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Strong AE, Zee J, Laskin BL, Howarth K, Blinder J, Chrischilles EA, Erez DL, Denburg MR. Urine dipstick blood and acute kidney injury in infants undergoing cardiopulmonary bypass. Pediatr Nephrol 2024:10.1007/s00467-024-06464-9. [PMID: 39093456 DOI: 10.1007/s00467-024-06464-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/14/2024] [Accepted: 07/05/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is associated with hemolysis and acute kidney injury (AKI). The study aim was to determine if urine dipstick blood in infants after CPB was associated with AKI and urine neutrophil gelatinase-associated lipocalin (NGAL). METHODS Infants who underwent CPB at a single center were enrolled prospectively between October 2017 and June 2019. Urine samples prior to CPB and 6 h after CPB cessation were analyzed in batch for NGAL and dipstick blood. AKI was defined using creatinine-based KDIGO criteria within 72 h of CPB. Spearman correlation examined associations between urine dipstick blood and NGAL at each time point. Linear regression estimated the associations between urine dipstick blood and log-transformed NGAL 6 h after CPB. Logistic regression estimated associations and compared discrimination between urine dipstick blood and NGAL for predicting AKI. RESULTS At baseline, 7/63 samples (11%) had > trace blood. Six hours after CPB, 62/98 samples (63%) had > trace blood and 26% had 3 + (large) blood. In total, 18/98 (18%) with a 6-h post-CPB sample had postoperative AKI. Urine dipstick blood values correlated with urine NGAL 6 h after CPB (r = 0.52, p < 0.01), but not at baseline (r = 0.06, p = 0.66). Those with 3 + (large) blood on urine dipstick had 6 times higher mean NGAL values compared to those with negative/trace blood (mean ratio 6.6, 95%CI 3.1-14.4, p < 0.01). Those with 3 + (large) blood had 8 times higher odds of AKI (OR 7.99, 95%CI 1.5-41.9, p = 0.01). CONCLUSIONS Urine dipstick blood post CPB may be a simple and inexpensive tool to help predict AKI in infants.
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Affiliation(s)
- Amy E Strong
- Division of Nephrology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Jarcy Zee
- Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin L Laskin
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kathryn Howarth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joshua Blinder
- Division of Cardiology, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | | | - Daniella Levy Erez
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michelle R Denburg
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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2
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Chand S, R A, Gupta D. Investigating non-immune haemolytic transfusion reactions in surgical patients. Transfus Med 2022; 32:512-516. [PMID: 36124716 DOI: 10.1111/tme.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 07/14/2022] [Accepted: 08/19/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To perform a Root Cause Analysis (RCA) to identify the cause for Acute Haemolytic Transfusion Reaction (AHTR) in five patients who received red cell transfusions. BACKGROUND The occurrence of red coloured urine following blood transfusion carries the possibility of an immune or non-immune mediated haemolytic transfusion reaction (HTR). Non-immune haemolysis can be due to thermal, osmotic, or mechanical injury to red blood cells. The authors report five cases of non-immune HTR that occurred in surgical patients in the peri-operative period. METHODS AHTR was reported to the Transfusion Medicine Department, in five patients who underwent surgery and received a blood transfusion in the peri-operative period. Transfusion reaction workup and RCA were performed to identify the cause for AHTR. RESULTS The initial presentation was red coloured urine and suspicion of an immune HTR. Immunohaematology workup ruled out an immune mediated haemolysis and further analysis revealed the possibility of mechanical red cell destruction in all these cases. CONCLUSION Multiple factors can result in non-immune destruction of red cells. Possibility of non-immune haemolysis should be considered while evaluating haemolytic transfusion reactions.
