BWACD, Melo VLD, Silva JAD, Costa IKF. Learning Needs and Educational Strategies for Adult Patients in the Preoperative Period of Myocardial Revascularization: Scoping Review. AQUICHAN 2022. [DOI: 10.5294/aqui.2022.22.3.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To identify and map learning needs and educational strategies for adult patients in the preoperative period of myocardial revascularization. Materials and method: Scoping review conducted between March and April 2021 in national and international databases to identify records published in scientific journals and gray literature, without period. Results: The selected sample consisted of 35 records, composed mostly of articles (32; 91.42 %) published from 1990 to 2021. The learning needs of patients before surgery were categorized into cardiovascular system and coronary artery disease; procedures and routines before, during, and after surgery. In addition, several educational strategies implemented in the studies were identified. Conclusions: The learning needs identified can contribute to planning and implementing patient-centered educational strategies before surgery.
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12
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Schlapbach LJ, Gibbons KS, Horton SB, Johnson K, Long DA, Buckley DHF, Erickson S, Festa M, d’Udekem Y, Alphonso N, Winlaw DS, Delzoppo C, van Loon K, Jones M, Young PJ, Butt W, Schibler A. Effect of Nitric Oxide via Cardiopulmonary Bypass on Ventilator-Free Days in Young Children Undergoing Congenital Heart Disease Surgery: The NITRIC Randomized Clinical Trial. JAMA 2022; 328:38-47. [PMID: 35759691 PMCID: PMC9237803 DOI: 10.1001/jama.2022.9376] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE In children undergoing heart surgery, nitric oxide administered into the gas flow of the cardiopulmonary bypass oxygenator may reduce postoperative low cardiac output syndrome, leading to improved recovery and shorter duration of respiratory support. It remains uncertain whether nitric oxide administered into the cardiopulmonary bypass oxygenator improves ventilator-free days (days alive and free from mechanical ventilation). OBJECTIVE To determine the effect of nitric oxide applied into the cardiopulmonary bypass oxygenator vs standard care on ventilator-free days in children undergoing surgery for congenital heart disease. DESIGN, SETTING, AND PARTICIPANTS Double-blind, multicenter, randomized clinical trial in 6 pediatric cardiac surgical centers in Australia, New Zealand, and the Netherlands. A total of 1371 children younger than 2 years undergoing congenital heart surgery were randomized between July 2017 and April 2021, with 28-day follow-up of the last participant completed on May 24, 2021. INTERVENTIONS Patients were assigned to receive nitric oxide at 20 ppm delivered into the cardiopulmonary bypass oxygenator (n = 679) or standard care cardiopulmonary bypass without nitric oxide (n = 685). MAIN OUTCOMES AND MEASURES The primary end point was the number of ventilator-free days from commencement of bypass until day 28. There were 4 secondary end points including a composite of low cardiac output syndrome, extracorporeal life support, or death; length of stay in the intensive care unit; length of stay in the hospital; and postoperative troponin levels. RESULTS Among 1371 patients who were randomized (mean [SD] age, 21.2 [23.5] weeks; 587 girls [42.8%]), 1364 (99.5%) completed the trial. The number of ventilator-free days did not differ significantly between the nitric oxide and standard care groups, with a median of 26.6 days (IQR, 24.4 to 27.4) vs 26.4 days (IQR, 24.0 to 27.2), respectively, for an absolute difference of -0.01 days (95% CI, -0.25 to 0.22; P = .92). A total of 22.5% of the nitric oxide group and 20.9% of the standard care group developed low cardiac output syndrome within 48 hours, needed extracorporeal support within 48 hours, or died by day 28, for an adjusted odds ratio of 1.12 (95% CI, 0.85 to 1.47). Other secondary outcomes were not significantly different between the groups. CONCLUSIONS AND RELEVANCE In children younger than 2 years undergoing cardiopulmonary bypass surgery for congenital heart disease, the use of nitric oxide via cardiopulmonary bypass did not significantly affect the number of ventilator-free days. These findings do not support the use of nitric oxide delivered into the cardiopulmonary bypass oxygenator during heart surgery. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12617000821392.
