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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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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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3
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Qu X, Sun X, Hu S. Analysis of the effect of multimedia-assisted psychological nursing in perioperative period of cardiac surgery with cardiopulmonary bypass. Panminerva Med 2021; 64:308-309. [PMID: 34240834 DOI: 10.23736/s0031-0808.21.04418-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Xueqin Qu
- Cardiovascular Surgery Intensive Care Unit, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xiaoning Sun
- Cardiovascular Surgery Intensive Care Unit, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shaojuan Hu
- Cardiovascular Surgery Intensive Care Unit, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China -
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Vos JJ, Scheeren TWL. Intraoperative hypotension and its prediction. Indian J Anaesth 2019; 63:877-885. [PMID: 31772395 PMCID: PMC6868662 DOI: 10.4103/ija.ija_624_19] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/17/2019] [Accepted: 10/06/2019] [Indexed: 12/11/2022] Open
Abstract
Intraoperative hypotension (IOH) very commonly accompanies general anaesthesia in patients undergoing major surgical procedures. The development of IOH is unwanted, since it is associated with adverse outcomes such as acute kidney injury and myocardial injury, stroke and mortality. Although the definition of IOH is variable, harm starts to occur below a mean arterial pressure (MAP) threshold of 65 mmHg. The odds of adverse outcome increase for increasing duration and/or magnitude of IOH below this threshold, and even short periods of IOH seem to be associated with adverse outcomes. Therefore, reducing the hypotensive burden by predicting and preventing IOH through proactive appropriate treatment may potentially improve patient outcome. In this review article, we summarise the current state of the prediction of IOH by the use of so-called machine-learning algorithms. Machine-learning algorithms that use high-fidelity data from the arterial pressure waveform, may be used to reveal 'traits' that are unseen by the human eye and are associated with the later development of IOH. These algorithms can use large datasets for 'training', and can subsequently be used by clinicians for haemodynamic monitoring and guiding therapy. A first clinically available application, the hypotension prediction index (HPI), is aimed to predict an impending hypotensive event, and additionally, to guide appropriate treatment by calculated secondary variables to asses preload (dynamic preload variables), contractility (dP/dtmax), and afterload (dynamic arterial elastance, Eadyn). In this narrative review, we summarise the current state of the prediction of hypotension using such novel, automated algorithms and we will highlight HPI and the secondary variables provided to identify the probable origin of the (impending) hypotensive event.
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Affiliation(s)
- Jaap J Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Does permissive hypoxaemia during extracorporeal membrane oxygenation cause long-term neurological impairment?: A study in patients with H1N1-induced severe respiratory failure. Eur J Anaesthesiol 2018; 34:98-103. [PMID: 28030441 DOI: 10.1097/eja.0000000000000544] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Extracorporeal Life Support Organisation accepts permissive hypoxaemia in adult patients during extracorporeal membrane oxygenation (ECMO). The neurological long-term outcome of this approach has not yet been studied. OBJECTIVES We investigated the prevalence of brain lesions and cognitive dysfunction in survivors from the Influenza A/H1N1 2009 pandemic treated with permissive hypoxaemia during ECMO for severe acute respiratory distress syndrome (ARDS). Our hypothesis was that this method is reasonable if tissue hypoxia is avoided. DESIGN Long-term follow-up study after ECMO. SETTING Karolinska University Hospital, Sweden, from October 2012 to July 2013. PATIENTS Seven patients treated with ECMO for severe influenza A/H1N1-induced ARDS were studied 3.2 years after treatment. Blood lactate concentrations were used as a surrogate for tissue oxygenation. INTERVENTIONS Neurocognitive outcome was studied with standardised cognitive tests and MRI of the brain. MAIN OUTCOME MEASURES Cognitive functioning and hypoxic brain lesions after permissive hypoxaemia during ECMO. The observation period was the first 10 days of ECMO or the entire treatment period if shorter than 10 days. RESULTS Eleven of 13 patients were still alive 3 years after ECMO. We were able to contact seven of these patients (mean age 31 years), who all agreed to participate in this study. Mean ± SD peripherally measured arterial saturation during the observation period was 79 ± 10%. Full-scale Intelligence Quotient was within one standard deviation or above from the mean of a healthy population in five patients, and was 1.5 SD below the mean in one patient. In one other patient, it could not be determined because of a lack of formal education. Memory functioning was normal in all patients. MRI showed no changes related to cerebral hypoxia. CONCLUSIONS Permissive hypoxaemia during ECMO might not negatively affect long-term cognitive outcome if adequate organ perfusion is maintained. TRIAL REGISTRATION at Clinicaltrials.gov NCT01763060.
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Low perfusion pressure is associated with renal tubular injury in infants undergoing cardiac surgery with cardiopulmonary bypass. Eur J Anaesthesiol 2018; 35:581-587. [DOI: 10.1097/eja.0000000000000782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Srinivasan AJ, Kausch K, Inglut C, Gray A, Landrigan M, Poisson JL, Schroder JN, Welsby IJ. Estimation of Achievable Oxygen Consumption Following Transfusion With Rejuvenated Red Blood Cells. Semin Thorac Cardiovasc Surg 2018; 30:134-141. [PMID: 29432891 DOI: 10.1053/j.semtcvs.2018.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 11/11/2022]
Abstract
Erythrocyte storage induces a nonphysiological increase in hemoglobin-oxygen affinity (quantified by low p50, the oxygen tension at 50% hemoglobin saturation), which can be restored through biochemical rejuvenation. The objective was to mathematically model the impact of transfusing up to 3 standard allogeneic units or rejuvenated units on oxygen delivery (DO2) and oxygen consumption (VO2). Oxygen dissociation curves were generated from additive solution-1 red blood cell (RBC) leukoreduced units (n = 7) before and after rejuvenation following manufacturer's instructions. Two of these units were used to prepare standard or rejuvenated donor RBC and added to samples of fresh whole blood. These admixtures were used to construct an in vitro transfusion model of postoperative anemia and determine a linear equation for calculating the sample p50, which was subsequently used to calculate DO2 and VO2 after simulated transfusions. Whole blood-packed red blood cell unit admixture p50s could be predicted from a linear model including the p50 of its components, the mass fraction of the transfused component, and interaction terms (R2 = .99, P < 0.001). Transfusion with standard units slightly, but significantly, increased projected DO2 compared with rejuvenated units (P = 0.03), but rejuvenated units markedly increased projected VO2 (P = 0.03). Standard units did not significantly change VO2 relative to pre-transfusion levels (P > 0.1). Using high-p50, rejuvenated RBC in simulated transfusions greatly improved projected VO2, indicating the potential for increased end-organ oxygen availability compared with standard transfusion. Patient capacity to increase cardiac output after cardiac surgery may be limited. Transfusing high-p50 RBC in this setting may improve the perioperative care of these patients.
