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Moyal A, Nazemian R, Colon EP, Zhu L, Benzar R, Palmer NR, Craycroft M, Hausladen A, Premont RT, Stamler JS, Klick J, Reynolds JD. Renal dysfunction in adults following cardiopulmonary bypass is linked to declines in S-nitroso hemoglobin: a case series. Ann Med Surg (Lond) 2024; 86:2425-2431. [PMID: 38694342 PMCID: PMC11060257 DOI: 10.1097/ms9.0000000000001880] [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: 11/01/2023] [Accepted: 02/21/2024] [Indexed: 05/04/2024] Open
Abstract
Background Impaired kidney function is frequently observed in patients following cardiopulmonary bypass (CPB). Our group has previously linked blood transfusion to acute declines in S-nitroso haemoglobin (SNO-Hb; the main regulator of tissue oxygen delivery), reductions in intraoperative renal blood flow, and postoperative kidney dysfunction. While not all CPB patients receive blood, kidney injury is still common. We hypothesized that the CPB procedure itself may negatively impact SNO-Hb levels leading to renal dysfunction. Materials and methods After obtaining written informed consent, blood samples were procured immediately before and after CPB, and on postoperative day (POD) 1. SNO-Hb levels, renal function (estimated glomerular filtration rate; eGFR), and plasma erythropoietin (EPO) concentrations were quantified. Additional outcome data were extracted from the patients' medical records. Results Twenty-seven patients were enroled, three withdrew consent, and one was excluded after developing bacteremia. SNO-Hb levels declined after surgery and were directly correlated with declines in eGFR (R=0.48). Conversely, plasma EPO concentrations were elevated and inversely correlated with SNO-Hb (R=-0.53) and eGFR (R=-0.55). Finally, ICU stay negatively correlated with SNO-Hb concentration (R=-0.32). Conclusion SNO-Hb levels are reduced following CPB in the absence of allogenic blood transfusion and are predictive of decreased renal function and prolonged ICU stay. Thus, therapies directed at maintaining or increasing SNO-Hb levels may improve outcomes in adult patients undergoing cardiac surgery.
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Affiliation(s)
| | - Ryan Nazemian
- Institute for Transformative Molecular Medicine
- Departments ofAnesthesiology & Perioperative Medicine
| | - Edwin Pacheco Colon
- Institute for Transformative Molecular Medicine
- Departments ofAnesthesiology & Perioperative Medicine
| | - Lin Zhu
- Institute for Transformative Molecular Medicine
- Departments ofAnesthesiology & Perioperative Medicine
| | - Ruth Benzar
- Institute for Transformative Molecular Medicine
- Departments ofAnesthesiology & Perioperative Medicine
| | | | | | - Alfred Hausladen
- Institute for Transformative Molecular Medicine
- Departments ofAnesthesiology & Perioperative Medicine
| | - Richard T. Premont
- Institute for Transformative Molecular Medicine
- Cardiology, School of Medicine Case Western Reserve University
- Harrington Discovery Institute, University Hospitals-Cleveland Medical Center, Cleveland, OH
| | - Jonathan S. Stamler
- Institute for Transformative Molecular Medicine
- Cardiology, School of Medicine Case Western Reserve University
- Harrington Discovery Institute, University Hospitals-Cleveland Medical Center, Cleveland, OH
| | - John Klick
- Departments ofAnesthesiology & Perioperative Medicine
| | - James D. Reynolds
- Institute for Transformative Molecular Medicine
- Departments ofAnesthesiology & Perioperative Medicine
- Harrington Discovery Institute, University Hospitals-Cleveland Medical Center, Cleveland, OH
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2
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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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3
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Andersen L, Appelblad M, Wiklund U, Sundström N, Svenmarker S. Our initial experience of monitoring the autoregulation of cerebral blood flow during cardiopulmonary bypass. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:209-217. [PMID: 38099638 PMCID: PMC10723576 DOI: 10.1051/ject/2023032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/05/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Cerebral blood flow (CBF) is believed to be relatively constant within an upper and lower blood pressure limit. Different methods are available to monitor CBF autoregulation during surgery. This study aims to critically analyze the application of the cerebral oxygenation index (COx), one of the commonly used techniques, using a reference to data from a series of clinical registrations. METHOD CBF was monitored using near-infrared spectroscopy, while cerebral blood pressure was estimated by recordings obtained from either the radial or femoral artery in 10 patients undergoing cardiopulmonary bypass. The association between CBF and blood pressure was calculated as a moving continuous correlation coefficient. A COx index > 0.4 was regarded as a sign of abnormal cerebral autoregulation (CA). Recordings were examined to discuss reliability measures and clinical feasibility of the measurements, followed by interpretation of individual results, identification of possible pitfalls, and suggestions of alternative methods. RESULTS AND CONCLUSION Monitoring of CA during cardiopulmonary bypass is intriguing and complex. A series of challenges and limitations should be considered before introducing this method into clinical practice.