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Affiliation(s)
- Luregn J. Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kristen S. Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Stephen B. Horton
- Cardiac Surgical Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Kerry Johnson
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Debbie A. Long
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David H. F. Buckley
- Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand
| | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Western Australia and The University of Western Australia, Crawley, Western Australia, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network, Sydney, New South Wales, Australia
| | - Yves d’Udekem
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Children’s National Hospital and The George Washington University School of Medicine and Health Sciences, Seattle, Washington
- Heart Research, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Nelson Alphonso
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Cardiac Surgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
- School of Medicine, Children’s Health Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - David S. Winlaw
- Heart Centre for Children, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Carmel Delzoppo
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kim van Loon
- Department of Anaesthesiology, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Mark Jones
- Institute of Evidence Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul J. Young
- The Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Warwick Butt
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School University of Melbourne, Victoria, Australia
- Central Clinical School Faculty of Medicine Monash University, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Critical Care Research Group, Wesley Medical Research, St Andrew’s War Memorial Hospital, Brisbane, Queensland, Australia
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13
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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14
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Pichugin VV, Seyfetdinov IR, Ryazanov MV, Domnin SE, Gamzaev AB, Chiginev VA, Bober VV, Medvedev AP. New Technology for the Use of Inhaled Nitric Oxide to Protect the Heart and Lungs during Operations with Cardiopulmonary Bypass. Sovrem Tekhnologii Med 2021; 12:28-34. [PMID: 34796002 PMCID: PMC8596258 DOI: 10.17691/stm2020.12.5.03] [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: 05/28/2020] [Indexed: 11/25/2022] Open
Abstract
The aim of the study was to evaluate the effectiveness of a new technology for the use of inhaled nitric oxide (NO) for the heart and lung protection during operations with cardiopulmonary bypass (СРВ).
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Affiliation(s)
- V V Pichugin
- Professor, Department of Anesthesiology, Resuscitation and Emergency Medical Aid; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - I R Seyfetdinov
- PhD Student, Department of Anesthesiology, Resuscitation and Emergency Medical Aid; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - M V Ryazanov
- Associate Professor, Department of Hospital Surgery named after B.A. Korolyov; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S E Domnin
- PhD Student, Department of Anesthesiology, Resuscitation and Emergency Medical Aid; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A B Gamzaev
- Professor, Department of X-ray Endovascular Diagnostics and Treatment; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - V A Chiginev
- Professor, Department of Hospital Surgery named after B.A. Korolyov; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - V V Bober
- Assistant, Department of Anesthesiology, Resuscitation and Emergency Medical Aid; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A P Medvedev
- Professor, Department of Hospital Surgery named after B.A. Korolyov Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
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15
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Belletti A, Lerose CC, Zangrillo A, Landoni G. Vasoactive-Inotropic Score: Evolution, Clinical Utility, and Pitfalls. J Cardiothorac Vasc Anesth 2021; 35:3067-3077. [DOI: 10.1053/j.jvca.2020.09.117] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023]
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Loughlin JM, Browne L, Hinchion J. The impact of exogenous nitric oxide during cardiopulmonary bypass for cardiac surgery. Perfusion 2021; 37:656-667. [PMID: 33983090 DOI: 10.1177/02676591211014821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Cardiac surgery using cardiopulmonary bypass frequently provokes a systemic inflammatory response syndrome. This can lead to the development of low cardiac output syndrome (LCOS). Both of these can affect morbidity and mortality. This study is a systematic review of the impact of gaseous nitric oxide (gNO), delivered via the cardiopulmonary bypass (CPB) circuit during cardiac surgery, on post-operative outcomes. It aims to summarise the evidence available, to assess the effectiveness of gNO via the CPB circuit on outcomes, and highlight areas of further research needed to develop this hypothesis. METHODS A comprehensive search of Pubmed, Embase, Web of Science and the Cochrane Library was performed in May 2020. Only randomised control trials (RCTs) were considered. RESULTS Three studies were identified with a total of 274 patients. There was variation in the outcomes measures used across the studies. These studies demonstrate there is evidence that this intervention may contribute towards cardioprotection. Significant reductions in cardiac troponin I (cTnI) levels and lower vasoactive inotrope scores were seen in intervention groups. A high degree of heterogeneity between the studies exists. Meta-analysis of the duration of mechanical ventilation, length of ICU stay and length of hospital stay showed no significant differences. CONCLUSION This systematic review explored the findings of three pilot RCTs. Overall the hypothesis that NO delivered via the CPB circuit can provide cardioprotection has been supported by this study. There remains a significant gap in the evidence, further high-quality research is required in both the adult and paediatric populations.