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Affiliation(s)
| | | | | | - Alan Gray
- Citra Labs. LLC (a Zimmer Biomet company), Braintree, Massachusetts
| | | | - Jessica L Poisson
- Duke University Transfusion Service, Department of Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Ian J Welsby
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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Thomassen SA, Kjærgaard B, Alstrup AKO, Munk OL, Frøkiær J, Larsson A, Rasmussen BS. Cerebral blood flow measured by positron emission tomography during normothermic cardiopulmonary bypass: an experimental porcine study. Perfusion 2018; 33:346-353. [PMID: 29380669 DOI: 10.1177/0267659118755271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mean arterial blood pressure (MAP) and/or pump flow during normothermic cardiopulmonary bypass (CPB) are the most important factors of cerebral perfusion. The aim of this study was to explore the influence of CPB blood flow on cerebral blood flow (CBF) measured by dynamic positron emission tomography (PET) using 15O-labelled water with no pharmacological interventions to maintain the MAP. METHODS Eight pigs (69-71 kg) were connected to normothermic CPB. After 60 minutes (min) with a CPB pump flow of 60 mL/kg/min, the pigs were changed to either 35 mL/kg/min or 47.5 mL/kg/min for 60 min and, thereafter, all the pigs returned to 60 mL/kg/min for another 60 min. The MAP was measured continuously and the CBF was measured by positron emission tomography (PET) during spontaneous circulation and at each CPB pump flow after 30 min of steady state. RESULTS Two pigs were excluded due to complications. CBF increased from spontaneous circulation to a CPB pump flow of 60 mL/kg/min. A reduction in CPB pump flow to 47.5 mL/kg/min (n=3) resulted in only minor changes in CBF while a reduction to 35 mL/kg/min (n=3) caused a pronounced change (correlation coefficient (R2) 0.56). A return of CPB pump flow to 60 mL/kg/min was followed by an increase in CBF, except in the one pig with the lowest CBF during low flow (R2=0.44). CBF and MAP were not correlated (R2=0.20). CONCLUSION In this experimental porcine study, a relationship was observed between pump flow and CBF under normothermic low-flow CPB. The effect of low pump flow on MAP showed substantial variations, with no correlation between CBF and MAP.
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Affiliation(s)
- Sisse Anette Thomassen
- 1 Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark.,2 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Benedict Kjærgaard
- 2 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,3 Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - Ole Lajord Munk
- 4 Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Aalborg, Denmark
| | - Jørgen Frøkiær
- 4 Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Aalborg, Denmark
| | - Anders Larsson
- 5 Department of Anaesthesiology and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Bodil Steen Rasmussen
- 1 Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark.,2 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Thomassen SA, Kjærgaard B, Olsen Alstrup AK, Munk OL, Frøkiær J, Larsson A, Rasmussen BS. Muscle Tissue Saturation Compared With Muscle Tissue Perfusion During Low Blood Flows: An Experimental Study. J Cardiothorac Vasc Anesth 2017; 31:2065-2071. [DOI: 10.1053/j.jvca.2017.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Indexed: 01/09/2023]
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Nenna A, Barbato R, Greco SM, Pugliese G, Lusini M, Covino E, Chello M. Near-infrared spectroscopy in adult cardiac surgery: between conflicting results and unexpected uses. J Geriatr Cardiol 2017; 14:659-661. [PMID: 29321795 PMCID: PMC5756738 DOI: 10.11909/j.issn.1671-5411.2017.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/13/2017] [Accepted: 10/17/2017] [Indexed: 12/04/2022] Open
Affiliation(s)
- Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Raffaele Barbato
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Giuseppe Pugliese
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Mario Lusini
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Elvio Covino
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Rettig TC, Peelen LM, Geuzebroek GS, van Klei WA, Boer C, van der Veer JW, Hofland J, van de Garde EM, Noordzij PG. Impact of Intraoperative Hypotension During Cardiopulmonary Bypass on Acute Kidney Injury After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2017; 31:522-528. [DOI: 10.1053/j.jvca.2016.07.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Indexed: 01/18/2023]
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Mayer B, Pohl M, Hummler HD, Schmid MB. Cerebral oxygenation and desaturations in preterm infants - a longitudinal data analysis. J Neonatal Perinatal Med 2017; 10:267-273. [PMID: 28854512 DOI: 10.3233/npm-16124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Hypoxemic episodes commonly occur in very preterm infants and may be associated with several adverse effects. Cerebral tissue oxygen saturation (StO2) as measured by near infrared spectroscopy (NIRS) may be a useful measure to assess brain oxygenation. However, knowledge on variability of StO2 is limited in preterm infants at this time, so StO2 dependency on arterial oxygenation (SpO2) and heart rate (HR) was assessed in preterm infants using statistical methods of time series analysis. STUDY DESIGN StO2, SpO2, and HR were recorded from 15 preterm infants every 2 seconds for six hours. Statistical methods of time series and longitudinal data analysis were applied to the data. RESULT The mean StO2 level was found as 72% (95% confidence interval (CI) 55.5% -85.5%) based on a moving average process with a 5 minute order. Accordingly, longitudinal SpO2 measurements showed a mean level of 91% (95% CI 69% -98%). Generally, compensation strategies to cope with both StO2 and SpO2 desaturations were observed in the studied patients. SpO2 had a significant effect on cerebral oxygenation (p < 0.001), but HR did not, which led to inconclusive results considering different time intervals. CONCLUSION In infants with intermittent hypoxemia and bradycardia, we found a mean StO2 level of 72% and a strong correlation with SpO2. We observed large differences between individuals in the ability to maintain StO2 at a stable level.