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Affiliation(s)
- Leon Andersen
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
| | - Micael Appelblad
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University 901 87 Umeå Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University 901 87 Umeå Sweden
| | - Staffan Svenmarker
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
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4
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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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5
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Change in Oxidative Stress and Mitochondrial Dynamics in Response to Elevated Cold-Inducible RNA-Binding Protein in Cardiac Surgery-Associated Acute Kidney Injury. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3576892. [PMID: 35855864 PMCID: PMC9288297 DOI: 10.1155/2022/3576892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 06/04/2022] [Accepted: 06/21/2022] [Indexed: 11/18/2022]
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common yet serious complication that is closely related to cardiopulmonary bypass (CPB). Extracellular cold-inducible RNA-binding protein (eCIRP) can mediate aseptic inflammation and trigger intracellular oxidative stress. In the present study, expression of serum CIRP was significantly elevated post-CPB (
pg/mL vs.
pg/mL,
) and was positively correlated with CPB duration (
,
). Patients with high expression of CIRP had higher risks of postoperative AKI than patients with low CIRP expression (OR: 1.67, 95% CI 1.04-2.68). In a rat CPB model, the serum CIRP concentration increased significantly after CPB. Similarly, the levels of Scr and BUN significantly increased 4 hours after CPB. KIM-1 and NGAL mRNA levels in the CPB group were 8.2 and 4.3 times higher than the sham group, respectively. In addition, the levels of inflammatory cell infiltration, oxidative stress, and apoptosis in the renal tissue of the CPB group were significantly higher compared to the sham group. The expression levels of serum inflammatory factors at 4 hours post-CPB were also increased. Administration of recombinant human CIRP protein promoted the expression of NADPH oxidase via the TLR-4/MyD88 pathway, aggravated intracellular oxidative stress, mediated mitochondrial dynamics disorder, and eventually increased apoptosis in HK-2 cells. However, the CIRP inhibitor C23 improved the CIRP-mediated oxidative stress and mitochondrial dysfunction in both rat and cell models. In summary, elevated CIRP could mediate oxidative stress and mitochondrial dynamics in the kidney to promote CSA-AKI.
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6
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Holmgaard F, Vistisen ST, Ravn HB, Scheeren TWL. The response of a standardized fluid challenge during cardiac surgery on cerebral oxygen saturation measured with near-infrared spectroscopy. J Clin Monit Comput 2020; 34:245-251. [PMID: 31134474 PMCID: PMC7080680 DOI: 10.1007/s10877-019-00324-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/28/2019] [Indexed: 02/03/2023]
Abstract
Near infrared spectroscopy (NIRS) has been used to evaluate regional cerebral tissue oxygen saturation (ScO2) during the last decades. Perioperative management algorithms advocate to maintain ScO2, by maintaining or increasing cardiac output (CO), e.g. with fluid infusion. We hypothesized that ScO2 would increase in responders to a standardized fluid challenge (FC) and that the relative changes in CO and ScO2 would correlate. This study is a retrospective substudy of the FLuid Responsiveness Prediction Using Extra Systoles (FLEX) trial. In the FLEX trial, patients were administered two standardized FCs (5 mL/kg ideal body weight each) during cardiac surgery. NIRS monitoring was used during the intraoperative period and CO was monitored continuously. Patients were considered responders if stroke volume increased more than 10% following FC. Datasets from 29 non-responders and 27 responders to FC were available for analysis. Relative changes of ScO2 did not change significantly in non-responders (mean difference - 0.3% ± 2.3%, p = 0.534) or in fluid responders (mean difference 1.6% ± 4.6%, p = 0.088). Relative changes in CO and ScO2 correlated significantly, p = 0.027. Increasing CO by fluid did not change cerebral oxygenation. Despite this, relative changes in CO correlated to relative changes in ScO2. However, the clinical impact of the present observations is unclear, and the results must be interpreted with caution.Trial registration:http://ClinicalTrial.gov identifier for main study (FLuid Responsiveness Prediction Using Extra Systoles-FLEX): NCT03002129.