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Affiliation(s)
- Joseph Mc Loughlin
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| | - Lorraine Browne
- Department of Clinical Perfusion, Cork University Hospital, Cork, Ireland
| | - John Hinchion
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
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17
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Liu K, Wang H, Yu SJ, Tu GW, Luo Z. Inhaled pulmonary vasodilators: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:597. [PMID: 33987295 PMCID: PMC8105872 DOI: 10.21037/atm-20-4895] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023]
Abstract
Pulmonary hypertension (PH) is a severe disease that affects people of all ages. It can occur as an idiopathic disorder at birth or as part of a variety of cardiovascular and pulmonary disorders. Inhaled pulmonary vasodilators (IPV) can reduce pulmonary vascular resistance (PVR) and improve RV function with minimal systemic effects. IPV includes inhaled nitric oxide (iNO), inhaled aerosolized prostacyclin, or analogs, including epoprostenol, iloprost, treprostinil, and other vasodilators. In addition to pulmonary vasodilating effects, IPV can also be used to improve oxygenation, reduce inflammation, and protect cell. Off-label use of IPV is common in daily clinical practice. However, evidence supporting the inhalational administration of these medications is limited, inconclusive, and controversial regarding their safety and efficacy. We conducted a search for relevant papers published up to May 2020 in four databases: PubMed, Google Scholar, EMBASE and Web of Science. This review demonstrates that the clinical using and updated evidence of IPV. iNO is widely used in neonates, pediatrics, and adults with different cardiopulmonary diseases. The limitations of iNO include high cost, flat dose-response, risk of significant rebound PH after withdrawal, and the requirement of complex technology for monitoring. The literature suggests that inhaled aerosolized epoprostenol, iloprost, treprostinil and others such as milrinone and levosimendan may be similar to iNO. More research of IPV is needed to determine acceptable inclusion criteria, long-term outcomes, and management strategies including time, dose, and duration.
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Affiliation(s)
- Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Med, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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18
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Wang J, Cong X, Miao M, Yang Y, Zhang J. Inhaled nitric oxide and acute kidney injury risk: a meta-analysis of randomized controlled trials. Ren Fail 2021; 43:281-290. [PMID: 33494652 PMCID: PMC7850389 DOI: 10.1080/0886022x.2021.1873805] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose There are conflicting results as to the effect of inhaled nitric oxide (iNO) therapy on the risk of acute kidney injury (AKI). The aim of this study was to perform a meta-analysis to assess the updated data. Methods We systematically searched Web of Science, the Cochrane Library, Wanfang, and PubMed for relevant randomized control trials between database inception and 9/07/2020. Relative risks (RRs) with 95% confidence intervals (CIs) predicting the risk of AKI were extracted to obtain summary estimates using fixed-effects models. The Trim and Fill method was used to evaluate the sensitivity of the results and adjust for publication bias in meta-analysis. Results 15 randomized controlled studies from 14 articles involving 1853 patients were included in the study. Analyzing the eligible studies we found: (1) iNO therapy significantly increased the risk of AKI in acute respiratory distress syndrome patients (RR 1.55, 95% CI 1.15–2.10, p = 0.004; I2 for heterogeneity 0%; Phet = 0.649). (2) The use of iNO was associated with reduced AKI risk in patients undergoing cardiac surgery (RR 0.80, 95% CI 0.64–0.99, p = 0.037; I2 for heterogeneity 0%; Phet = 0.528). (3) For organ transplantation recipients, there was no effect of iNO administration on the risk of AKI (RR 0.50, 95% CI 0.16–1.56, p = 0.233; I2 for heterogeneity 0%; Phet = 0.842). The Trim and Fill analysis showed that the overall effect of this meta-analysis was stable. Conclusions The effect of iNO on AKI risk might be disease-specific. Future RCTs with larger patient populations should aim to validate our findings.