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Affiliation(s)
- Sreethu Chand
- Department of Transfusion Medicine, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Amita R
- Department of Transfusion Medicine, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Debasish Gupta
- Department of Transfusion Medicine, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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3
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Cell-Free Hemoglobin Concentration in Blood Prime Solution Is a Major Determinant of Cell-Free Hemoglobin Exposure during Cardiopulmonary Bypass Circulation in the Newborn. J Clin Med 2022; 11:jcm11144071. [PMID: 35887835 PMCID: PMC9317140 DOI: 10.3390/jcm11144071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Abstract
Exposure to circulating cell-free hemoglobin is a ubiquitous feature of open-heart surgery on cardiopulmonary bypass circulation. This study aims to determine the origins and dynamics of circulating cell-free hemoglobin and its major scavenger proteins haptoglobin and hemopexin during neonatal cardiopulmonary bypass. Forty neonates with an isolated critical congenital heart defect were included in a single-center prospective observational study. Blood samples were obtained preoperatively, hourly during bypass circulation, after bypass separation, at admission to the pediatric intensive care unit, and at postoperative days 1–3. Concentrations of cell-free hemoglobin, haptoglobin and hemopexin were determined using ELISA. Neonates were exposed to significantly elevated plasma concentrations of cell-free hemoglobin and a concomitant depletion of scavenger protein supplies during open-heart surgery. The main predictor of cell-free hemoglobin exposure was the concentration of cell-free hemoglobin in blood prime solution. Concentrations of haptoglobin and hemopexin in prime solution were important determinants for intra- and postoperative circulating scavenger protein resources.
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Nuttha Lumlertgul
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Division of Nephrology and Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand
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6
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Foti L, Villa G, Romagnoli S, Ricci Z. Acute Kidney Injury and Extracorporeal Membrane Oxygenation: Review on Multiple Organ Support Options. Int J Nephrol Renovasc Dis 2021; 14:321-329. [PMID: 34413667 PMCID: PMC8370847 DOI: 10.2147/ijnrd.s292893] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/03/2021] [Indexed: 12/01/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a temporary life support system used to assist patients with life-threatening severe cardiac and/or respiratory insufficiency. Patients requiring ECMO can be considered the sickest patients admitted to the intensive care unit (ICU). Acute kidney injury (AKI) represents a frequent complication during ECMO, affecting up to 70% of patients, with multifactorial pathophysiology and an independent risk factor for mortality. Severe AKI requiring Continuous Renal Replacement Therapy (CRRT) occurs in 20% of ECMO patients, but multiple indications and different timing may imply a significantly higher application rate in different centers. CRRT can be run in parallel to ECMO through different vascular access, or it can be conducted in series by connecting the circuits. Anticoagulation of ECMO is typically managed with systemic heparin, but several approaches can be applied for the CRRT circuit, from no anticoagulation to the addition of intra-filter heparin or regional citrate anticoagulation. The combination of CRRT and ECMO can be considered a form of multiple organ support therapy, but this approach still requires optimization in timing, set-up, anticoagulation, prescription and delivery. The aim of this report is to review the pathophysiology of AKI, the CRRT delivery, anticoagulation strategies and outcomes of patients with AKI treated with ECMO.
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Affiliation(s)
- Lorenzo Foti
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Gianluca Villa
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Zaccaria Ricci
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy.,Pediatric Intensive Care Unit, Meyer Children's University Hospital, Florence, Italy
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7
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Gorvitovskaia AY, Scrimgeour LA, Potz BA, Sellke NC, Ehsan A, Sodha NR, Sellke FW. Lower preoperative hematocrit, longer hospital stay, and neurocognitive decline after cardiac surgery. Surgery 2020; 168:147-154. [PMID: 32178865 PMCID: PMC7311300 DOI: 10.1016/j.surg.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/29/2020] [Accepted: 02/01/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiopulmonary bypass may be associated with postoperative neurocognitive dysfunction; however, risk factors have not been clearly identified. We hypothesize that lower hematocrit levels are correlated with postoperative neurocognitive dysfunction. METHODS A total of 30 patients underwent cardiac operations utilizing cardiopulmonary bypass and screening for neurocognitive dysfunction preoperatively and on postoperative day 4. Patients were analyzed according to hematocrit preoperatively, 6 hours postoperatively, and on postoperative day 4, and whether they received intra or postoperative transfusions of packed red blood cells. Neurocognitive data is presented as a difference in Repeatable Battery for the Assessment of Neuropsychological Status standardized score from baseline to postoperative day 4 and analyzed by unpaired two-tailed Spearman test and unpaired Mann-Whitney U test. RESULTS There was a significant correlation between patients with lower hematocrit before surgery and a decline in neurocognitive function at postoperative day 4 (P < .05). All patients experienced a decrease in hematocrit during their hospital stay, but the hematocrit 6 hours postoperatively and postoperative day 4 did not impact cognition. Receiving a transfusion was also not associated with neurocognitive dysfunction. Patients with low hematocrit preoperatively had a consistently lower hematocrit throughout their stay. Prolonged total length of stay was also significantly associated with neurocognitive decline. CONCLUSION A lower preoperative hematocrit and prolonged length of hospital stay are correlated with neurocognitive decline after cardiac surgery utilizing cardiopulmonary bypass.