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Affiliation(s)
- Frederik Holmgaard
- Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Simon T Vistisen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Clinical Medicine, Aarhus University, Århus, Denmark.,Department of Anesthesiology & Intensive Care, Aarhus University Hospital, Århus, Denmark
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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7
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Schanche T, Kondratiev T, Tveita T. Extracorporeal rewarming from experimental hypothermia: Effects of hydroxyethyl starch versus saline priming on fluid balance and blood flow distribution. Exp Physiol 2019; 104:1353-1362. [PMID: 31219201 DOI: 10.1113/ep087786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/18/2019] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? Mortality in accidental hypothermia patients rewarmed by extracorporeal circulation remains high. Knowledge concerning optimal fluid additions for extracorporeal rewarming is lacking, with no apparent consensus. Does colloid versus crystalloid priming have different effects on fluid balance and blood flow distribution during extracorporeal rewarming? What is the main finding and its importance? In our rat model of extracorporeal rewarming from hypothermic cardiac arrest, hydroxyethyl starch generates less tissue oedema and increases circulating blood volume and organ blood flow, compared with saline. The composition of fluid additions appears to be important during extracorporeal rewarming from hypothermia. ABSTRACT Rewarming by extracorporeal circulation (ECC) is the recommended treatment for accidental hypothermia patients with cardiac instability. Hypothermia, along with initiation of ECC, introduces major changes in fluid homeostasis and blood flow. Scientific data to recommend best practice use of ECC for rewarming these patients is lacking, and no current guidelines exist concerning the choice of priming fluid for the extracorporeal circuit. The primary aim of this study was to compare the effects of different fluid protocols on fluid balance and blood flow distribution during rewarming from deep hypothermic cardiac arrest. Sixteen anaesthetized rats were cooled to deep hypothermic cardiac arrest and rewarmed by ECC. During cooling, rats were equally randomized into two groups: an extracorporeal circuit primed with saline or primed with hydroxyethyl starch (HES). Calculations of plasma volume (PV), circulating blood volume (CBV), organ blood flow, total tissue water content, global O2 delivery and consumption were made. During and after rewarming, the pump flow rate, mean arterial pressure, PV and CBV were significantly higher in HES-treated compared with saline-treated rats. After rewarming, the HES group had significantly increased global O2 delivery and blood flow to the brain and kidneys compared with the saline group. Rats in the saline group demonstrated a significantly higher total tissue water content in the kidneys, skeletal muscle and lung. Compared with crystalloid priming, the use of an iso-oncotic colloid prime generates less tissue oedema and increases PV, CBV and organ blood flow during ECC rewarming. The composition of fluid additions appears to be an important factor during ECC rewarming from hypothermia.