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Affiliation(s)
- Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Germany
| | - Moritz Pohl
- Institute of Epidemiology and Medical Biometry, Ulm University, Germany
| | - Helmut D Hummler
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology and Pediatric Intensive Care, Ulm University Medical Centre, Germany
| | - Manuel B Schmid
- Clinic for Neonatology, University Hospital Zurich, Switzerland
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Thomassen SA, Kjærgaard B, Sørensen P, Andreasen JJ, Larsson A, Rasmussen BS. Regional muscle tissue saturation is an indicator of global inadequate circulation during cardiopulmonary bypass: a randomized porcine study using muscle, intestinal and brain tissue metabolomics. Perfusion 2016; 32:192-199. [DOI: 10.1177/0267659116674271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Muscle tissue saturation (StO2) measured with near-infrared spectroscopy has generally been considered a measurement of the tissue microcirculatory condition. However, we hypothesized that StO2 could be more regarded as a fast and reliable measure of global than of regional circulatory adequacy and tested this with muscle, intestinal and brain metabolomics at normal and two levels of low cardiopulmonary bypass blood flow rates in a porcine model. Methods: Twelve 80 kg pigs were connected to normothermic cardiopulmonary bypass with a blood flow of 60 mL/kg/min for one hour, reduced randomly to 47.5 mL/kg/min (Group I) or 35 mL/kg/min (Group II) for one hour followed by one hour of 60 mL/kg/min in both groups. Regional StO2 was measured continuously above the musculus gracilis (non-cannulated leg). Metabolomics were obtained by brain tissue oxygen monitoring system (Licox) measurements of the brain and microdialysis perfusate from the muscle, intestinal mucosa and brain. A non-parametric statistical method was used. Results: The systemic parameters showed profound systemic ischaemia during low CPB blood flow. StO2 did not change markedly in Group I, but in Group II, StO2 decreased immediately when blood flow was reduced and, furthermore, was not restored despite blood flow being normalized. Changes in the metabolomics from the muscle, colon and brain followed the changes in StO2. Conclusion: We found, in this experimental cardiopulmonary bypass model, that StO2 reacted rapidly when the systemic circulation became inadequate and, furthermore, reliably indicate insufficient global tissue perfusion even when the systemic circulation was restored after a period of systemic hypoperfusion.
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Affiliation(s)
- Sisse Anette Thomassen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Benedict Kjærgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Preben Sørensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
| | - Jan Jesper Andreasen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Anders Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Abstract
There is no single optimal set of conditions for cardio pulmonary bypass. What is optimal is determined by patient factors, surgical need, and the mechanics of perfusion. Additionally, the best way to manage bypass typically varies over its course.
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Affiliation(s)
- David J. Cook
- Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, MN
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Funk DJ, Kumar A, Klar G. Decreases in cerebral saturation in patients with septic shock are associated with increased risk of death: a prospective observational single center study. J Intensive Care 2016; 4:42. [PMID: 27366323 PMCID: PMC4928281 DOI: 10.1186/s40560-016-0167-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 06/21/2016] [Indexed: 12/18/2022] Open
Abstract
Background The mortality rate from septic shock has been declining. Cerebral hypoxia, measured non-invasively with cerebral oximetry, has been correlated with neurologic and non-neurologic sequelae. Whether cerebral desaturations occur in septic shock patients and what consequences these may have is untested. Methods Adult patients with septic shock had cerebral saturation monitoring initiated. The primary objective was to determine if the incidence and magnitude of cerebral desaturations in septic shock patients correlated with delirium. We also compared the incidence and magnitude of cerebral desaturations in patients with septic shock with patients undergoing high-risk non-cardiac surgical procedures, a group known to be at high risk for cerebral desaturations. Results Fifteen patients were enrolled. Twelve (80 %) patients had a decrease in SctO2 below 65 %. Delirium was not associated with the area under the curve of an SctO2 of 65 % (p = 0.84). Patients who died of septic shock had more significant decreases in SctO2 than those who survived (p = 0.04). Decreased SctO2 was more common in patients with septic shock and was of greater magnitude than those undergoing high-risk non-cardiac surgery. Conclusions Cerebral desaturations occur more commonly and are of a greater magnitude in septic shock patients compared with those undergoing high-risk non-cardiac surgery. There did not appear to be a relationship between the incidence or magnitude of decreases in SctO2 and ICU delirium. Patients who died of septic shock had more significant decreases in SctO2 than patients who survived.
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Affiliation(s)
- Duane J Funk
- University of Manitoba, Winnipeg, Canada ; Department of Medicine, Section of Critical Care, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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Cerebral Autoregulation Monitoring with Ultrasound-Tagged Near-Infrared Spectroscopy in Cardiac Surgery Patients. Anesth Analg 2016; 121:1187-93. [PMID: 26334746 DOI: 10.1213/ane.0000000000000930] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Individualizing mean arterial blood pressure (MAP) based on cerebral blood flow (CBF) autoregulation monitoring during cardiopulmonary bypass (CPB) holds promise as a strategy to optimize organ perfusion. The purpose of this study was to evaluate the accuracy of cerebral autoregulation monitoring using microcirculatory flow measured with innovative ultrasound-tagged near-infrared spectroscopy (UT-NIRS) noninvasive technology compared with transcranial Doppler (TCD). METHODS Sixty-four patients undergoing CPB were monitored with TCD and UT-NIRS (CerOx™). The mean velocity index (Mx) was calculated as a moving, linear correlation coefficient between slow waves of TCD-measured CBF velocity and MAP. The cerebral flow velocity index (CFVx) was calculated as a similar coefficient between slow waves of cerebral flow index measured using UT-NIRS and MAP. When MAP is outside the autoregulation range, Mx is progressively more positive. Optimal blood pressure was defined as the MAP with the lowest Mx and CFVx. The right- and left-sided optimal MAP values were averaged to define the individual optimal MAP and were the variables used for analysis. RESULTS The Mx for the left side was 0.31 ± 0.17 and for the right side was 0.32 ± 0.17. The mean CFVx for the left side was 0.33 ± 0.19 and for the right side was 0.35 ± 0.19. Time-averaged Mx and CFVx during CPB had a statistically significant "among-subject" correlation (r = 0.39; 95% confidence interval [CI], 0.22-0.53; P < 0.001) but had only a modest agreement within subjects (bias 0.03 ± 0.20; 95% prediction interval for the difference between Mx and CFVx, -0.37 to 0.42). The MAP with the lowest Mx and CFVx ("optimal blood pressure") was correlated (r = 0.71; 95% CI, 0.56-0.81; P < 0.0001) and was in modest within-subject agreement (bias -2.85 ± 8.54; 95% limits of agreement for MAP predicted by Mx and CFVx, -19.60 to 13.89). Coherence between ipsilateral middle CBF velocity and cerebral flow index values averaged 0.61 ± 0.07 (95% CI, 0.59-0.63). CONCLUSIONS There was a statistically significant correlation and agreement between CBF autoregulation monitored by CerOx compared with TCD-based Mx.