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Affiliation(s)
- Anastassia Y Gorvitovskaia
- Brown University School of Medicine, Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, RI
| | - Laura A Scrimgeour
- Brown University School of Medicine, Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, RI
| | - Brittany A Potz
- Brown University School of Medicine, Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, RI
| | - Nicholas C Sellke
- Brown University School of Medicine, Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, RI
| | - Afshin Ehsan
- Brown University School of Medicine, Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, RI
| | - Neel R Sodha
- Brown University School of Medicine, Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, RI
| | - Frank W Sellke
- Brown University School of Medicine, Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, RI.
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8
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Jungner Å, Vallius Kvist S, Romantsik O, Bruschettini M, Ekström C, Bendix I, Herz J, Felderhoff-Mueser U, Bibic A, In Apos T Zandt R, Gram M, Ley D. White Matter Brain Development after Exposure to Circulating Cell-Free Hemoglobin and Hyperoxia in a Rat Pup Model. Dev Neurosci 2020; 41:234-246. [PMID: 31991415 DOI: 10.1159/000505206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022] Open
Abstract
Neonates born with critical congenital heart defects are at risk of diffuse white matter injuries and neurodevelopmental impairments. This study aimed to determine the impact of circulating cell-free hemoglobin and hyperoxia, both present during cardiopulmonary bypass circulation, on white matter brain development. Postnatal day 6 rat pups were injected intraperitoneally with cell-free Hb or vehicle and exposed to hyperoxia (fiO2 = 0.8) or normoxia (fiO2 = 0.21) for 24 h. We evaluated apoptosis, myelination, and oligodendrocyte maturation with immunohistochemistry, gene and protein analyses, and in vivo diffusion tensor magnetic resonance imaging (MRI). Consistent with previous studies, we found an increase in apoptosis of oligodendrocytes as determined by TUNEL+ staining in Olig2+ cells in white matter, cortex, thalamus, and hippocampus following exposure to hyperoxia with no additional effect of cell-free Hb. A transient increase in the mRNA expression of intercellular adhesion molecule 1 at 6 h was observed following combined exposure to cell-free Hb and hyperoxia. No indications of oligodendrocyte maturational delay or hypomyelination were observed after either insult, delivered separately or combined, as determined by immunohistochemistry, Western blot, and diffusion tensor MRI. In our model, exposure to circulatory cell-free Hb, with or without concomitant hyperoxia, did not significantly alter brain white matter development.