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Affiliation(s)
- Junqiu Wang
- Journal Editorial Department, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Xuhui Cong
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengrong Miao
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yitian Yang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
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Nitric Oxide Attenuates the Inflammatory Effects of Air During Extracorporeal Circulation. ASAIO J 2021; 66:818-824. [PMID: 31425266 DOI: 10.1097/mat.0000000000001057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cardiopulmonary bypass causes a systemic inflammatory response reaction that may contribute to postoperative complications. One cause relates to the air/blood interface from the extracorporeal circuit. The modulatory effects of blending nitric oxide (NO) gas into the ventilation/sweep gas of the membrane lung was studied in a porcine model of air-induced inflammation in which NO gas was added and compared with controls with or without an air/blood interface. Healthy swine were supported on partial bypass under four different test conditions. Group 1: no air exposure, group 2: air alone, group 3: air plus 50 ppm NO, and group 4: air plus 500 ppm NO. The NO gas was blended into the ventilation/sweep site of the membrane lung. The platelets and leucocytes were activated by air alone. Addition of NO to the sweep gas attenuated the inflammatory response created by the air/blood interface in this model.
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Abstract
Perioperative cardioprotection aims to minimize the consequences of myocardial ischemia-reperfusion injury. In isolated tissue and animal experiments, several treatments have been identified providing cardioprotection. Some of these strategies have been confirmed in clinical proof-of-concept studies. However, the final translation of cardioprotective strategies to really improve clinical outcome has been disappointing: large randomized controlled clinical trials mostly revealed inconclusive, neutral, or negative results. This review provides an overview of the currently available evidence regarding clinical implications of perioperative cardioprotective therapies from an anesthesiological perspective, highlighting nonpharmacological as well as pharmacological strategies. We discuss reasons why translation of promising experimental results into clinical practice and outcome improvement is hampered by potential confounders and suggest future perspectives to overcome these limitations.
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Wang M, Zhou R, Xiong W, Wang Z, Wang J, He L, Qian J. Oxytocin mediated cardioprotection is independent of coronary endothelial function in rats. Peptides 2020; 130:170333. [PMID: 32497565 DOI: 10.1016/j.peptides.2020.170333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 12/19/2022]
Abstract
The cardioprotective effect of oxytocin (OT) has been well established. However, there are no related studies on the role of endothelia in oxytocin-induced cardioprotection. Endothelial dysfunction (ED) model was established by injection of 0.01 % Triton X-100 in the isolated rat heart. Oxytocin pretreatment was conducted at the end of stabilization for 40 min, followed by 30 min global ischemia and 60 min reperfusion to induce I/R injury. Coronary perfusion pressure, hemodynamics and arrhythmia severity scores were measured respectively. High-sensitivity cardiac troponin T (hs-cTnT) was evaluated by enzyme-linked immunosorbent assay. Infarct size was detected by triphenyltetrazolium chloride staining. The morphological changes in coronary endothelium were observed by scanning electron microscopy. Injection of 0.01 % Triton X-100 caused significant reduction of CPP induced by histamine and endothelium removal from scanning electron microscopy, but SNP had no significant effect. Oxytocin pretreatment showed significant recovery in LVDP, ±dp/dtmax, RPP and SI after reperfusion (P < 0.05). Additionally, I/R injury led to a rise of arrhythmia severity score, hs-cTnT and infarct size. No significant differences between ED-OT-I/R and OT-I/R groups were found in arrhythmia severity score, hs-cTnT, and infarct size (P > 0.05). I/R injury exacerbated the decrease in CPP and worsened the migration, deformation, and fracture of coronary endothelium, while oxytocin reversed these injuries. Despite the presence of endothelial damages, oxytocin partially alleviated I/R- and Triton-induced endothelial damages. The cardioprotective effects of oxytocin are independent of endothelial function in alleviating I/R injury and I/R-induced coronary endothelial dysfunction.