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Should Cerebral Near-infrared Spectroscopy be Standard of Care in Adult Cardiac Surgery? Heart Lung Circ 2015; 24:544-50. [DOI: 10.1016/j.hlc.2015.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 01/19/2015] [Indexed: 11/18/2022]
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Thiele RH, Bartels K, Gan TJ. Inter-device differences in monitoring for goal-directed fluid therapy. Can J Anaesth 2014; 62:169-81. [PMID: 25391734 DOI: 10.1007/s12630-014-0265-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 10/24/2014] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Goal-directed fluid therapy is an integral component of many Enhanced Recovery After Surgery (ERAS) protocols currently in use. The perioperative clinician is faced with a myriad of devices promising to deliver relevant physiologic data to better guide fluid therapy. The goal of this review is to provide concise information to enable the clinician to make an informed decision when choosing a device to guide goal-directed fluid therapy. PRINCIPAL FINDINGS The focus of many devices used for advanced hemodynamic monitoring is on providing measurements of cardiac output, while other, more recent, devices include estimates of fluid responsiveness based on dynamic indices that better predict an individual's response to a fluid bolus. Currently available technologies include the pulmonary artery catheter, esophageal Doppler, arterial waveform analysis, photoplethysmography, venous oxygen saturation, as well as bioimpedance and bioreactance. The underlying mechanistic principles for each device are presented as well as their performance in clinical trials relevant for goal-directed therapy in ERAS. CONCLUSIONS The ERAS protocols typically involve a multipronged regimen to facilitate early recovery after surgery. Optimizing perioperative fluid therapy is a key component of these efforts. While no technology is without limitations, the majority of the currently available literature suggests esophageal Doppler and arterial waveform analysis to be the most desirable choices to guide fluid administration. Their performance is dependent, in part, on the interpretation of dynamic changes resulting from intrathoracic pressure fluctuations encountered during mechanical ventilation. Evolving practice patterns, such as low tidal volume ventilation as well as the necessity to guide fluid therapy in spontaneously breathing patients, will require further investigation.
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Affiliation(s)
- Robert H Thiele
- Technology in Anesthesia & Critical Care Group, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, Departments of Anesthesiology and Biomedical Engineering, University of Virginia School of Medicine, P.O. Box 800710-0710, Charlottesville, VA, 22908-0710, USA,
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Sørensen H, Rasmussen P, Sato K, Persson S, Olesen N, Nielsen H, Olsen N, Ogoh S, Secher N. External carotid artery flow maintains near infrared spectroscopy-determined frontal lobe oxygenation during ephedrine administration. Br J Anaesth 2014; 113:452-8. [DOI: 10.1093/bja/aet481] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Grocott HP, Davie SN. Future uncertainties in the development of clinical cerebral oximetry. Front Physiol 2013; 4:360. [PMID: 24385967 PMCID: PMC3866380 DOI: 10.3389/fphys.2013.00360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 11/22/2013] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hilary P Grocott
- Department of Anesthesia & Perioperative Medicine, University of Manitoba Winnipeg, MB, Canada ; Department of Surgery, University of Manitoba Winnipeg, MB, Canada
| | - Sophie N Davie
- Department of Anesthesia & Perioperative Medicine, University of Manitoba Winnipeg, MB, Canada
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Microcirculatory perfusion shift in the gut wall layers induced by extracorporeal circulation. J Vasc Surg 2013; 61:497-503. [PMID: 24275079 DOI: 10.1016/j.jvs.2013.10.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/27/2013] [Accepted: 10/10/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Extracorporeal circulation (ECC) is regularly applied to maintain organ perfusion during major aortic and cardiovascular surgery. During thoracoabdominal aortic repair, ECC-driven selective visceral arterial perfusion (SVP) results in changed microcirculatory perfusion (shift from the muscularis toward the mucosal small intestinal layer) in conjunction with macrohemodynamic hypoperfusion. The underlying mechanism, however, is unclear. Therefore, the aim of this study was to assess in a porcine model whether ECC itself or the hypoperfusion induced by SVP is responsible for the mucosal/muscular shift in the small intestinal wall. METHODS A thoracoabdominal aortic approach was performed in 15 healthy pigs divided equally into three groups: group I, control; group II, thoracic aortic cross-clamping with distal aortic perfusion; and group III, thoracic aortic cross-clamping with distal aortic perfusion and SVP. Macrocirculatory and microcirculatory blood flow was assessed by transit time ultrasound volume flow measurement and fluorescent microspheres. In addition, markers for metabolism and intestinal ischemia-reperfusion injury were determined. RESULTS ECC with a roller pump induced a significant switch from the muscularis and mucosal layer of the small intestine, even with adequate macrocirculation (mucosal/muscular perfusion ratio: group I vs II, P = .005; group I vs III, P = .0018). Furthermore, the oxygen extraction ratio increased significantly in groups II (>30%) and III (>40%) in the beginning of the ECC compared with the control (group I vs II, P = .0037; group I vs III, P = .0062). Lactate concentrations and pH values did not differ between groups I and II; but group III demonstrated a significant shifting toward a lactate-associated acidosis (lactate: group I vs III, P = .0031; pH: group I vs III, P = .0001). CONCLUSIONS We demonstrated a significant shifting between the small intestinal gut wall layers induced by roller pump-driven ECC. The shift occurs independently of macrohemodynamics, with a significant effect on aerobic metabolism in the gut wall. Consequently, an optimal intestinal perfusion cannot be guaranteed by a roller pump; therefore, perfusion techniques need to be optimized.
