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Vlastos D, Zeinah M, Ninkovic-Hall G, Vlachos S, Salem A, Asonitis A, Chavan H, Kalampalikis L, Al Shammari A, Alvarez Gallesio JM, Pons A, Andreadou I, Ikonomidis I. The effects of ischaemic conditioning on lung ischaemia-reperfusion injury. Respir Res 2022; 23:351. [PMID: 36527070 PMCID: PMC9756694 DOI: 10.1186/s12931-022-02288-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Ischaemia-reperfusion injury (IRI) encompasses the deleterious effects on cellular function and survival that result from the restoration of organ perfusion. Despite their unique tolerance to ischaemia and hypoxia, afforded by their dual (pulmonary and bronchial) circulation as well as direct oxygen diffusion from the airways, lungs are particularly susceptible to IRI (LIRI). LIRI may be observed in a variety of clinical settings, including lung transplantation, lung resections, cardiopulmonary bypass during cardiac surgery, aortic cross-clamping for abdominal aortic aneurysm repair, as well as tourniquet application for orthopaedic operations. It is a diagnosis of exclusion, manifesting clinically as acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Ischaemic conditioning (IC) signifies the original paradigm of treating IRI. It entails the application of short, non-lethal ischemia and reperfusion manoeuvres to an organ, tissue, or arterial territory, which activates mechanisms that reduce IRI. Interestingly, there is accumulating experimental and preliminary clinical evidence that IC may ameliorate LIRI in various pathophysiological contexts. Considering the detrimental effects of LIRI, ranging from ALI following lung resections to primary graft dysfunction (PGD) after lung transplantation, the association of these entities with adverse outcomes, as well as the paucity of protective or therapeutic interventions, IC holds promise as a safe and effective strategy to protect the lung. This article aims to provide a narrative review of the existing experimental and clinical evidence regarding the effects of IC on LIRI and prompt further investigation to refine its clinical application.
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Affiliation(s)
- Dimitrios Vlastos
- grid.415914.c0000 0004 0399 9999Department of Vascular Surgery, Countess of Chester Hospital, Chester, UK ,grid.411449.d0000 0004 0622 4662Second Department of Cardiology, Attikon University Hospital, Athens, Greece ,Present Address: Liverpool, UK
| | - Mohamed Zeinah
- grid.415992.20000 0004 0398 7066Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK ,grid.7269.a0000 0004 0621 1570Ain Shams University, Cairo, Egypt
| | - George Ninkovic-Hall
- grid.415970.e0000 0004 0417 2395Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Stefanos Vlachos
- grid.411449.d0000 0004 0622 4662Second Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Agni Salem
- grid.415992.20000 0004 0398 7066Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Athanasios Asonitis
- grid.413157.50000 0004 0590 2070Department of Cardiothoracic Surgery, NHS Golden Jubilee National Hospital, Glascow, UK
| | - Hemangi Chavan
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Lazaros Kalampalikis
- grid.414012.20000 0004 0622 6596Department of Minimally Invasive Cardiac Surgery, Metropolitan General Hospital, Athens, Greece
| | - Abdullah Al Shammari
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - José María Alvarez Gallesio
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Aina Pons
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ioanna Andreadou
- grid.5216.00000 0001 2155 0800School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Ignatios Ikonomidis
- grid.411449.d0000 0004 0622 4662Second Department of Cardiology, Attikon University Hospital, Athens, Greece
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Karacalilar M, Onan IS, Onan B, Sen O, Gonca S, Solakoglu S, Yeniterzi M. Effects of pulmonary perfusion during cardiopulmonary bypass on lung functions after cardiac operation. J Card Surg 2020; 35:2469-2476. [PMID: 32789962 DOI: 10.1111/jocs.14934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary artery perfusion during cardiopulmonary bypass (CPB) is a known but rarely used technique in adult cardiac surgery. In this study, we aimed to investigate biochemical and histopathological effects of pulmonary artery perfusion during CPB on lung functions. METHODS Between May 2014 and August 2014, all patients (n = 24) who gave informed consent for participating this study with inclusion criteria were included. Patients undergoing isolated coronary artery bypass grafting were sequentially randomized to conventional CPB (control group, n = 12) and conventional CPB with selective pulmonary artery perfusion (study group, n = 12). Lung functions were monitored using PF ratio, alveolar-arterial oxygen gradient, and lactate levels. A small sample tissue from the left lung was excised for histopathologic examination. Immunocytochemistry analysis was performed using anti-rabbit polyclonal vascular endothelial growth factor (VEGF), rabbit polyclonal inducible nitric oxide synthase (i-NOS), and BCL-2 antibodies. RESULTS Postoperative course of the patients were uneventful without any clinical outcome differences in terms of cardiopulmonary complications, ventilation time and hospital stay. Pulmonary perfusion group had significantly better oxygenation values after extubation and at postoperative 24-hour. Electron microscopy examinations revealed better preservation of the alveolar wall integrity with pulmonary perfusion. The intensity of VEGF, i-NOS, and BCL-2 antibody expressions in bronchial epithelial cells were more prominent in the pulmonary perfusion group. CONCLUSIONS Pulmonary artery perfusion during aortic cross-clamping provides better oxygenation and preservation of the wall alveolar integrity after coronary artery bypass grafting surgery. This technique can be used as a protective strategy to minimize CPB-induced lung injury in adult cardiac surgery.