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Affiliation(s)
- Mo Wang
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Rui Zhou
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wei Xiong
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhuoran Wang
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jun Wang
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Liang He
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China; Department of Anesthesiology, Yan'an Hospital of Kunming City, Kunming Medical University, Kunming, China
| | - Jinqiao Qian
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China.
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22
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Mandel IA, Podoksenov YK, Suhodolo IV, An DA, Mikheev SL, Podoksenov AY, Svirko YS, Gusakova AM, Shipulin VM, Yavorovskiy AG. Influence of Hypoxic and Hyperoxic Preconditioning on Endothelial Function in a Model of Myocardial Ischemia-Reperfusion Injury with Cardiopulmonary Bypass (Experimental Study). Int J Mol Sci 2020; 21:ijms21155336. [PMID: 32727110 PMCID: PMC7432780 DOI: 10.3390/ijms21155336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 11/22/2022] Open
Abstract
The aim of the experiment was to evaluate the effect of preconditioning based on changes in inspiratory oxygen fraction on endothelial function in the model of ischemia-reperfusion injury of the myocardium in the condition of cardiopulmonary bypass. The prospective randomized study included 32 rabbits divided into four groups: hypoxic preconditioning, hyperoxic preconditioning, hypoxic-hyperoxic preconditioning, and control group. All animals were anesthetized and mechanically ventilated. We provided preconditioning, then started cardiopulmonary bypass, followed by induced acute myocardial infarction (ischemia 45 min, reperfusion 120 min). We investigated endothelin-1, nitric oxide metabolites, asymmetric dimethylarginine during cardiopulmonary bypass: before ischemia, after ischemia, and after reperfusion. We performed light microscopy of myocardium, kidney, lungs, and gut mucosa. The endothelin-1 level was much higher in the control group than in all preconditioning groups after ischemia. The endothelin-1 even further increased after reperfusion. The total concentration of nitric oxide metabolites was significantly higher after all types of preconditioning compared with the control group. The light microscopy of the myocardium and other organs revealed a diminished damage extent in the hypoxic-hyperoxic preconditioning group as compared to the control group. Hypoxic-hyperoxic preconditioning helps to maintain the balance of nitric oxide metabolites, reduces endothelin-1 hyperproduction, and enforces organ protection.
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Affiliation(s)
- Irina A. Mandel
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Cardiology Research Institute, 111a Kievskaya Str., Tomsk 634012, Russia; (Y.K.P.); (S.L.M.); (A.Y.P.); (Y.S.S.); (A.M.G.); (V.M.S.)
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Str., Moscow 119991, Russia;
- Federal Scientific and Clinical Center of Specialized Types of Medical Care and Medical Technologies of the Federal Medical and Biological Agency of Russia, 28 Orekhoviy Blvd., Moscow 115682, Russia
- Correspondence: ; Tel.: +790-3952-8337
| | - Yuri K. Podoksenov
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Cardiology Research Institute, 111a Kievskaya Str., Tomsk 634012, Russia; (Y.K.P.); (S.L.M.); (A.Y.P.); (Y.S.S.); (A.M.G.); (V.M.S.)
- Siberian State Medical University of the Ministry of Health of the Russian Federation, 2 Moskovskiy Tract Str., Tomsk 634050, Russia; (I.V.S.); (D.A.A.)
| | - Irina V. Suhodolo
- Siberian State Medical University of the Ministry of Health of the Russian Federation, 2 Moskovskiy Tract Str., Tomsk 634050, Russia; (I.V.S.); (D.A.A.)
| | - Darya A. An
- Siberian State Medical University of the Ministry of Health of the Russian Federation, 2 Moskovskiy Tract Str., Tomsk 634050, Russia; (I.V.S.); (D.A.A.)
| | - Sergey L. Mikheev
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Cardiology Research Institute, 111a Kievskaya Str., Tomsk 634012, Russia; (Y.K.P.); (S.L.M.); (A.Y.P.); (Y.S.S.); (A.M.G.); (V.M.S.)