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Mandak J, Brzek V, Svitek V, Dergel M, Lago Chek J, Volt M, Horak M, Kubicek J, Lonsky V. Peripheral tissue oxygenation during standard CPB and miniaturized CPB (direct oxymetric tissue perfusion monitoring study). Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:81-9. [DOI: 10.5507/bp.2012.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 01/03/2012] [Indexed: 11/23/2022] Open
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Forti A, Comin A, Lazzarotto N, Battistella G, Salandin V, Sorbara C. Pump Flow Changes Do Not Impair Sublingual Microcirculation During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2012; 26:785-90. [DOI: 10.1053/j.jvca.2012.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Indexed: 11/11/2022]
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Isetta C, Janot N. [Vasomotor tone and CBP : monitoring components, pratical and therapeutic approaches]. ACTA ACUST UNITED AC 2012; 31 Suppl 1:S40-7. [PMID: 22721521 DOI: 10.1016/s0750-7658(12)70054-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The vasomotor tone is an essential determinant of blood pressure. Vascular resistance is the result of a calculation including vasomotor tone, blood flow and blood viscosity. The vascular tone is modulated by the sympathetic system and the direct actions of drugs (patient's pathology, anaesthesia). The pressure and flow allow the vascular tone apprehension. A decrease in vasomotor tone lowers the mean arterial pressure and may cause an intense vasoplegia with arterial vascular resistance below than 800 dyn/s/cm(5) leading to a lack of tissue oxygenation. Vasomotor paralysis can be caused by the patient medications or an intense inflammatory reaction starting at the extracorporeal circulation onset. Monitoring parameters of extracorporeal circulation such as pressure, flow, arterial and venous oxygen saturation, blood level in the venous reservoir, and extensively blood gases, haemoglobin, CO(2) partial pressure level of the oxygenator vent, bispectral index, and oxygen saturation of cerebral tissue are reviewed. They will know the vasoplegia consequences and bear an indication of adequate tissue oxygenation. It may be obtained by using vasopressors (ephedrine, norepinephrine, terbutalin and vasopressin) methylene blue, increasing blood viscosity (erythrocytes) and blood flow, even by inducing hypothermia.
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Affiliation(s)
- C Isetta
- Anesthésie Réanimation, IDE Perfusionniste Unité de Circulation Extra Corporelle, Chirurgie Cardio-vasculaire et Thoracique, CHU Pierre Zobda-Quitman, La Meynard, 97200 Fort de France.
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Vassalos A, Young D, MacArthur K, Pollock J, Lyall F, Danton MHD. Cystatin C: influence of perfusion and myocardial injury on early (<24 h) renal function after pediatric cardiac surgery. Paediatr Anaesth 2011; 21:1185-91. [PMID: 21831111 DOI: 10.1111/j.1460-9592.2011.03654.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB)-associated renal dysfunction following cardiac surgery is well recognized. In patients with renal disease, cystatin C has emerged as a new biomarker which in contrast to creatinine (Cr) is sensitive to minor changes in glomerular filtration rate (GFR). AIM We utilized cystatin C to investigate the association of CPB perfusion parameters with acute renal injury after pediatric cardiac surgery. METHODS Twenty children, aged 4-58 months (AVSD, n = 7; VSD, n = 9; and ASD, n = 4), were prospectively studied. Glomerular filtration rate was quantified postoperatively by creatinine clearance (first and second 12-h periods; CrCl(0-12) and CrCl(12-24) ). Serum cystatin C and Cr were measured preoperatively and on days 0-3. Recorded CPB parameters included bypass duration (BP), perfusion pressure (PP), lowest pump flow (Q(min) ), lowest hematocrit, and corresponding lowest oxygen delivery (DO(2 min) ). Myocardial injury was determined by troponin-I. RESULTS Postoperatively, GFR remained unchanged (CrCl(0-12) 63.6 ± 37.0 vs CrCl(12-24) 65.1 ± 27.5; P = 0.51) and only correlated with cystatin C (CrCl(0-12) vs cystatin C(Day 0) [r = 0.58, P = 0.018] and Cr(Day 0) [r = 0.09, P = 0.735]). Cr and cystatin C increased postoperatively to peak on days 2 and 3, respectively (Cr(PreOp) 31 ± 6.9 vs Cr(Day 2) 36.9 ± 12.2, P = 0.03; cystatin C(Day 0) 0.83 ± 0.27 vs cystatin C(Day 3) 1.45 ± 0.53, P = 0.02). Increased cystatin C was significantly associated with BP (P = 0.001), mean PP (P = 0.029), Q(min) (P = 0.005), troponin-I (P < 0.001), and DO(2 min) <300 ml·min(-1) ·m(-2) (P = 0.007). Receiver-operator cutoff >1.044 mg·l(-1) for cystatin C exhibited 100% sensitivity and 67% specificity for detecting renal dysfunction, defined as GFR <55 ml·min(-1) ·1.73 m(-2). CONCLUSIONS Cystatin C is a sensitive marker of early renal dysfunction following pediatric heart surgery. Variations in bypass parameters, myocardial injury, and ultimately critical oxygen delivery are significantly associated with the degree of renal impairment.
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Affiliation(s)
- Antony Vassalos
- Royal Hospital for Sick Children, Yorkhill Division, Glasgow, UK
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Thomassen SA, Larsson A, Andreasen JJ, Bundgaard W, Boegsted M, Rasmussen BS. Should blood flow during cardiopulmonary bypass be individualized more than to body surface area? Perfusion 2010; 26:45-50. [DOI: 10.1177/0267659110382062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood flow during cardiopulmonary bypass (CPB) is calculated on body surface area (BSA). Increasing comorbidity, age and weight of today’s cardiac patients question this calculation as it may not reflect individual metabolic requirement. The hypothesis was that a measured cardiac index (CI) prior to normothermic CPB is a better estimate. A cross-over study, with random allocation to CPB blood flow for 20 minutes based on either a calculation (2.4 L/min/m2) or on CI, with a switch to the opposite flow for another 20 minutes, was performed. Twenty-two elective cardiac surgery patients with normal ventricular function were included. Effect parameters were cerebral oxygenation, mixed venous saturation and arterial lactate. CI varied from 1.9 to 3.1 L/min/m2 (median 2.4 L/min/m2). No differences in effect parameters were seen. In conclusion, a CPB blood flow based on an individual estimate did not improve cerebral and systemic oxygenation compared to a blood flow based on BSA.