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Affiliation(s)
- Torstein Schanche
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Timofei Kondratiev
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Torkjel Tveita
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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8
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Holmgaard F, Vedel AG, Lange T, Nilsson JC, Ravn HB. Impact of 2 Distinct Levels of Mean Arterial Pressure on Near-Infrared Spectroscopy During Cardiac Surgery: Secondary Outcome From a Randomized Clinical Trial. Anesth Analg 2019; 128:1081-1088. [PMID: 31094772 DOI: 10.1213/ane.0000000000003418] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is used worldwide to monitor regional cerebral oxygenation (rScO2) during cardiopulmonary bypass (CPB). Intervention protocols meant to mitigate cerebral desaturation advocate to increase mean arterial pressure (MAP) when cerebral desaturation occurs. However, the isolated effect of MAP on rScO2 is uncertain. The aim of the present study was in a randomized, blinded design to elucidate the effect of 2 distinct levels of MAP on rScO2 values during CPB.We hypothesized that a higher MAP would be reflected in higher rScO2 values, lower frequency of patients with desaturation, and a less pronounced cerebral desaturation load. METHODS This is a substudy of the Perfusion Pressure Cerebral Infarct trial, in which we investigated the impact of MAP levels during CPB on ischemic brain injury after cardiac surgery. Deviation in rScO2 was a predefined outcome in the Perfusion Pressure Cerebral Infarct trial. Patients were randomized to low MAP (LMAP; 40-50 mm Hg) or high MAP (HMAP; 70-80 mm Hg) during CPB. CPB pump flow was fixed at 2.4 L/min/m, and MAP levels were targeted using norepinephrine. Intraoperatively, NIRS monitoring was performed in a blinded fashion, with sensors placed on the left and right side of the patient's forehead. NIRS recordings were extracted for offline analysis as the mean value of left and right signal during prespecified periods. Mean rScO2 during CPB was defined as the primary outcome in the present study. RESULTS The average MAP level during CPB was 67 mm Hg ± SD 5.0 in the HMAP group (n = 88) and 45 mm Hg ± SD 4.4 in the LMAP group (n = 88). Mean rScO2 was significantly lower in the HMAP group during CPB (mean difference, 3.5; 95% confidence interval, 0.9-6.1; P = .010). There was no difference in rScO2 values at specified time points during the intraoperative period between the 2 groups. Significantly more patients experienced desaturation below 10% and 20% relative to rScO2 baseline in the HMAP group (P = .013 and P = .009, respectively), and the cerebral desaturation load below 10% relative to rScO2 baseline was more pronounced in the HMAP group (P = .042). CONCLUSIONS In a randomized blinded study, we observed that a higher MAP induced by vasopressors, with a fixed CPB pump flow, leads to lower mean rScO2 and more frequent and pronounced cerebral desaturation during CPB. The mechanism behind these observations is not clear. We cannot exclude extracranial contamination of the NIRS signal as a possible explanation. However, we cannot recommend increasing MAP by vasoconstrictors during cerebral desaturation because this is not supported by the findings of the present study.
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Affiliation(s)
- Frederik Holmgaard
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne G Vedel
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Center for Statistical Science, Peking University, Beijing, China
| | - Jens C Nilsson
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B Ravn
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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9
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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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10
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Biedrzycka A, Kowalik M, Pawlaczyk R, Jagielak D, Świetlik D, Szymanowicz W, Lango R. Aortic cross-clamping phase of cardiopulmonary bypass is related to decreased microvascular reactivity after short-term ischaemia of the thenar muscle both under intravenous and volatile anaesthesia: a randomized trial. Interact Cardiovasc Thorac Surg 2016; 23:770-778. [PMID: 27401083 DOI: 10.1093/icvts/ivw232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 05/06/2016] [Accepted: 05/26/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The purpose of the present study was to assess, by near-infrared spectroscopy with an INVOS oximeter during the vascular occlusion test (VOT), the influence of cardiopulmonary bypass (CPB) on tissue saturation in the thenar muscle. The secondary aim was to compare the effects of propofol and sevoflurane anaesthesia on tissue saturation. METHODS This was a prospective, randomized, open-label study. Sixty cardiac surgery patients received either propofol or sevoflurane anaesthesia. Three-minute VOT was performed at the following time points: 30 min after anaesthesia induction, directly after sternotomy, 20 and 40 min after aortic cross-clamping, 20 min after aortic cross-clamp removal and 45 min after weaning of cardiopulmonary bypass. Group and time effects on tissue saturation were analysed with RM-ANOVA and the post hoc Tukey test. RESULTS In both groups at baseline, the lowest and the highest tissue saturation and the rate of saturation recovery during the reperfusion phase of the vascular occlusion test were lower during aortic cross-clamping in comparison to the values before CPB. Lower nadir tissue saturation during ischaemia was observed under propofol in comparison to sevoflurane anaesthesia (P = 0.018). CONCLUSIONS This study demonstrated that the aortic cross-clamping phase of CPB cardiac surgery is associated with lower values of tissue saturation and a decreased rate of saturation recovery under both propofol and sevoflurane anaesthesia. Aortic cross-clamp release is followed by accelerated tissue desaturation during VOT. Propofol anaesthesia for CPB cardiac surgery results in greater reduction of nadir tissue saturation during the ischaemic phase of VOT in comparison to that of sevoflurane. TRIAL REGISTRATION NUMBER NCT02593448.