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Affiliation(s)
- Mehmet Karacalilar
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Ismihan S Onan
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Burak Onan
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Onur Sen
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Suheyla Gonca
- Department of Histology and Embryology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Seyhun Solakoglu
- Department of Histology and Embryology, Capa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Yeniterzi
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, University of Health Sciences Turkey, Istanbul, Turkey
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Al-Fares A, Pettenuzzo T, Del Sorbo L. Extracorporeal life support and systemic inflammation. Intensive Care Med Exp 2019; 7:46. [PMID: 31346840 PMCID: PMC6658641 DOI: 10.1186/s40635-019-0249-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/22/2019] [Indexed: 01/10/2023] Open
Abstract
Extracorporeal life support (ECLS) encompasses a wide range of extracorporeal modalities that offer short- and intermediate-term mechanical support to the failing heart or lung. Apart from the daily use of cardiopulmonary bypass (CPB) in the operating room, there has been a resurgence of interest and utilization of veno-arterial and veno-venous extracorporeal membrane oxygenation (VA- and VV-ECMO, respectively) and extracorporeal carbon dioxide removal (ECCO2R) in recent years. This might be attributed to the advancement in technology, nonetheless the morbidity and mortality associated with the clinical application of this technology is still significant. The initiation of ECLS triggers a systemic inflammatory response, which involves the activation of the coagulation cascade, complement systems, endothelial cells, leukocytes, and platelets, thus potentially contributing to morbidity and mortality. This is due to the release of cytokines and other biomarkers of inflammation, which have been associated with multiorgan dysfunction. On the other hand, ECLS can be utilized as a therapy to halt the inflammatory response associated with critical illness and ICU therapeutic intervention, such as facilitating ultra-protective mechanical ventilation. In addition to addressing the impact on outcome of the relationship between inflammation and ECLS, two different but complementary pathophysiological perspectives will be developed in this review: ECLS as the cause of inflammation and ECLS as the treatment of inflammation. This framework may be useful in guiding the development of novel therapeutic strategies to improve the outcome of critical illness.
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Affiliation(s)
- Abdulrahman Al-Fares
- Adult Critical Care Medicine Fellowship Program, University of Toronto, Toronto, Canada.,Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait.,Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Tommaso Pettenuzzo
- Adult Critical Care Medicine Fellowship Program, University of Toronto, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada. .,Toronto General Hospital, 585 University Avenue, PMB 11-122, Toronto, Ontario, M5G 2 N2, Canada.
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Buggeskov KB, Maltesen RG, Rasmussen BS, Hanifa MA, Lund MAV, Wimmer R, Ravn HB. Lung Protection Strategies during Cardiopulmonary Bypass Affect the Composition of Blood Electrolytes and Metabolites-A Randomized Controlled Trial. J Clin Med 2018; 7:E462. [PMID: 30469433 PMCID: PMC6262287 DOI: 10.3390/jcm7110462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 11/16/2022] Open
Abstract
Cardiac surgery with cardiopulmonary bypass (CPB) causes an acute lung ischemia-reperfusion injury, which can develop to pulmonary dysfunction postoperatively. This sub-study of the Pulmonary Protection Trial aimed to elucidate changes in arterial blood gas analyses, inflammatory protein interleukin-6, and metabolites of 90 chronic obstructive pulmonary disease patients following two lung protective regimens of pulmonary artery perfusion with either hypothermic histidine-tryptophan-ketoglutarate (HTK) solution or normothermic oxygenated blood during CPB, compared to the standard CPB with no pulmonary perfusion. Blood was collected at six time points before, during, and up to 20 h post-CPB. Blood gas analysis, enzyme-linked immunosorbent assay, and nuclear magnetic resonance spectroscopy were used, and multivariate and univariate statistical analyses were performed. All patients had decreased gas exchange, augmented inflammation, and metabolite alteration during and after CPB. While no difference was observed between patients receiving oxygenated blood and standard CPB, patients receiving HTK solution had an excess of metabolites involved in energy production and detoxification of reactive oxygen species. Also, patients receiving HTK suffered a transient isotonic hyponatremia that resolved within 20 h post-CPB. Additional studies are needed to further elucidate how to diminish lung ischemia-reperfusion injury during CPB, and thereby, reduce the risk of developing severe postoperative pulmonary dysfunction.
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Affiliation(s)
- Katrine B Buggeskov
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark.
| | - Raluca G Maltesen
- Department of Anesthesia and Intensive Care, Aalborg University Hospital, 9000 Aalborg, Denmark.
| | - Bodil S Rasmussen
- Department of Anesthesia and Intensive Care, Aalborg University Hospital, 9000 Aalborg, Denmark.
- Department of Clinical Medicine, School of Medicine and Health, Aalborg University, 9000 Aalborg, Denmark.
| | - Munsoor A Hanifa
- Department of Anesthesia and Intensive Care, Aalborg University Hospital, 9000 Aalborg, Denmark.
- Department of Clinical Medicine, School of Medicine and Health, Aalborg University, 9000 Aalborg, Denmark.
| | - Morten A V Lund
- Department of Biomedical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark.
| | - Reinhard Wimmer
- Department of Chemistry and Bioscience, Aalborg University, 9220 Aalborg, Denmark.
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark.
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Maltesen RG, Buggeskov KB, Andersen CB, Plovsing R, Wimmer R, Ravn HB, Rasmussen BS. Lung Protection Strategies during Cardiopulmonary Bypass Affect the Composition of Bronchoalveolar Fluid and Lung Tissue in Cardiac Surgery Patients. Metabolites 2018; 8:metabo8040054. [PMID: 30241409 PMCID: PMC6316472 DOI: 10.3390/metabo8040054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/31/2018] [Accepted: 09/19/2018] [Indexed: 11/18/2022] Open
Abstract
Pulmonary dysfunction is among the most frequent complications to cardiac surgeries. Exposure of blood to the cardiopulmonary bypass (CPB) circuit with subsequent lung ischemia-reperfusion leads to the production of inflammatory mediators and increases in microvascular permeability. The study aimed to elucidate histological, cellular, and metabolite changes following two lung protective regimens during CPB with Histidine-Tryptophan-Ketoglutarate (HTK) enriched or warm oxygenated blood pulmonary perfusion compared to standard regimen with no pulmonary perfusion. A total of 90 patients undergoing CPB were randomized to receiving HTK, oxygenated blood or standard regimen. Of these, bronchoalveolar lavage fluid (BALF) and lung tissue biopsies were obtained before and after CPB from 47 and 25 patients, respectively. Histopathological scores, BALF cell counts and metabolite screening were assessed. Multivariate and univariate analyses were performed. Profound histological, cellular, and metabolic changes were identified in all patients after CPB. Histological and cellular changes were similar in the three groups; however, some metabolite profiles were different in the HTK patients. While all patients presented an increase in inflammatory cells, metabolic acidosis, protease activity and oxidative stress, HTK patients seemed to be protected against severe acidosis, excessive fatty acid oxidation, and inflammation during ischemia-reperfusion. Additional studies are needed to confirm these findings.