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Affiliation(s)
- SA Thomassen
- Department of Anaesthesia, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Denmark,
| | - A. Larsson
- Department of Anaesthesiology and Intensive Care, Uppsala University, Sweden
| | - JJ Andreasen
- Department of Cardiothoracic Surgery, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Denmark
| | - W. Bundgaard
- Department of Cardiothoracic Surgery, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Denmark
| | - M. Boegsted
- Department of Haematology, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Denmark
| | - BS Rasmussen
- Department of Anaesthesia, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Denmark
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Cook DJ. CON: Temperature Regimens and Neuroprotection During Cardiopulmonary Bypass: Does Rewarming Rate Matter? Anesth Analg 2009; 109:1733-7. [DOI: 10.1213/ane.0b013e3181b89414] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Murphy GS, Hessel EA, Groom RC. Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach. Anesth Analg 2009; 108:1394-417. [DOI: 10.1213/ane.0b013e3181875e2e] [Citation(s) in RCA: 233] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Maier S, Hasibeder W, Hengl C, Pajk W, Schwarz B, Margreiter J, Ulmer H, Engl J, Knotzer H. Effects of phenylephrine on the sublingual microcirculation during cardiopulmonary bypass. Br J Anaesth 2009; 102:485-91. [DOI: 10.1093/bja/aep018] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Murphy GJ, Angelini GD. Indications for Blood Transfusion in Cardiac Surgery. Ann Thorac Surg 2006; 82:2323-34. [PMID: 17126171 DOI: 10.1016/j.athoracsur.2006.06.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 06/09/2006] [Accepted: 06/12/2006] [Indexed: 01/29/2023]
Abstract
In addition to its life-saving effect in hemorrhagic shock, transfusion of allogenic packed red blood cells can be beneficial in situations where a critically low hematocrit is contributing to a state of oxygen-supply dependency. These benefits are countered by the risks of transfusion-associated lung injury, transfusion-associated immunomodulation, and cellular hypoxia after RBC transfusion. The critical hematocrit is patient and organ specific, and varies intraoperatively according to the duration and temperature of bypass, as well as for a variable postoperative period. Future randomized studies must prospectively evaluate regional indicators of tissue oxygenation in transfusion algorithms.
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Affiliation(s)
- Gavin J Murphy
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom.
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Brondén B, Dencker M, Allers M, Plaza I, Jönsson H. Differential Distribution of Lipid Microemboli After Cardiac Surgery. Ann Thorac Surg 2006; 81:643-8. [PMID: 16427867 DOI: 10.1016/j.athoracsur.2005.08.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Revised: 07/30/2005] [Accepted: 08/15/2005] [Indexed: 01/09/2023]
Abstract
BACKGROUND Lipid microemboli found in shed blood during cardiac surgery have been shown to block capillaries of the brain postoperatively. In this study, the distribution of lipid microemboli in different regions of the brain and other organs was examined. A novel porcine model using radioactive lipid particles was used. METHODS Ten animals (2 controls and 8 cases) were anesthetized and put on cardiopulmonary bypass. A shed-blood phantom was produced from arterial blood, saline, and tritium-labeled triolein. The phantom was infused into the cardiopulmonary bypass circuit. Tissue samples were taken postmortem from examined organs and prepared for scintillation counting. Levels of radioactivity were used as a measure of the uptake of lipid microemboli. RESULTS High levels of radioactivity were found in kidney and spleen (5 to 10 times higher than in the other organs investigated). In the brain, radioactivity was found in all regions examined. The gray matter of cerebrum showed the highest level of the regions examined. CONCLUSIONS This study shows that embolization of lipids is not a phenomenon restricted to the brain, but affected all the organs examined. The high levels found in the kidneys, and the relatively high levels in the gray matter of the cerebrum further legitimize the debate on the impact lipid microemboli has on postoperative kidney and cognitive dysfunction.
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Affiliation(s)
- Björn Brondén
- Department of Cardiothoracic Anesthesiology, Center for Heart and Lung Disease, Lund University Hospital, Lund, Sweden
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Van der Linden PJ, De Hert SG, Belisle S, Sahar G, Deltell A, Bekkrar Y, Blauwaert M, Vincent JL. Critical oxygen delivery during cardiopulmonary bypass in dogs. Eur J Anaesthesiol 2006; 23:10-6. [PMID: 16390559 DOI: 10.1017/s0265021505001699] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2005] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine the minimal oxygen delivery and pump flow that can maintain systemic oxygen uptake during normothermic (37 degrees C) pulsatile and non-pulsatile cardiopulmonary bypass in dogs. METHODS Eighteen anaesthetized dogs were randomly assigned to receive either non-pulsatile (Group C; n = 9) or pulsatile bypass flow (Group P; n = 9). Oxygen delivery was reduced by a progressive decrease in pump flow, while arterial oxygen content was maintained constant. In each animal, critical oxygen delivery was determined from plots of oxygen uptake vs. oxygen delivery and from plots of blood lactate vs. oxygen delivery using a least sum of squares technique. Critical pump flow was determined from plots of lactate vs. pump flow. RESULTS At the critical point, oxygen delivery obtained from oxygen uptake was 7.7 +/- 1.1 mL min(-1) kg(-1) in Group C and 6.8 +/- 1.8 mL min(-1) kg(-1) in Group P (n.s.). These values were similar to those obtained from lactate measurements (Group C: 7.8 +/- 1.6 mL min(-1) kg(-1); Group P: 7.6 +/- 2.0 mL min(-1) kg(-1)). Critical pump flows determined from lactate measurements were 55.6 +/- 13.8 mL min(-1) kg(-1) in Group C and 60.8 +/- 13.9 mL min(-1) kg(-1) in Group P (n.s.). CONCLUSIONS Oxygen delivery values greater than 7-8 mL min(-1) kg(-1) were required to maintain oxygen uptake during normothermic cardiopulmonary bypass with either pulsatile or non-pulsatile blood flow. Elevation of blood lactate levels during bypass helps to identify inadequate tissue oxygen delivery related to insufficient pump flow.