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Affiliation(s)
- Aleksandra Biedrzycka
- Department of Anaesthesiology and Intensive Care, Medical University of Gdansk, Gdańsk, Poland
| | - Maciej Kowalik
- Department of Cardiac Anaesthesia, Medical University of Gdansk, Gdańsk, Poland
| | - Rafał Pawlaczyk
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdańsk, Poland
| | - Dariusz Jagielak
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdańsk, Poland
| | - Dariusz Świetlik
- Intrafaculty College of Medical Informatics and Biostatistics, Medical University of Gdansk, Gdańsk, Poland
| | - Wiktor Szymanowicz
- Department of Cardiac Anaesthesia, Medical University of Gdansk, Gdańsk, Poland
| | - Romuald Lango
- Department of Cardiac Anaesthesia, Medical University of Gdansk, Gdańsk, Poland
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11
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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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12
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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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13
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Abstract
Approximately 18% of patients undergoing cardiac surgery experience AKI (on the basis of modern standardized definitions of AKI), and approximately 2%-6% will require hemodialysis. The development of AKI after cardiac surgery portends poor short- and long-term prognoses, with those developing RIFLE failure or AKI Network stage III having an almost 2-fold increase in the risk of death. AKI is caused by a variety of factors, including nephrotoxins, hypoxia, mechanical trauma, inflammation, cardiopulmonary bypass, and hemodynamic instability, and it may be affected by the clinician's choice of fluids and vasoactive agents as well as the transfusion strategy used. The risk of AKI may be ameliorated by avoidance of nephrotoxins, achievement of adequate glucose control preoperatively, and use of goal-directed therapy hemodynamic strategies. Remote ischemic preconditioning is an exciting future strategy, but more work is needed before widespread implementation. Unfortunately, there are no pharmacologic agents known to reduce the risk of AKI or treat established AKI.
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Affiliation(s)
| | | | - Mitchell H Rosner
- Medicine, University of Virginia Health System, Charlottesville, Virginia
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Epstein CD, Haghenbeck KT. Bedside assessment of tissue oxygen saturation monitoring in critically ill adults: an integrative review of the literature. Crit Care Res Pract 2014; 2014:709683. [PMID: 24900919 PMCID: PMC4034454 DOI: 10.1155/2014/709683] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/23/2014] [Accepted: 04/03/2014] [Indexed: 12/22/2022] Open
Abstract
Objective. Tissue oxygen saturation (StO2) monitoring is a noninvasive technology with the purpose of alerting the clinician of peripheral hypoperfusion and the onset of tissue hypoxia. This integrative review examines the rigor and quality of studies focusing on StO2 monitoring in adult critically ill patients. Background. Clinicians must rapidly assess adverse changes in tissue perfusion while minimizing potential complications associated with invasive monitoring. The noninvasive measurement of tissue oxygen saturation is based on near-infrared spectroscopy (NIRS), an optical method of illuminating chemical compounds which absorb, reflect, and scatter light directed at that compound. Methods. An integrative review was conducted to develop a context of greater understanding about complex topics. An Integrative review draws on multiple experimental and nonexperimental research methodologies. Results. Fourteen studies were graded at the C category. None reported the use of probability sampling or demonstrated a cause-and-effect relationship between StO2 values and patient outcomes. Conclusions. Future research should be based on rigorous methods of sampling and design in order to enhance the internal and external validity of the findings.