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Affiliation(s)
- Raluca G Maltesen
- Department of Anesthesia and Intensive Care Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark.
| | - Katrine B Buggeskov
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, 2100 Copenhagen, Denmark.
| | - Claus B Andersen
- Department of Forensic Medicine, University of Copenhagen, 2100 Copenhagen, Denmark.
| | - Ronni Plovsing
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark.
- Department of Anesthesiology, Hvidovre Hospital, University of Copenhagen, 2650 Hvidovre, Denmark.
| | - Reinhard Wimmer
- Department of Chemistry and Bioscience, Aalborg University, 9220 Aalborg, Denmark.
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, 2100 Copenhagen, Denmark.
| | - Bodil S Rasmussen
- Department of Anesthesia and Intensive Care Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark.
- Department of Clinical Medicine, School of Medicine and Health, Aalborg University, 9220 Aalborg, Denmark.
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Buggeskov KB, Grønlykke L, Risom EC, Wei ML, Wetterslev J. Pulmonary artery perfusion versus no perfusion during cardiopulmonary bypass for open heart surgery in adults. Cochrane Database Syst Rev 2018; 2:CD011098. [PMID: 29419895 PMCID: PMC6491280 DOI: 10.1002/14651858.cd011098.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Available evidence has been inconclusive on whether pulmonary artery perfusion during cardiopulmonary bypass (CPB) is associated with decreased or increased mortality, pulmonary events, and serious adverse events (SAEs) after open heart surgery. To our knowledge, no previous systematic reviews have included meta-analyses of these interventions. OBJECTIVES To assess the benefits and harms of single-shot or continuous pulmonary artery perfusion with blood (oxygenated or deoxygenated) or a preservation solution compared with no perfusion during cardiopulmonary bypass (CPB) in terms of mortality, pulmonary events, serious adverse events (SAEs), and increased inflammatory markers for adult surgical patients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, and advanced Google for relevant studies. We handsearched retrieved study reports and scanned citations of included studies and relevant reviews to ensure that no relevant trials were missed. We searched for ongoing trials and unpublished trials in the World Health Organization International Clinical Trials Registry Platform (ICTRP) and at clinicaltrials.gov (4 July 2017). We contacted medicinal firms producing preservation solutions to retrieve additional studies conducted to examine relevant interventions. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared pulmonary artery perfusion versus no perfusion during CPB in adult patients (≧ 18 years). DATA COLLECTION AND ANALYSIS Two independent review authors extracted data, conducted fixed-effect and random-effects meta-analyses, and calculated risk ratios (RRs) or odds ratios (ORs) for dichotomous outcomes. For continuous data, we have presented mean differences (MDs) and 95% confidence intervals (CIs) as estimates of the intervention effect. To minimize the risk of systematic error, we assessed risk of bias of included trials. To reduce the risk of random errors caused by sparse data and repetitive updating of cumulative meta-analyses, we applied Trial Sequential Analyses (TSAs). We used GRADE principles to assess the quality of evidence. MAIN RESULTS We included in this review four RCTs (210 participants) reporting relevant outcomes. Investigators randomly assigned participants to pulmonary artery perfusion with blood versus no perfusion during CPB. Only one trial included the pulmonary artery perfusion intervention with a preservation solution; therefore we did not perform meta-analysis. Likewise, only one trial reported patient-specific data for the outcome "pulmonary events"; therefore we have provided no results from meta-analysis. Instead, review authors added two explorative secondary outcomes for this version of the review: the ratio of partial pressure of oxygen in arterial blood (PaO2) to fraction of inspired oxygen (FiO2); and intubation time. Last, review authors found no comparable data for the secondary outcome inflammatory markers.The effect of pulmonary artery perfusion on all-cause mortality was uncertain (Peto OR 1.78, 95% CI 0.43 to 7.40; TSA adjusted CI 0.01 to 493; 4 studies, 210 participants; GRADE: very low quality). Sensitivity analysis of one trial with overall low risk of bias (except for blinding of personnel during the surgical procedure) yielded no evidence of a difference for mortality (Peto OR 1.65, 95% CI 0.27 to 10.15; 1 study, 60 participants). The TSA calculated required information size was not reached and the futility boundaries did not cross; thus this analysis cannot refute a 100% increase in mortality.The effect of pulmonary artery perfusion with blood on SAEs was likewise uncertain (RR 1.12, 95% CI 0.66 to 1.89; 3 studies, 180 participants; GRADE: very low quality). Data show an association between pulmonary artery perfusion with blood during CPB and a higher postoperative PaO2/FiO2 ratio (MD 27.80, 95% CI 5.67 to 49.93; 3 studies, 119 participants; TSA adjusted CI 5.67 to 49.93; GRADE: very low quality), although TSA could not confirm or refute a 10% increase in the PaO2/FiO2 ratio, as the required information size was not reached. AUTHORS' CONCLUSIONS The effects of pulmonary artery perfusion with blood during cardiopulmonary bypass (CPB) are uncertain owing to the small numbers of participants included in meta-analyses. Risks of death and serious adverse events may be higher with pulmonary artery perfusion with blood during CPB, and robust evidence for any beneficial effects is lacking. Future randomized controlled trials (RCTs) should provide long-term follow-up and patient stratification by preoperative lung function and other documented risk factors for mortality. One study that is awaiting classification (epub abstract with preliminary results) may change the results of this review when full study details have been published.