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Affiliation(s)
- P J Van der Linden
- Charleroi University Hospital, Department of Cardiac Anaesthesia (now CHU-Brugmann, Department of Anaesthesiology, Brussels), Charleroi, Belgium
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Sato K, Sogawa M, Namura O, Hayashi JI. Deterioration of Body Oxygen Metabolism by Vasodilator and/or Vasoconstrictor Administration during Cardiopulmonary Bypass. ASAIO J 2006; 52:96-9. [PMID: 16436897 DOI: 10.1097/01.mat.0000194094.81548.e8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
During cardiopulmonary bypass (CPB), tissue perfusion injury occurs even if perfusion pressure is maintained. Although a vasodilator and a vasoconstrictor are clinically administered if bypass flow is maintained, they may restore perfusion pressure without improving tissue perfusion. We evaluated the influence of vasodilators and vasoconstrictors on the whole body during CPB. Fifty-six patients with valvular disease who received moderately hypothermic CPB without blood transfusion were divided into four groups, depending upon whether a vasodilator and/or a vasoconstrictor was administered, and postoperative data were compared. Bypass flow and aortic pressure were maintained at 2.4 l/min/m and 5090 mm Hg. Body weight, dilution, hematocrit level, CPB, and aortic clamp duration, blood temperature, bypass flow, perfusion pressure, base excess levels during CPB, cardiac index, arterial and mixed venous oxygen pressure, and alveolar-arterial oxygen distribution after CPB were comparable among the four groups. However, the time to extubation was significantly longer. Blood lactate levels, measured for patients returned to the ward, were significantly higher in the agent-administered groups than in the no-agent group, whereas blood lactate levels on extubation and blood creatinine levels on postoperative day 1 were comparable among the groups. Vasodilator and/or vasoconstrictor administration during CPB may deteriorate the body oxygen metabolism, which might imply tissue perfusion and worsen the complications induced by hypoperfusion during CPB.
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Affiliation(s)
- Koichi Sato
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi street 1-757, Niigata, Japan
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Abstract
Gastrointestinal complications occur in about 2.5% of patients undergoing cardiac surgery, are associated with a high mortality (about 33%), and account for nearly 15% (and perhaps increasing) of all postoperative deaths. The various complications and risk factors are reviewed. Splanchnic ischemia prior to, during, and especially postoperatively appears to be an important cause of these complications. In addition, splanchnic ischemia is hypothesized to be one cause of the systemic inflammatory response syndrome and multiorgan failure that may follow cardiac surgery. The physiology of splanchic perfusion and the effects of cardiac surgery, including cardiopulmonary bypass, on it are reviewed. Finally, possible methods to minimize splanchnic ischemia and reduce the incidence of abdominal complications are discussed.
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Affiliation(s)
- Eugene A Hessel
- University of Kentucky College of Medicine, Lexington, Kentucky, USA.
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Fanneløp T, Dahle GO, Matre K, Segadal L, Grong K. An anaesthetic protocol in the young domestic pig allowing neuromuscular blockade for studies of cardiac function following cardioplegic arrest and cardiopulmonary bypass. Acta Anaesthesiol Scand 2004; 48:1144-54. [PMID: 15352961 DOI: 10.1111/j.1399-6576.2004.00464.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neuromuscular blockade should, for ethical reasons, not be allowed in animal experiments unless the use is strongly motivated. Beforehand, the anaesthetic protocol must be documented without muscle relaxation in the species studied. Documentation is difficult to obtain from the scientific literature. When focusing on cardiac function over time, in particular, the ideal anaesthetic protocol should cause no or minor alterations in cardiac variables. METHODS We intended to document an anaesthetic protocol involving ventilation with N(2)O combined with loading doses and continuous infusions of pentobarbital, fentanyl and midazolam in seven pigs by applying potentially painful stimuli every 15 min for 7 h. Subsequently, left ventricular global and regional function was studied with conductance catheter and strain rate imaging by echocardiography in eight pigs with pancuronium included. RESULTS Pigs without pancuronium were completely immobilized and unresponsive to potentially painful stimuli and sternotomy, with no accumulation or degradation of anaesthetic agents. With pancuronium included, left ventricular preload gradually decreased together with reduction of cardiac index from 3.52 +/- 0.14 at 2 h to 2.84 +/- 0.11 L min(-1). m(-2) (+/-SEM) after 7 h of observation. Preload recruitable stroke work decreased after 7 h, whereas peak systolic strain in the anterior left ventricular wall and load-independent indices of diastolic function were not significantly altered. CONCLUSION In specific experimental protocols, the anaesthetic protocol described could allow the use of muscular paralysis in young domestic pigs, for instance when involving hypothermic cardiopulmonary bypass, cardioplegic arrest and reperfusion.
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Affiliation(s)
- T Fanneløp
- Surgical Research Laboratory, Department of Surgical Sciences, University of Bergen, Bergen, Norway.
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Soller BR, Idwasi PO, Balaguer J, Levin S, Simsir SA, Vander Salm TJ, Collette H, Heard SO. Noninvasive, near infrared spectroscopic-measured muscle pH and Po2 indicate tissue perfusion for cardiac surgical patients undergoing cardiopulmonary bypass*. Crit Care Med 2003; 31:2324-31. [PMID: 14501963 DOI: 10.1097/01.ccm.0000086999.21673.6a] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether near infrared spectroscopic measurement of tissue pH and Po2 has sufficient accuracy to assess variation in tissue perfusion resulting from changes in blood pressure and metabolic demand during cardiopulmonary bypass. DESIGN Prospective clinical study. SETTING Academic medical center. SUBJECTS Eighteen elective cardiac surgical patients. INTERVENTION Cardiac surgery under cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS A near infrared spectroscopic fiber optic probe was placed over the hypothenar eminence. Reference Po2 and pH sensors were inserted in the abductor digiti minimi (V). Data were collected every 30 secs during surgery and for 6 hrs following cardiopulmonary bypass. Calibration equations developed from one third of the data were used with the remaining data to investigate sensitivity of the near infrared spectroscopic measurement to physiologic changes resulting from cardiopulmonary bypass. Near infrared spectroscopic and reference pH and Po2 measurements were compared for each subject using standard error of prediction. Near infrared spectroscopic pH and Po2 at baseline were compared with values during cardiopulmonary bypass just before rewarming commenced (hypotensive, hypothermic), after rewarming (hypotensive, normothermic) just before discontinuation of cardiopulmonary bypass, and at 6 hrs following cardiopulmonary bypass (normotensive, normothermic) using mixed-model analysis of variance. Near infrared spectroscopic pH and Po2 were well correlated with the invasive measurement of pH (R2 =.84) and Po2 (R 2 =.66) with an average standard error of prediction of 0.022 +/- 0.008 pH units and 6 +/- 3 mm Hg, respectively. The average difference between the invasive and near infrared spectroscopic measurement was near zero for both the pH and Po2 measurements. Near infrared spectroscopic Po2 significantly decreased 50% on initiation of cardiopulmonary bypass and remained depressed throughout the bypass and monitored intensive care period. Near infrared spectroscopic pH decreased significantly during cardiopulmonary bypass, decreased significantly during rewarming, and remained depressed 6 hrs after cardiopulmonary bypass. Diabetic patients responded differently than nondiabetic subjects to cardiopulmonary bypass, with lower muscle pH values (p =.02). CONCLUSIONS Near infrared spectroscopic-measured muscle pH and Po2 are sensitive to changes in tissue perfusion during cardiopulmonary bypass.