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Affiliation(s)
- Carol Diane Epstein
- College of Health Professions, Lienhard School of Nursing, Pace University, Office 319, 861 Bedford Road, Pleasantville, NY 10570, USA
| | - Karen Toby Haghenbeck
- College of Health Professions, Lienhard School of Nursing, Pace University, Office L308, 861 Bedford Road, Pleasantville, NY 10570, USA
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15
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Bierbach B, Bomberg H, Pritzer H, Prabhu S, Petzina R, Kempski O, Horstick G, Cremer J, Hoffmann G. Off-pump coronary artery bypass prevents visceral organ damage. Interact Cardiovasc Thorac Surg 2014; 18:717-26. [PMID: 24626936 DOI: 10.1093/icvts/ivu063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Visceral malperfusion after coronary artery bypass grafting (CABG) results in high morbidity and mortality. This study was designed to evaluate the effect of CABG performed by surgical techniques on visceral perfusion and function. METHODS Pigs (n = 28) were studied in four groups: I. Sham; II. Off-pump coronary artery bypass grafting (OPCAB): 1 h stabilizer with 40 min intracoronary shunt; III. Extracorporeal circulation (ECC): 1 h ECC with 40 min aortic cross-clamping and cardioplegic arrest; IV. Impella: 1 h left ventricular blood-pump support and stabilizer with 40 min intracoronary shunt. A left internal mammary to left anterior descending coronary artery bypass was performed in Groups II-IV. All animals were observed for a further 240 min. During the experiment haemodynamics, creatinine clearance, intestinal fatty acid binding protein (iFABP), pancreatic (lipase and amylase) and liver enzymes (α-glutathione s-transferase, glutamate-oxaloacetate transaminase (GOT), gamma-glutamyl transferase (GGT), glutamate dehydrogenase and glutamate-pyruvate transaminase (GPT)) were measured. Visceral perfusion (VP) was assessed in both kidneys, intestine, pancreas, liver and spleen with 15 µm fluorescent microspheres. RESULTS During OPCAB surgery, VP decreased slightly. Renal functional parameters, iFABP, pancreatic and liver enzymes remained unchanged. ECC and Impella led to significantly reduced renal, pancreatic and intestinal blood flow (P < 0.05). Creatinine clearance, pancreatic and liver (GPT, GGT) enzymes were significantly decreased only after ECC (P < 0.05). ECC and Impella resulted in a significantly increased iFABP level (P < 0.05). GOT was elevated significantly after surgery in Groups II, III and IV (P < 0.05). CONCLUSIONS CABG with ECC or Impella leads to impaired visceral blood flow and function. OPCAB minimizes these procedure associated alterations.
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Affiliation(s)
- Benjamin Bierbach
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany Institute for Neurosurgical Pathophysiology, University Mainz, Mainz, Germany
| | - Hagen Bomberg
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine University Hospital of Saarland, Homburg, Germany
| | - Hartmut Pritzer
- Institute for Neurosurgical Pathophysiology, University Mainz, Mainz, Germany
| | - Sudesh Prabhu
- Queensland Paediatric Cardiac Services, Mater Children's Hospital, Brisbane, Australia
| | - Rainer Petzina
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Oliver Kempski
- Institute for Neurosurgical Pathophysiology, University Mainz, Mainz, Germany
| | - Georg Horstick
- Institute for Neurosurgical Pathophysiology, University Mainz, Mainz, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Grischa Hoffmann
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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16
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Twal M, Kiefer P, Salameh A, Schnabel J, Ossmann S, von Salisch S, Krämer K, Sobiraj A, Kostelka M, Mohr FW, Dhein S. Reno-protective effects of epigallocatechingallate in a small piglet model of extracorporeal circulation. Pharmacol Res 2012; 67:68-78. [PMID: 23103594 DOI: 10.1016/j.phrs.2012.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 10/16/2012] [Accepted: 10/16/2012] [Indexed: 10/27/2022]
Abstract
Cardiopulmonary bypass still often is a necessary tool in cardiac surgery in particular in the correction of congenital heart defects in small infants. Nevertheless, among the complications linked to extracorporeal circulation (ECC) with cardiopulmonary bypass (CPB) in both infants and adults one of the most serious problems is renal impairment. Since this might be caused by ischemia/reperfusion injury and accumulation of free radicals, we used (-)-epigallocatechin-3-gallate (EGCG), a derivate from green tea, which is known to possess antioxidant, antiapoptotic and NO-scavenging properties in order to find out whether EGCG may protect the kidney. 23 four-week-old Angler Sattelschwein-piglets (8-15 kg) were divided into three groups: control-group (n=7), ECC-group (n=10), EGCG-group (n=6). The ECC- and EGCG-group were thoracotomized and underwent CPB for 120 min followed by a 90-min recovery-time. The EGCG-group received 10 mg/kg EGCG before and after CPB. Histology revealed that CPB led to widening of Bowman's capsule, and to vacuolization of proximal tubular cells (p<0.05) which could be prevented by EGCG (p<0.05). Using immunohistology, we found significant nuclear translocation of hypoxia-inducible-factor-1-alpha (HIF-1-alpha) and increased nitrotyrosine formation in the ECC-group. Both were significantly (p<0.05) inhibited by EGCG. ECC-induced loss of energy-rich phosphates was prevented by EGCG. In blood samples we found that CPB resulted in increases in creatinine and urea (in serum) and led to loss of total protein (p<0.05), which all was not present in EGCG-treated animals. We conclude that CPB causes damage in the kidney which can be attenuated by EGCG.