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Affiliation(s)
- Katrine B Buggeskov
- Copenhagen University Hospital, RigshospitaletDepartment of Thoracic AnaesthesiologyBlegdamsvej 9CopenhagenDenmark2100
| | - Lars Grønlykke
- Copenhagen University Hospital, RigshospitaletDepartment of Thoracic AnaesthesiologyBlegdamsvej 9CopenhagenDenmark2100
| | - Emilie C Risom
- Copenhagen University Hospital, RigshospitaletDepartment of Thoracic AnaesthesiologyBlegdamsvej 9CopenhagenDenmark2100
| | - Mao Ling Wei
- West China Hospital, Sichuan UniversityChinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Abstract
Pulmonary injury during cardiopulmonary bypass is common as patient factors (smoking, pain, pneumonia) and the effects of cardiopulmonary bypass combine to compromise lung function after cardiac surgery. Lung injury follows the propagation of an inflammatory response involving cytokines, complement, neutrophils, monocytes, activated endothelial cells and platelets. Neutrophils sequester in the lung in response to chemo-tactic agents and release injurious oxygen free radicals and specific enzymes resulting in widespread pulmonary injury. To alleviate this lung injury a number of possible interventions exist. Off pump surgery may reduce the degree of systemic inflammation but respiratory impairment still occurs and the clinical advantage is uncertain. The use of leukocyte filtration can attenuate the acute inflammatory response with encouraging though variable results. Aprotinin, Pentoxyfilline, Nitric oxide, Aspirin and other agents have shown benefits in lung function after cardiopulmonary bypass induced lung injury. Given the magnitude and diversity of the inflammatory response to cardiopulmonary bypass many possible interventions exist to attenuate lung injury resulting from extracorporeal circulation. Immediate clinical benefits are likely to result from successful amelioration of the processes involved.
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Affiliation(s)
- Stephen C Clark
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.
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8
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Pulmonary complications of cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol 2015; 29:163-75. [PMID: 26060028 PMCID: PMC10068650 DOI: 10.1016/j.bpa.2015.04.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/03/2015] [Accepted: 04/09/2015] [Indexed: 12/16/2022]
Abstract
Pulmonary complications after the use of extracorporeal circulation are common, and they range from transient hypoxemia with altered gas exchange to acute respiratory distress syndrome (ARDS), with variable severity. Similar to other end-organ dysfunction after cardiac surgery with extracorporeal circulation, pulmonary complications are attributed to the inflammatory response, ischemia-reperfusion injury, and reactive oxygen species liberated as a result of cardiopulmonary bypass. Several factors common in cardiac surgery with extracorporeal circulation may worsen the risk of pulmonary complications including atelectasis, transfusion requirement, older age, heart failure, emergency surgery, and prolonged duration of bypass. There is no magic bullet to prevent or treat pulmonary complications, but supportive care with protective ventilation is important. Targets for the prevention of pulmonary complications include mechanical, surgical, and anesthetic interventions that aim to reduce the contact activation, systemic inflammatory response, leukocyte sequestration, and hemodilution associated with extracorporeal circulation.
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Ugurlucan M, Basaran M, Erdim F, Selimoglu O, Caglar IM, Zencirci E, Filizcan U, Ogus NT, Yildiz Y, Tireli E, Isik O, Dayioglu E. Pressure-controlled mechanical ventilation is more advantageous in the follow-up of patients with chronic obstructive pulmonary disease after open heart surgery. Heart Surg Forum 2015; 17:E1-6. [PMID: 24631983 DOI: 10.1532/hsf98.2013236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass deteriorates pulmonary functions to a certain extent. Patients with chronic obstructive pulmonary disease (COPD) are associated with increased mortality and morbidity risks in the postoperative period of open-heart surgery. In this study we compared 2 different mechanical ventilation modes, pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV), in this particular patient population. PATIENTS AND METHODS Forty patients with severe COPD were assigned to 1 of 2 groups and enrolled to receive PCV or VCV in the postoperative period. Arterial blood gases, respiratory parameters, and intensive care unit and hospital stays were compared between the 2 groups. RESULTS Maximum airway pressure was higher in the VCV group. Pulmonary compliance was lower in the VCV group and minute ventilation was significantly lower in the group ventilated with PCV mode. The respiratory index was increased in the PCV group compared with the VCV group and with preoperative findings. Duration of mechanical ventilation was significantly shorter with PCV; however, intensive care unit and hospital stays did not differ. CONCLUSION There is not a single widely accepted and established mode of ventilation for patients with COPD undergoing open-heart surgery. Our modest experience indicated promising results with PCV mode; however, further studies are warranted.