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Affiliation(s)
- Babs R Soller
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
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Sato K, Takewa Y, Taenaka Y, Tatsumi E, Nishinaka T, Shioya K, Fukuda T, Ohnishi H, Oshikawa M, Uesho K, Takano H, Hayashi JI. Prostaglandin Synthesis Inhibitor Prevents Hypotension Without Impairing Gut Perfusion During Normothermic Cardiopulmonary Bypass. ASAIO J 2002; 48:503-7. [PMID: 12296570 DOI: 10.1097/00002480-200209000-00011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aortic pressure declines during cardiopulmonary bypass (CPB), particularly at normothermia. It has been reported that administering vasoconstrictors during normothermic CPB (NCPB) to restore perfusion pressure might induce hypoperfusion of splanchnic organs. We have reported that prostaglandin (PG), metabolized in the lung but increased during CPB, might have played a substantial role in hypotension, and that a PG synthesis inhibitor (PGSI) could improve hypotension during CPB. This study was designed to examine whether regional perfusion of splanchnic organs was reduced when PGSI restored systemic perfusion pressure during NCPB. NCPB was performed in eight adult goats for 60 minutes (body weight 57.0 +/- 5.9 kg). PGSI was administered in group P (n = 4), while norepinephrine was administered in group C (n = 4), to keep aortic pressure in the range of 50 to 80 mm Hg. The total systemic flow was maintained at approximately 70 ml/kg/min. Tissue blood flow was measured by means of the colored microsphere method before and 30 and 60 minutes after the start of CPB. In group P, gut blood flows after the start of CPB were higher than those before CPB, significantly in the stomach and jejunum at 30 minutes (p < 0.05), whereas gut blood flows in group C were decreased or not changed. In conclusion, PGSI prevents hypotension without impairing gut perfusion during NCPB.
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Affiliation(s)
- Koichi Sato
- Department of Artificial Organs, National Cardiovascular Center Research Institute, Suita, Osaka, Japan
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Slater JM, Orszulak TA, Cook DJ. Distribution and hierarchy of regional blood flow during hypothermic cardiopulmonary bypass. Ann Thorac Surg 2001; 72:542-7. [PMID: 11515895 DOI: 10.1016/s0003-4975(01)02778-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) may decrease oxygen delivery relative to the nonbypass state. We predicted that a hierarchy of regional blood flow could be characterized under hypothermic (27 degrees C) CPB. METHODS Ten pigs underwent bypass at 27 degrees C. Fluorescent microspheres were administered before and during CPB at four randomized flows: 1.9, 1.6, 1.3, and 1.0 L x min(-1) x m(-2). At completion, tissue samples were obtained from brain, renal cortex and medulla, pancreas, small bowel, and limb muscle for regional blood flow determination. RESULTS Cerebral blood flow remained unchanged between CPB flows of 1.9 and 1.3 L x min(-1) x m(-2). Renal perfusion was stable between flows of 1.9 and 1.6 L x min(-1) x m(-2), whereas perfusion of small bowel decreased linearly with pump flow. Pancreatic perfusion was unchanged over the range of flows studied; muscle blood flow was profoundly reduced at the highest CPB flow and further decreased if pump flow was reduced below 1.6 L x min(-1) x m(-2). CONCLUSIONS This study characterizes the organ-specific hierarchy of blood flow and oxygen distribution during hypothermic CPB. These dynamics are relevant to clinical decisions for perfusion management.
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Affiliation(s)
- J M Slater
- Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Cook DJ. Cerebral hyperthermia and cardiac surgery: consequences and prevention. Semin Thorac Cardiovasc Surg 2001; 13:176-83. [PMID: 11494209 DOI: 10.1053/stcs.2001.23557] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Temperature management during cardiac surgery deserves considerable attention because it has broad effects, altering virtually every physiologic process, including oxygen demand, blood flow, cardiac output, and coagulation. Temperature is also important in cardiac surgery because virtually all patients undergo significant temperature change. These changes can be unique in mammalian physiology both with regard to their magnitude and rate of change. Furthermore, cardiac surgical patients may be uniquely vulnerable to the effects of temperature. Because of vascular disease and embolization, many patients are at risk for cerebral ischemia. Additionally, their cardiac, pulmonary, and renal reserve is typically limited; and there is risk for perioperative bleeding. Patient temperature can affect all of these processes and has its greatest effect on those who are physiologically most fragile. An appreciation for temperature management is also compelling because, unlike new technologies, procedures, or drugs; temperature management is simple, practical, applicable to every patient, and can be performed with very little cost. This article will show why cerebral hyperthermia should be avoided in cardiac surgery. Second, it will discuss why it occurs and the management steps that may prevent it. Finally, we will highlight recent discussion of postoperative hyperthermia and speculate as to its origin and relevance.
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Affiliation(s)
- D J Cook
- Department of Anesthesiology, Mayo Medical School, Mayo Foundation and Mayo Clinic, Rochester, MN 55905, USA.
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