- Siberian State Medical University of the Ministry of Health of the Russian Federation, 2 Moskovskiy Tract Str., Tomsk 634050, Russia; (I.V.S.); (D.A.A.)
- Swiss Medica XXI C.A., 21/1 Annenskaya str., Moscow 127521, Russia
| | - Andrey Yu. Podoksenov
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Cardiology Research Institute, 111a Kievskaya Str., Tomsk 634012, Russia; (Y.K.P.); (S.L.M.); (A.Y.P.); (Y.S.S.); (A.M.G.); (V.M.S.)
| | - Yulia S. Svirko
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Cardiology Research Institute, 111a Kievskaya Str., Tomsk 634012, Russia; (Y.K.P.); (S.L.M.); (A.Y.P.); (Y.S.S.); (A.M.G.); (V.M.S.)
- Siberian State Medical University of the Ministry of Health of the Russian Federation, 2 Moskovskiy Tract Str., Tomsk 634050, Russia; (I.V.S.); (D.A.A.)
| | - Anna M. Gusakova
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Cardiology Research Institute, 111a Kievskaya Str., Tomsk 634012, Russia; (Y.K.P.); (S.L.M.); (A.Y.P.); (Y.S.S.); (A.M.G.); (V.M.S.)
| | - Vladimir M. Shipulin
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Cardiology Research Institute, 111a Kievskaya Str., Tomsk 634012, Russia; (Y.K.P.); (S.L.M.); (A.Y.P.); (Y.S.S.); (A.M.G.); (V.M.S.)
- Siberian State Medical University of the Ministry of Health of the Russian Federation, 2 Moskovskiy Tract Str., Tomsk 634050, Russia; (I.V.S.); (D.A.A.)
| | - Andrey G. Yavorovskiy
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Str., Moscow 119991, Russia;
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23
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Kamenshchikov NO, Anfinogenova YJ, Kozlov BN, Svirko YS, Pekarskiy SE, Evtushenko VV, Lugovsky VA, Shipulin VM, Lomivorotov VV, Podoksenov YK. Nitric oxide delivery during cardiopulmonary bypass reduces acute kidney injury: A randomized trial. J Thorac Cardiovasc Surg 2020; 163:1393-1403.e9. [PMID: 32718702 DOI: 10.1016/j.jtcvs.2020.03.182] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to evaluate the effects of nitric oxide (NO) supplementation to the CPB circuit on the development of cardiac surgery-associated AKI. METHODS This prospective randomized controlled study included 96 patients with moderate risk of renal complications who underwent elective cardiac surgery with CPB. The study protocol was registered at ClinicalTrials.gov (identifier NCT03527381). Patients were randomly allocated to either NO supplementation to the CPB bypass circuit (NO treatment group; n = 48) or usual care (control group; n = 48). In the NO treatment group, 40-ppm NO was administered during the entire CPB period. The primary outcome was the incidence of AKI. RESULTS NO treatment was associated with a significant decrease in AKI incidence (10 cases [20.8%] vs 20 cases [41.6%] in the control group; relative risk, 0.5; 95% confidence interval, 0.26-0.95; P = .023) and a higher median urine output during CPB (2.6 mL/kg/h [interquartile range (IQR), 2.1-5.08 mL/kg/h] vs 1.7 mL/kg/h [IQR, 0.80-2.50 mL/kg/h]; P = .0002). The median urinary neutrophil gelatinase-associated lipocalin level at 4 hours after surgery was significantly lower in the NO treatment group (1.12 ng/mL [IQR, 0.75-5.8 ng/mL] vs 4.62 ng/mL [IQR, 2.02-34.55 ng/mL]; P = .005). In the NO treatment group, concentrations of NO metabolites were significantly increased at 5 minutes postclamping, at 5 minutes after declamping, and at the end of the operation. Concentrations of proinflammatory and anti-inflammatory mediators and free plasma hemoglobin did not differ significantly between the 2 groups. CONCLUSIONS NO administration in patients at moderate risk of renal complications undergoing elective cardiac surgery with CPB was associated with a lower incidence of AKI.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia.