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Affiliation(s)
- Murat Ugurlucan
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Murat Basaran
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Filiz Erdim
- Cardiovascular Surgery Clinic, Istanbul Cerrahi Hospital, Istanbul, Turkey
| | - Ozer Selimoglu
- Cardiovascular Surgery Clinic, Istanbul Cerrahi Hospital, Istanbul, Turkey
| | - Ilker Murat Caglar
- Cardiology Clinic, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | | | - Ugur Filizcan
- Department of Cardiovascular Surgery, Maltepe University Medical Faculty, Istanbul, Turkey
| | | | - Yahya Yildiz
- Cardiovascular Surgery Clinic, Pendik Bolge Hospital, Istanbul, Turkey
| | - Emin Tireli
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
| | - Omer Isik
- Cardiovascular Surgery Clinic, Pendik Bolge Hospital, Istanbul, Turkey
| | - Enver Dayioglu
- Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty, Istanbul, Turkey
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10
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Buggeskov KB, Nielsen JB, Wetterslev J. Pulmonary perfusion versus no pulmonary perfusion during cardiopulmonary bypass for cardiac surgery. Hippokratia 2014. [DOI: 10.1002/14651858.cd011098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Katrine B Buggeskov
- Copenhagen University Hospital, Rigshospitalet; Department of Cardiothoracic Anaesthesiology; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Jonas B Nielsen
- Copenhagen University Hospital, Rigshospitalet; Department of Cardiology; Juliane Maries Vej 20 Copenhagen Denmark 2100
| | - Jørn Wetterslev
- Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Blegdamsvej 9 Copenhagen Denmark DK-2100
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11
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Postfiltration und Lungenperfusion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1035-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Kiessling AH, Guo FW, Gökdemir Y, Thudt M, Reyher C, Scherer M, Beiras-Fernandez A, Moritz A. The influence of selective pulmonary perfusion on the inflammatory response and clinical outcome of patients with chronic obstructive pulmonary disease undergoing cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 2014; 18:732-9. [DOI: 10.1093/icvts/ivu062] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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13
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Gologorsky E, Macedo FI, Salerno TA. Beating heart valve surgery with lung perfusion/ventilation during cardiopulmonary bypass: do we need to break the limits? Expert Rev Cardiovasc Ther 2014; 9:927-37. [DOI: 10.1586/erc.11.88] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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Buggeskov KB, Wetterslev J, Secher NH, Andersen LW, Jonassen T, Steinbrüchel DA. Pulmonary perfusion with oxygenated blood or custodiol HTK solution during cardiac surgery for postoperative pulmonary function in COPD patients: a trial protocol for the randomized, clinical, parallel group, assessor and data analyst blinded Pulmonary Protection Trial. Trials 2013; 14:30. [PMID: 23363494 PMCID: PMC3576307 DOI: 10.1186/1745-6215-14-30] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/16/2013] [Indexed: 11/30/2022] Open
Abstract
Background Five to thirty percent of patients undergoing cardiac surgery present with chronic obstructive pulmonary disease (COPD) and have a 2- to 10-fold higher 30-day mortality risk. Cardiopulmonary bypass (CPB) creates a whole body systemic inflammatory response syndrome (SIRS) that could impair pulmonary function. Impaired pulmonary function can, however, be attenuated by pulmonary perfusion with oxygenated blood or custodiol HTK (histidine-tryptophan-ketoglutarate) solution. Methods/Design The Pulmonary Protection Trial (PP-Trial) randomizes 90 patients undergoing CPB-dependent cardiac surgery to evaluate whether pulmonary perfusion with oxygenated blood or custodiol HTK solution reduces postoperative pulmonary dysfunction in COPD patients. Further, we aim for a non-randomized evaluation of postoperative pulmonary function after transcatheter aortic-valve implantation (TAVI). The primary outcome measure is the oxygenation index measured from anesthesia induction to the end of surgery and until 24 hours after anesthesia induction for a total of six evaluations. Discussion Patients with COPD may be impaired by hypoxemia and SIRS. Thus, prolonged recovery and even postoperative complications and death may be reflected by the degree of hypoxemia and SIRS. The limited sample size does not aim for confirmatory conclusions on mortality, cardiovascular complications or risk of pneumonia and sepsis, but the PP-Trial is considered an important feasibility trial paving the road for a multicenter confirmatory trial. Trial registration ClinicalTrials.gov: NCT01614951.
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Affiliation(s)
- Katrine B Buggeskov
- Department of Thoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, The Heart Centre dept, 4142, Blegdamsvej 9, 2100 Copenhagen, Denmark.
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Mo A, Wen Z, Lin H, Lu C, Liang S. Mitral valve replacements under on-pump beating heart and lung perfusion/ventilation using a minithoracotomy: an experience with 11 cases. Heart Surg Forum 2012; 15:E133-5. [PMID: 22698599 DOI: 10.1532/hsf98.20121013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The primary aims of minimally-invasive cardiac valve surgery are to lessen the impact of the incision, extracorporeal circulation, myocardial ischemia, and pulmonary ischemia, to obtain satisfactory therapeutic results, and to allow a quicker rehabilitation. In this study, the feasibility of minimally-invasive mitral valve replacements without ascending aorta and vena cava cross-clamping under beating heart was evaluated by surveying 11 patients. METHODS Preoperative risk factors, intraoperative techniques, and postoperative complications were surveyed and evaluated for one year (April 1, 2009 to March 30, 2010) in 11 patients who had undergone beating-heart mitral valve replacement surgery at The People's Hospital of Guangxi Zhuang Autonomous Region. Minithoracotomy and femoral arterial cannulation procedures were used in the surgeries for cardiopulmonary bypass (CPB) without ascending aorta and vena cava cross-clamping. RESULTS The operations were performed successfully in all 11 patients. The CPB time was 52.80 ± 11.36 minutes; the mean postoperative mechanical ventilation assistance time was 8.20 ± 2.84 hours; and the mean transfusion volume of red cells was 2.20 ± 1.04 units. There were no cerebral complications, no periprosthetic leakage, no occurrence of permanent high-degree atrioventricular blockage, and no mortality. CONCLUSION Mitral valve replacement on the beating heart using a minithoracotomy and femoral arterial cannulation for CPB without ascending aorta and vena cava crossclamping under pulmonary ventilation is feasible. A larger number of patients are required to further characterize the efficacy and safety of this procedure.
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Affiliation(s)
- Ansheng Mo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Traditional Chinese Medical University, Nanning Department of Cardiothoracic Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China.
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17
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Santini F, Onorati F, Telesca M, Menon T, Mazzi P, Berton G, Faggian G, Mazzucco A. Selective pulmonary pulsatile perfusion with oxygenated blood during cardiopulmonary bypass attenuates lung tissue inflammation but does not affect circulating cytokine levels. Eur J Cardiothorac Surg 2012; 42:942-50. [DOI: 10.1093/ejcts/ezs199] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Macedo FIB, Gologorsky E, Salerno TA. Beating-heart valve surgery: is the introduction of lung perfusion/ventilation the next step? Future Cardiol 2011; 7:61-7. [DOI: 10.2217/fca.10.115] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Myocardial and pulmonary ischemia during cardiopulmonary bypass has been associated with postoperative cardiac and pulmonary dysfunction, as well as poor outcomes. Beating-heart valve surgery utilizing continuous coronary perfusion with warm oxygenated blood via the antegrade/retrograde routes, is a novel strategy for myocardial protection. Conceptually, it is proposed that maintenance of pulmonary perfusion and ventilation during the cardiopulmonary bypass period also might be advantageous. The most current evidence regarding these evolving techniques and further areas of research are discussed in this article.
