Management of priming fluids in cardiopulmonary bypass for adult cardiac surgery: network meta-analysis

Intraoperative Use of Sodium Bicarbonate Ringer's Solution Instead of Sodium Lactate Ringer's Solution to Reduce Endothelial Glycocalyx Degradation and Improve Postoperative Recovery During Cardiopulmonary Bypass Cardiac Surgery: A Single-Center Prospective Cohort Study

Objective

To investigate the effect of sodium bicarbonate Ringer's solution (BRS) on the degradation of endothelial glycocalyx components in patients undergoing cardiopulmonary bypass (CPB) during cardiac surgery, and to evaluate its impact on endothelial glycocalyx preservation and postoperative recovery.

Patients and Methods

A total of eight patients scheduled for elective CPB heart surgery were included and randomly divided into two groups: the sodium lactate Ringer's solution (LRS) group and the BRS group. ELISA was used to measure plasma concentrations of syndecan-1, matrix metalloproteinase-9 (MMP-9), matrix metalloproteinase-3 (MMP-3), IL-6, IL-8, TNF-α, and TGF-β at predefined time points: T0 (before induction of anesthesia), T3 (immediately after weaning from CPB), T5 and T6 (24 and 72 hours postoperatively). Serum creatinine concentrations were measured within 48 hours postoperatively. The incidence of postoperative delirium (POD) was assessed three days after surgery. Postoperative mechanical ventilation time, duration of stay in the intensive care unit and hospital stay were also documented.

Results

The BRS group had significantly lower plasma concentrations of syndecan-1 at T3 (7.98 [7.43, 8.92] ng/mL vs 9.54 [8.4, 10.73] ng/mL, P < 0.001) and T5 (4.20 [3.31, 4.96] ng/mL vs 5.40 [3.95, 6.55] ng/mL, P = 0.001) in comparison with the LRS group (P<0.01). Syndecan-1 levels in both groups were similar at T6 (3.18 [2.88, 3.5]ng/mL vs 3.12 [2.77, 3.45] ng/mL, P > 0.05). Additionally, MMP-9, MMP-3, IL-6 and IL-8 were significantly lower at T3 and T5 in the BRS group (P<0.05 and P<0.01, respectively). However, no significant differences were observed between the two groups in the incidence of acute kidney injury (AKI) or POD (P > 0.05).

Conclusion

BRS has the potential to reduce glycocalyx degradation in patients undergoing heart valve surgery with CPB. However, both groups demonstrated similar post-postoperative clinical outcomes, including the rates of AKI and POD.

The effect of mannitol on postoperative renal function in patients undergoing coronary artery bypass surgery: A double-blinded randomized controlled trial

Introduction

Mannitol, an osmotic diuretic solution, is commonly utilized in priming cardiopulmonary bypass (CPB) and can impact kidney function. This study was conducted to investigate the impact of mannitol use during CPB on kidney function in patients undergoing coronary artery bypass surgery.

Methods

This randomized, double-blind clinical trial studied 90 patients undergoing coronary artery bypass surgery. In the control group (n=45), the prime solution included Ringer's lactate, and in the intervention group (n=45), the prime solution had 200 ml of mannitol 20% and Ringer's lactate. A P-value<0.05 was considered significant. The primary endpoint of this study is renal function.

Results

Demographic characteristics and risk factors were not significantly different between the two groups (P>0.05). Additionally, there was no statistically significant difference between two groups in terms of CPB time, aortic cross-clamp time, length of time connected to mechanical ventilation, 30-day mortality, ICU, and hospital stay time (P>0.05). Furthermore, no statistically significant difference was observed between the two groups in serum creatinine levels (P=0.53) or BUN levels (P=0.13). The study also found no statistically significant difference in the diuresis rate between the two groups (P=0.10).

Conclusion

The present study has shown that adding mannitol to the prime has no effect on kidney function, length of time connected to mechanical ventilation, length of stay in the ICU, or 30-day mortality. Therefore, it suggests that mannitol cannot be used as a preventative strategy for acute kidney injury after cardiac surgery.

Effects of albumin and crystalloid priming strategies on red blood cell transfusions in on-pump cardiac surgery: a network meta-analysis

BACKGROUND

In on-pump cardiac surgery, the albumin priming strategy could maintain colloid osmotic pressure better than crystalloid solutions and reduce excessive perioperative fluid balance. However, a high-quality meta-analysis is required to compare the safety of these approaches in perioperative red blood cell (RBC) transfusions. Owing to limited direct evidence, we conducted a network meta-analysis (NMA) to increase the pool of studies and provide indirect evidence.

METHODS

The pre-defined primary outcomes were intraoperative and the first 24 h postoperative RBC transfusion volume in units. The pre-defined secondary outcome was postoperative blood loss (the first 24 h). We reviewed all randomized controlled trials comparing albumin, crystalloid, and artificial colloid priming strategies. Studies that only displayed pre-defined outcomes could be included. A pairwise meta-analysis was performed on studies that directly compared the pre-defined outcomes between albumin and crystalloids. Additionally, a random-effects network meta-analysis (NMA) model was employed to generate indirect evidence for the pre-defined outcomes between albumin and crystalloids.

RESULTS

The literature search identified 830 studies,10 of which were included in the final analysis. Direct meta-analysis indicated that crystalloid priming significantly decreased total perioperative RBC transfusions (MD: -0.68U; 95%CI: -1.26, -0.09U; P = 0.02) and intraoperative RBC transfusions (MD: -0.20U; 95%CI: -0.39, -0.01U; P = 0.03) compared to albumin. Postoperative RBC transfusions showed a decreasing trend in the crystalloid group; however, the difference was not statistically significant. (MD: -0.16U; 95%CI: -0.45, 0.14U; P = 0.30). After including indirect evidence, the NMA results continued to demonstrate a higher RBC receiving with the albumin priming strategy compared to crystalloids, although the differences did not reach statistical significance. For postoperative blood loss, direct evidence showed no significant differences between albumin and crystalloid priming strategies. However, NMA evidence displayed that albumin exist higher probability of reducing postoperative blood loss than crystalloid.

CONCLUSION

Both direct and NMA evidence indicated that the albumin priming strategy resulted in more perioperative RBC transfusions than crystalloids. Considering the additional blood management burden, the application of an albumin-priming strategy in on-pump cardiac surgery still needs more consideration.