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Affiliation(s)
- Miriam Twal
- Clinic for Cardiac Surgery, University of Leipzig, Heart Centre, Leipzig, Germany
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17
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Whole body oxygen delivery and consumption during cardiopulmonary bypass surgery. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012. [PMID: 22259106 DOI: 10.1007/978-1-4614-1566-4_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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18
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Oxygen dependence of metabolism and cellular adaptation in vertebrate muscles: a review. J Comp Physiol B 2011; 182:177-88. [DOI: 10.1007/s00360-011-0616-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 08/30/2011] [Accepted: 09/03/2011] [Indexed: 01/23/2023]
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19
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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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20
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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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21
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Antegrade selektive Hirnperfusion – ein neuroprotektives Verfahren in der thorakalen Aortenchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0674-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Murphy GJ, Reeves BC, Rogers CA, Rizvi SIA, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116:2544-52. [PMID: 17998460 DOI: 10.1161/circulationaha.107.698977] [Citation(s) in RCA: 953] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Red blood cell transfusion can both benefit and harm. To inform decisions about transfusion, we aimed to quantify associations of transfusion with clinical outcomes and cost in patients having cardiac surgery. METHODS AND RESULTS Clinical, hematology, and blood transfusion databases were linked with the UK population register. Additional hematocrit information was obtained from intensive care unit charts. Composite infection (respiratory or wound infection or septicemia) and ischemic outcomes (myocardial infarction, stroke, renal impairment, or failure) were prespecified as coprimary end points. Secondary outcomes were resource use, cost, and survival. Associations were estimated by regression modeling with adjustment for potential confounding. All adult patients having cardiac surgery between April 1, 1996, and December 31, 2003, with key exposure and outcome data were included (98%). Adjusted odds ratios for composite infection (737 of 8516) and ischemic outcomes (832 of 8518) for transfused versus nontransfused patients were 3.38 (95% confidence interval [CI], 2.60 to 4.40) and 3.35 (95% CI, 2.68 to 4.35), respectively. Transfusion was associated with increased relative cost of admission (any transfusion, 1.42 times [95% CI, 1.37 to 1.46], varying from 1.11 for 1 U to 3.35 for >9 U). At any time after their operations, transfused patients were less likely to have been discharged from hospital (hazard ratio [HR], 0.63; 95% CI, 0.60 to 0.67) and were more likely to have died (0 to 30 days: HR, 6.69; 95% CI, 3.66 to 15.1; 31 days to 1 year: HR, 2.59; 95% CI, 1.68 to 4.17; >1 year: HR, 1.32; 95% CI, 1.08 to 1.64). CONCLUSIONS Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.