| | - Yana J Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Boris N Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
| | - Yulia S Svirko
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
| | - Stanislav E Pekarskiy
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Vladimir V Evtushenko
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Vladimir A Lugovsky
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Vladimir M Shipulin
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Critical Care, Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Yuriy K Podoksenov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
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24
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Hu J, Spina S, Zadek F, Kamenshchikov NO, Bittner EA, Pedemonte J, Berra L. Effect of nitric oxide on postoperative acute kidney injury in patients who underwent cardiopulmonary bypass: a systematic review and meta-analysis with trial sequential analysis. Ann Intensive Care 2019; 9:129. [PMID: 31754841 PMCID: PMC6872705 DOI: 10.1186/s13613-019-0605-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The effect of nitric oxide (NO) on renal function is controversial in critical illness. We performed a systematic meta-analysis and trial sequential analysis to determine the effect of NO gas on renal function and other clinical outcomes in patients requiring cardiopulmonary bypass (CPB). The primary outcome was the relative risk (RR) of acute kidney injury (AKI), irrespective of the AKI stage. The secondary outcome was the mean difference (MD) in the length of ICU and hospital stay, the RR of postoperative hemorrhage, and the MD in levels of methemoglobin. Trial sequential analysis (TSA) was performed for the primary outcome. RESULTS 54 trials were assessed for eligibility and 5 studies (579 patients) were eligible for meta-analysis. NO was associated with reduced risk of AKI (RR 0.76, 95% confidential interval [CI], 0.62 to 0.93, I2 = 0%). In the subgroup analysis by NO initiation timing, NO did not decrease the risk of AKI when started at the end of CPB (RR 1.20, 95% CI 0.52-2.78, I2 = 0%). However, NO did significantly reduce the risk of AKI when started from the beginning of CPB (RR 0.71, 95% CI 0.54-0.94, I2 = 10%). We conducted TSA based on three trials (400 patients) using KDIGO criteria and with low risk of bias. TSA indicated a CI of 0.50-1.02 and an optimal information size of 589 patients, suggesting a lack of definitive conclusion. Furthermore, NO does not affect the length of ICU and hospital stay or the risk of postoperative hemorrhage. NO slightly increased the level of methemoglobin at the end of CPB (MD 0.52%, 95% CI 0.27-0.78%, I2 = 90%), but it was clinically negligible. CONCLUSIONS NO appeared to reduce the risk of postoperative AKI in patients undergoing CPB. Additional studies are required to ascertain the finding and further determine the dosage, timing and duration of NO administration.
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Affiliation(s)
- Jie Hu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
- Department of Critical Care Medicine, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Stefano Spina
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Francesco Zadek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Nikolay O Kamenshchikov
- Department of Anesthesia and Critical Care Medicine, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk, 634012, Russia
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Juan Pedemonte
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
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25
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Zadek F, Spina S, Hu J, Berra L. Nitric Oxide Treatment for Lungs and Beyond. Novel Insights from Recent Literature. Am J Respir Crit Care Med 2019; 200:628-630. [PMID: 31185176 DOI: 10.1164/rccm.201901-0037rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Francesco Zadek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Stefano Spina
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jie Hu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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26
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Spina S, Lei C, Pinciroli R, Berra L. Hemolysis and Kidney Injury in Cardiac Surgery: The Protective Role of Nitric Oxide Therapy. Semin Nephrol 2019; 39:484-495. [DOI: 10.1016/j.semnephrol.2019.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Wu D, Ghanta RK. Commentary: Just say NO? Does nitric oxide improve myocardial protection during cardiac surgery? J Thorac Cardiovasc Surg 2018; 157:2337-2338. [PMID: 30470539 DOI: 10.1016/j.jtcvs.2018.10.044] [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: 10/10/2018] [Accepted: 10/10/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Darrell Wu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Ravi K Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
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28
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Mehaffey JH, Hawkins RB. Commentary: Nitric oxide: Might make it better? J Thorac Cardiovasc Surg 2018; 157:2339. [PMID: 30314687 DOI: 10.1016/j.jtcvs.2018.08.070] [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: 08/30/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
Affiliation(s)
- J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
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