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Affiliation(s)
- Francisco Igor B Macedo
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL, USA
| | - Edward Gologorsky
- Department of Anesthesiology, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL, USA
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den Hengst WA, Gielis JF, Lin JY, Van Schil PE, De Windt LJ, Moens AL. Lung ischemia-reperfusion injury: a molecular and clinical view on a complex pathophysiological process. Am J Physiol Heart Circ Physiol 2010; 299:H1283-99. [PMID: 20833966 DOI: 10.1152/ajpheart.00251.2010] [Citation(s) in RCA: 274] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Lung ischemia-reperfusion injury remains one of the major complications after cardiac bypass surgery and lung transplantation. Due to its dual blood supply system and the availability of oxygen from alveolar ventilation, the pathogenetic mechanisms of ischemia-reperfusion injury in the lungs are more complicated than in other organs, where loss of blood flow automatically leads to hypoxia. In this review, an extensive overview is given of the molecular and cellular mechanisms that are involved in the pathogenesis of lung ischemia-reperfusion injury and the possible therapeutic strategies to reduce or prevent it. In addition, the roles of neutrophils, alveolar macrophages, cytokines, and chemokines, as well as the alterations in the cell-death related pathways, are described in detail.
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Affiliation(s)
- Willem A den Hengst
- Department of Thorax and Vascular Surgery, University of Antwerp, Antwerp, Belgium
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20
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Stassano P, Di Tommaso L, Monaco M, Mannacio VA, Mottola M, La Marca A, Pepino P, Vosa C. Left ventricular-assisted myocardial revascularization favorably affects levels of circulating adhesion molecules and lung function. Surgery 2010; 147:434-40. [DOI: 10.1016/j.surg.2009.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 10/05/2009] [Indexed: 10/20/2022]
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Macedo FIB, Carvalho EM, Gologorsky E, Barron M, Hassan M, Salerno TA. Gas Exchange during Lung Perfusion/Ventilation during Cardiopulmonary Bypass: Preliminary Results of a Pilot Study. Open J Cardiovasc Surg 2010. [DOI: 10.4137/ojcs.s4109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Lung perfusion/ventilation was introduced as a means to minimize cardiopulmonary (CPB)-related pulmonary ischemic injury. Current results in the literature are divergent, and the role of gas exchange during lung perfusion/ventilation during CPB, remains undefined. This report details a) the technique of continuous lung perfusion/ventilation during CPB, b) provides initial observations, and c) discusses gas exchange during CPB.
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Affiliation(s)
| | | | - Edward Gologorsky
- Department of Anesthesiology, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida
| | - Michael Barron
- Department of Anesthesiology, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida
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22
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Gabriel EA, Fagionato Locali R, Katsumi Matsuoka P, Santiago Almeida L, Guerreiro Silva I, Capelozzi VL, Salerno TA, Buffolo E. Lung perfusion during cardiac surgery with cardiopulmonary bypass: is it necessary? Interact Cardiovasc Thorac Surg 2008; 7:1089-95. [DOI: 10.1510/icvts.2008.184275] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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23
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Siepe M, Goebel U, Mecklenburg A, Doenst T, Benk C, Stein P, Beyersdorf F, Loop T, Schlensak C. Pulsatile pulmonary perfusion during cardiopulmonary bypass reduces the pulmonary inflammatory response. Ann Thorac Surg 2008; 86:115-22. [PMID: 18573409 DOI: 10.1016/j.athoracsur.2008.03.062] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Revised: 03/19/2008] [Accepted: 03/25/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pulmonary dysfunction presumably linked to an inflammatory response is frequent after cardiac operations using cardiopulmonary bypass (CPB) and pulmonary hypoperfusion. We previously demonstrated that active perfusion of the lungs during CPB reduces ischemic lung injury. We now hypothesized that avoiding ischemia of the lungs during CPB by active pulmonary perfusion would decrease pulmonary inflammatory response. METHODS Pigs were randomized to a control group with CPB for 120 minutes, followed by 120 minutes of postbypass reperfusion, or to the study groups where animals underwent active pulmonary perfusion with pulsatile or nonpulsatile perfusion during CPB (n = 7 in each group). Activation of transcription factor activity (nuclear factor [NF]-kappaB and activating protein [AP]-1) was determined by electrophoretic mobility shift assay. Levels of proinflammatory protein expression (interleukin [IL]-1, IL-6, and tumor necrosis factor [TNF]-alpha) were quantified by enzyme-linked immunoabsorbent assay. Caspase-3 activity was measured using a fluorogenic assay. RESULTS The activation of transcription factor AP-1 and NF-kappaB was reduced in the pulsatile pulmonary perfusion group. The caspase-3 activity and the expression of IL-1, IL-6, and TNF-alpha revealed a significant decrease in the pulsatile and nonpulsatile pulmonary perfusion groups. Animals of the pulsatile pulmonary perfusion group showed significantly reduced IL-6 expression and caspase-3 activity compared with the nonpulsatile pulmonary perfusion group. CONCLUSIONS Active pulmonary perfusion reduces the inflammatory response and apoptosis in the lungs observed during conventional CPB. This effect is greatest when pulmonary perfusion is performed with pulsatility. The reduction in cytokine expression by pulsatile pulmonary perfusion might be mediated by AP-1 and NF-kappaB.
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Affiliation(s)
- Matthias Siepe
- Department of Cardiovascular Surgery, University Medical Center, Freiburg, Germany
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24
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Abstract
Postoperative lung injury is a common, although decreasing, complication of cardiac surgery. This article discusses various means to prevent and minimize postoperative lung injury. These include lung-protective strategies, pharmacologic strategies, and mechanical ventilation.
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Affiliation(s)
- Jayashree K Raikhelkar
- Department of Anesthesiology, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, New York, NY 10029-6574, USA.