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Affiliation(s)
- Gavin J Murphy
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, BS2 8HW, UK
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23
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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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24
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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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25
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Hoffman GM, Stuth EA, Jaquiss RD, Vanderwal PL, Staudt SR, Troshynski TJ, Ghanayem NS, Tweddell JS. Changes in cerebral and somatic oxygenation during stage 1 palliation of hypoplastic left heart syndrome using continuous regional cerebral perfusion. J Thorac Cardiovasc Surg 2004; 127:223-33. [PMID: 14752434 DOI: 10.1016/j.jtcvs.2003.08.021] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Stage 1 palliation of hypoplastic left heart syndrome requires the interruption of whole-body perfusion. Delayed reflow in the cerebral circulation secondary to prolonged elevation in vascular resistance occurs in neonates after deep hypothermic circulatory arrest. We examined relative changes in cerebral and somatic oxygenation with near-infrared spectroscopy while using a modified perfusion strategy that allowed continuous cerebral perfusion. METHODS Nine neonates undergoing stage 1 palliation for hypoplastic left heart syndrome had regional tissue oxygenation continuously measured by frontal cerebral and thoraco-lumbar (T10-L2) somatic (renal) reflectance oximetry probes (rSO(2), INVOS; Somanetics, Troy, Mich). Surgery was accomplished using cardiopulmonary bypass with whole-body cooling (18 degrees C-20 degrees C) and regional cerebral perfusion through the innominate artery at flow rates guided by estimated minimum flow requirements and measured rSO(2) during reconstruction of the aortic arch. Data were logged at 1-minute intervals and analyzed using repeated measures analysis of variance. RESULTS A total of 3176 minutes of data were analyzed. Prebypass cerebral rSO(2) was 65.4 +/- 8.9, and somatic rSO(2) was 58.9 +/- 12.4 (P <.001, cerebral vs somatic). During regional cerebral perfusion, cerebral rSO(2) was 80.7 +/- 8.6, and somatic rSO(2) was 41.4 +/- 7.1 (P <.001). Postbypass cerebral rSO(2) was 53.2 +/- 14.9, and somatic rSO(2) was 76.4 +/- 7.7 (P <.001). The risk of cerebral desaturation was significantly increased after cardiopulmonary bypass. CONCLUSIONS Cerebral oxygenation was maintained during regional cerebral perfusion at prebypass levels with deep hypothermia. However, after rewarming and separation from cardiopulmonary bypass, cerebral oxygenation was lower compared with prebypass or somatic values. These results indicate that cerebrovascular resistance is increased after deep hypothermic cardiopulmonary bypass, even with continuous perfusion techniques, placing the cerebral circulation at risk postoperatively.
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Affiliation(s)
- George M Hoffman
- Department of Pediatric Anesthesiology, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee 53226, USA.
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Soller BR, Khan T, Favreau J, Hsi C, Puyana JC, Heard SO. Investigation of muscle pH as an indicator of liver pH and injury from hemorrhagic shock 1 1This work was supported, in part, by the US Army Medical Research Command through a grant to the Center for Integration of Medicine and Innovative Technology (Boston, MA). J Surg Res 2003; 114:195-201. [PMID: 14559446 DOI: 10.1016/s0022-4804(03)00251-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND During hemorrhagic shock blood flow to vital organs is maintained by the diversion of blood from both the splanchnic organs and skeletal muscle. In this swine study, we tested the hypotheses that (1). liver and muscle pH are correlated during both shock and resuscitation and (2). muscle pH during shock is an indicator of potential liver injury after resuscitation. MATERIALS AND METHODS Hemorrhagic shock was induced over 15 min to lower systolic blood pressure to 40 mm Hg and was maintained for 60 (n = 5) or 90 (n = 5) min. Resuscitation was achieved with shed blood and warm saline to maintain mean pressure >60 mm Hg for 120 min. Liver and muscle pH were measured with microelectrodes throughout the entire shock and resuscitation periods, along with hepatic venous oxygen saturation. Arterial lactate and aspartate aminotransferase were measured at baseline, end of shock, and resuscitation. Correlation between muscle and liver pH was determined. The ability of muscle pH to predict liver injury (40% increase in arterial aspartate aminotransferase) was compared with other predictors: liver pH, arterial lactate, and tonometric-arterial PCO(2) gap. RESULTS pH values and rates of change were similar in both muscle and liver tissue. Liver pH was well correlated with muscle pH during both shock and resuscitation, R(2) = 0.84. Muscle pH predicts potential liver injury with the same sensitivity as blood lactate in this swine shock model. CONCLUSIONS Minimally invasive measurement of muscle pH warrants further study as a method to assess splanchnic hypoperfusion and resultant injury.
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Affiliation(s)
- Babs R Soller
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
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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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