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Nakajima T, Kawazoe K, Izumoto H, Kataoka T, Niinuma H, Shirahashi N. Risk Factors for Hypoxemia After Surgery for Acute Type A Aortic Dissection. Surg Today 2006; 36:680-5. [PMID: 16865510 DOI: 10.1007/s00595-006-3226-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 01/17/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE Postoperative hypoxemia is a frequent complication of surgery for acute type A aortic dissection. We tried to determine the factors associated with postoperative hypoxemia. METHODS Between 1997 and 2003, 114 patients underwent surgery for acute type A aortic dissection. Multivariate logistic regression analysis was done to identify the independent predictors of postoperative hypoxemia, defined by an arterial partial oxygen/inspired oxygen fraction (PaO(2)/FiO(2)) ratio of 200 or lower. RESULTS The overall in-hospital mortality was 6.1% (7 of 114 patients), being 5.2% in the hypoxemia group and 6.9% in the non-hypoxemia group. The ventilation time and intensive care unit stay were significantly longer in the hypoxemia group than in the non-hypoxemia group (P = 0.0044, P = 0.038, respectively). Logistic regression identified the following variables as predictors for postoperative hypoxemia: body mass index > or = 25 (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.1-15.01; P < 0.001), preoperative PaO(2)/FiO(2) ratio < or = 300 (OR, 2.6; 95% CI, 1.09-6.13; P = 0.031), and the volume of transfused blood (OR, 1.08; 95% CI, 1.01-1.18; P = 0.037). CONCLUSIONS Initiating early treatment for hypoxemia and reducing the volume of blood transfused intraoperatively may improve the postoperative clinical course of obese patients with preoperative hypoxemia.
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Affiliation(s)
- Takayuki Nakajima
- Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center, Iwate Medical University, 1-2-1 Chuodori, Morioka 020-8505, Japan
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Huang PS, Tang GJ, Chen CH, Kou YR. Whole-body moderate hypothermia confers protection from wood smoke-induced acute lung injury in rats: The therapeutic window*. Crit Care Med 2006; 34:1160-7. [PMID: 16484924 DOI: 10.1097/01.ccm.0000207342.50559.0f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Toxic smoke inhalation causes acute lung injury. We studied the efficacy and therapeutic window of whole-body hypothermia in rats with wood smoke-induced acute lung injury. DESIGN Randomized, controlled study. SETTING Research laboratory. SUBJECTS Anesthetized, paralyzed, and artificially ventilated rats (n = 100) were used. INTERVENTIONS Air or wood smoke (30 breaths) was delivered into the lung using a respirator. Immediately after challenge, the rat's colonic temperature was kept a) 37 degrees C (normothermia, NT) for 1 (NT-1-Air and NT-1-Smoke), 2.5 (NT-2.5-Air and NT-2.5-Smoke), or 5 hrs (NT-5-Air and NT-5-Smoke) in six groups; b) 30 degrees C (hypothermia, HT) for 2.5 (HT-2.5-Smoke) or 5 hrs (HT-5-Air and HT-5-Smoke) in three groups; c) 30 degrees C for the first 2.5 hrs followed by 37 degrees C for another 2.5 hrs (HT-NT-5-Smoke) in one group; or d) 37 degrees C for the first 2.5 hrs followed by 30 degrees C for another 2.5 hrs (NT-HT-5-Smoke) in on group. MEASUREMENTS AND MAIN RESULTS Various acute lung injury indexes were assessed at 1, 2.5, or 5 hrs after challenge. In the air group, whole-body hypothermia did not affect the level of lung lipid peroxidation and the amount of proteins, total and differential cell counts, and concentrations of tumor necrosis factor-alpha and interleukin-1beta in bronchoalveolar lavage fluid. In the smoke groups, these acute lung injury indexes were increased showing that NT-5-Smoke > NT-2.5-Smoke > NT-1-Smoke. Whole-body hypothermia prevented increases in these acute lung injury indexes in the HT-2.5-Smoke and HT-5-Smoke groups. The efficacy of whole-body hypothermia in the HT-NT-5-Smoke group was superior to that in the NT-HT-5-Smoke group and similar to that in the HT-5-Smoke group. Whole-body hypothermia also alleviated smoke-induced poor gas exchange, pulmonary edema, and pathohistologic injurious signs. CONCLUSIONS Whole-body hypothermia confers protection from wood smoke-induced acute lung injury in rats by suppressing oxidant bronchoalveolar damage and pulmonary inflammation. Early and short-period (2 hrs) application of whole-body hypothermia provides favorable therapeutic effects.
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Affiliation(s)
- Pin-Shiun Huang
- Institute of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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27
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An JK, Blomenkamp K, Lindblad D, Teckman JH. Quantitative isolation of alphalAT mutant Z protein polymers from human and mouse livers and the effect of heat. Hepatology 2005; 41:160-7. [PMID: 15619240 DOI: 10.1002/hep.20508] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Alpha-1-antitrypsin (alpha1AT) deficiency in its most common form is caused by homozygosity for the alpha1AT mutant Z gene. This gene encodes a mutant Z secretory protein, primarily synthesized in the liver, that assumes an abnormal conformation and accumulates within hepatocytes causing liver cell injury. Studies have shown that mutant alpha1ATZ protein molecules form unique protein polymers. These Z protein polymers have been hypothesized to play a critical role in the pathophysiology of liver injury in this disease, although a lack of quantitative methods to isolate the polymers from whole liver has hampered further analysis. In this study, we demonstrate a quantitative alpha1ATZ polymer isolation technique from whole liver and show that the hepatocellular periodic acid-Schiff-positive globular inclusions that are the histopathological hallmark of this disease are composed almost entirely of the polymerized alpha1ATZ protein. Furthermore, we examine the previously proposed but untested hypothesis that induction of alpha1ATZ polymerization by the heat of physiological fever is part of the mechanism of hepatic alpha1ATZ protein accumulation. The results, however, show that fever-range temperature elevations have no detectable effect on steady-state levels of intrahepatic Z protein polymer in a model in vivo system. In conclusion, methods to separate insoluble protein aggregates from liver can be used for quantitative isolation of alpha1ATZ protein polymers, and the effect of heat from physiological fever may be different in vivo compared with in vitro systems.
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Affiliation(s)
- Jae-Koo An
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
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28
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Eichler W, Bechtel MJF, Klaus S, Heringlake M, Hernandez M, Toerber K, Klotz KF, Bartels C. Na /H+ exchange inhibitor cariporide: effects on respiratory dysfunction after cardiopulmonary bypass. Perfusion 2004; 19:33-40. [PMID: 15072253 DOI: 10.1191/0267659104pf712oa] [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] [Indexed: 11/05/2022]
Abstract
The purpose of the present study was to evaluate the potential of the Na+/H+ exchange inhibitor cariporide to protect the lung from injury after cardiopulmonary bypass (CPB). In a randomized placebo-controlled study, 16 pigs were subjected to CPB for 75 min. Administration of vehicle or cariporide (bolus 180 mg, 40 mg/hour) began 30 min pre-CPB and was continued throughout the protocol. The alveolo-arterial O2-gradient (AaDO2), the pulmonary shunt (Qs/Qt), the compliance (Cpl), haemodynamic variables and glycerol and water content in lung tissue were measured 10 min before and up to 180 min post-CPB. All animals in the control versus 75% in the cariporide group survived the experiment. At 5 and 60 min post-CPB, the mean AaDO2 and at 5, 60 and 180 min post-CPB, the mean pulmonary vascular resistance index were higher in the cariporide group (p < 0.05), respectively. More lung water accumulation was found in the cariporide group (p < 0.05). Mean Cpl decreased; the Qs/ Qt and glycerol in lung tissue increased without significant intergroup difference. In this model, the inhibitor of the Na+/H+ antiporter showed no protective effect on lung injury after CPB and might even have harmful effects on pulmonary vascular tone and function.
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De Santo LS, Romano G, Amarelli C, Della Corte A, Onorati F, Torella M, De Feo M, Nappi GA, Cotrufo M. Pilot study on prevention of lung injury during surgery for type A acute aortic dissection: no evident improvements with celsior flushing through the pulmonary artery. Int J Artif Organs 2004; 26:1032-8. [PMID: 14708832 DOI: 10.1177/039139880302601109] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Postoperative respiratory failure is a frequent and serious complication in patients with type A acute aortic dissection. Experimental evidence suggests that pulmonary artery perfusion using hypothermic protective solutions helps prevent lung injury. The aim of this pilot prospective study was to evaluate the effect of pulmonary artery flushing during selective cerebral perfusion (SCP) on lung function. METHODS Twenty patients referred for acute type A aortic dissection, who were free from preoperative respiratory dysfunction, were assigned prospectively and alternately to two treatment groups. Pulmonary flushing was performed during SCP in group P (10 patients), while conventional Kazui technique was applied in group N (10 patients). Lung perfusion consisted of single-shot hypothermic pulmonary artery flush with Celsior. Lung function was evaluated by intubation time, scoring of chest radiograms at 12 hours after CPB, and PaO2/FiO2 assessed from immediately before surgery to 72 hours after termination of cardiopulmonary bypass. RESULTS Incidence of pre, intra and post operative determinants of lung dysfunction proved homogeneous in both groups. Lung oxygenation function showed a marked post operative decline followed by a slow improvement in both groups. Analysis of respiratory ratios did not disclose significant differences even though the flushed group had a better performance in all study patients. The incidence of prolonged ventilator support (longer than 72 hours) (30% vs 20%, p = NS) and severity of x-ray pulmonary infiltrate score were comparable (mean score 1.7 +/- 0.71 vs 1.6 +/- 0.68, p = NS). CONCLUSIONS Pulmonary artery flushing with Celsior solution does not seem to provide an effective preservation of lung function.
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Affiliation(s)
- L S De Santo
- Department of Cardio-Thoracic and Respiratory Sciences, Second University of Naples, V. Monaldi Hospital, Naples, Italy.
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Maharaj C, Laffey JG. New strategies to control the inflammatory response in cardiac surgery. Curr Opin Anaesthesiol 2004; 17:35-48. [PMID: 17021527 DOI: 10.1097/00001503-200402000-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To present and interpret data from recent clinical studies (July 2002-August 2003) of strategies to control the inflammatory response after cardiac surgery. RECENT FINDINGS Off-pump coronary artery bypass techniques, which avoid the need for extracorporeal circulation, attenuate the inflammatory response and appear to confer clinical benefit. Concerns regarding the quality of the revascularization after off-pump coronary artery bypass appear to have been allayed. At present, ventricular assist devices do not enhance the efficacy of off-pump coronary artery bypass. In patients undergoing cardiopulmonary bypass, heparin-coated circuits, hypothermic pulmonary perfusion, normoxic reperfusion after aortic unclamping, and modified ultrafiltration hold promise. Strategies to maintain perioperative haemodynamic stability, such as enoximone therapy, may be beneficial, particularly in elderly patients. Aprotinin may have important beneficial anti-inflammatory actions in higher-risk adult and paediatric patients. The therapeutic potential of corticosteroids, particularly when administered in multiple dosages is increasingly clear. Direct anti-mediator therapies that focus upon key effector molecules and pathways of the inflammatory response offer future therapeutic options. SUMMARY The potential for strategies that inhibit the inflammatory response to improve outcome after cardiac surgery is clear. Large-scale multicentre trials investigating the most promising strategies, including off-pump coronary artery bypass, heparin-coated circuits, and perioperative corticosteroid and aprotinin therapy, are urgently needed. These trials need to be restricted to the high-risk patient groups most likely to experience benefit. In the interim, the optimal strategy to minimize the inflammatory response to cardiac surgery will remain elusive.
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Affiliation(s)
- Chris Maharaj
- Department of Anaesthesia and Intensive Care, University College Hospital, Galway, Ireland
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