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Affiliation(s)
- Åsa Jungner
- Department of Clinical Sciences Lund, Pediatric Surgery and Neonatal Care, Skane University Hospital, Lund University, Lund, Sweden,
| | - Suvi Vallius Kvist
- Department of Clinical Sciences Lund, Pediatrics, Lund University, Lund, Sweden
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Pediatric Surgery and Neonatal Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Pediatrics, Lund University, Lund, Sweden
| | - Claes Ekström
- Department of Clinical Sciences Lund, Pediatrics, Lund University, Lund, Sweden
| | - Ivo Bendix
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neuroscience, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Josephine Herz
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neuroscience, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ursula Felderhoff-Mueser
- Department of Pediatrics I, Neonatology and Experimental Perinatal Neuroscience, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Adnan Bibic
- Lund University Bioimaging Center, Lund University, Lund, Sweden
| | | | - Magnus Gram
- Department of Clinical Sciences Lund, Pediatrics, Lund University, Lund, Sweden
| | - David Ley
- Department of Clinical Sciences Lund, Pediatric Surgery and Neonatal Care, Skane University Hospital, Lund University, Lund, Sweden
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9
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Abstract
OBJECTIVES Cardiopulmonary bypass-induced endothelial dysfunction has been inferred by changes in pulmonary vascular resistance, alterations in circulating biomarkers, and postoperative capillary leak. Endothelial-dependent vasomotor dysfunction of the systemic vasculature has never been quantified in this setting. The objective of the present study was to quantify acute effects of cardiopulmonary bypass on endothelial vasomotor control and attempt to correlate these effects with postoperative cytokines, tissue edema, and clinical outcomes in infants. DESIGN Single-center prospective observational cohort pilot study. SETTING Pediatric cardiac ICU at a tertiary children's hospital. PATIENTS Children less than 1 year old requiring cardiopulmonary bypass for repair of a congenital heart lesion. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Laser Doppler perfusion monitoring was coupled with local iontophoresis of acetylcholine (endothelium-dependent vasodilator) or sodium nitroprusside (endothelium-independent vasodilator) to quantify endothelial-dependent vasomotor function in the cutaneous microcirculation. Measurements were obtained preoperatively, 2-4 hours, and 24 hours after separation from cardiopulmonary bypass. Fifteen patients completed all laser Doppler perfusion monitor (Perimed, Järfälla, Sweden) measurements. Comparing prebypass with 2-4 hours postbypass responses, there was a decrease in both peak perfusion (p = 0.0006) and area under the dose-response curve (p = 0.005) following acetylcholine, but no change in responses to sodium nitroprusside. Twenty-four hours after bypass responsiveness to acetylcholine improved, but typically remained depressed from baseline. Conserved endothelial function was associated with higher urine output during the first 48 postoperative hours (R = 0.43; p = 0.008). CONCLUSIONS Cutaneous endothelial dysfunction is present in infants immediately following cardiopulmonary bypass and recovers significantly in some patients within 24 hours postoperatively. Confirmation of an association between persistent endothelial-dependent vasomotor dysfunction and decreased urine output could have important clinical implications. Ongoing research will explore the pattern of endothelial-dependent vasomotor dysfunction after cardiopulmonary bypass and its relationship with biochemical markers of inflammation and clinical outcomes.
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10
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Girgis A, Millar J, Butt W, d'Udekem Y, Namachivayam SP. Peak Creatinine, Cardiopulmonary Bypass, and Mortality After Stage 1 Single-Ventricle Reconstruction. Ann Thorac Surg 2019; 109:1488-1494. [PMID: 31614137 DOI: 10.1016/j.athoracsur.2019.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/21/2019] [Accepted: 09/06/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Serum creatinine is the most commonly used marker to diagnose acute kidney injury. Studies exploring creatinine patterns in the single-ventricle population are scarce. We studied serum creatinine up to 5 postoperative days after the stage 1 operation and assessed its relationship with outcomes. METHODS Neonates who underwent a first-stage single-ventricle operation (Norwood or a Damus-Kaye-Stansel) between 2005 and 2017 were retrospectively analyzed. Peak percentage creatinine change (PPCC) was defined as the difference between the baseline (preoperative) and the peak postoperative level (within 5 postoperative days), expressed as a percentage of the baseline level. RESULTS Among 187 neonates included, the median PPCC was 38.7% (interquartile range, 14.1%-73.1%), and in-hospital mortality was 17% (31 of 187). A controlled analysis showed that for every 10-minute increase in cardiopulmonary bypass duration (CPB), the PPCC increased by 1.8% (95% confidence interval [CI], 0.7%-2.9%; P = .002). Risk of in-hospital death increased log-linearly with PPCC. The adjusted odds ratios for death in the hospital associated with a 50%, 100%, and 200%, increase in peak percentage creatinine change were 1.85 (95% CI, 1.23-2.78), 3.41 (95% CI, 1.15-7.72), and 11.66 (95% CI, 2.28-59.63), respectively. In-hospital death was also associated with CPB duration (adjusted odds ratio, 1.13 per 10-minute increase; 95% CI, 1.05-1.22; P = .001). CONCLUSIONS Increase in CPB duration has a strong linear association with increase in PPCC after stage 1 single-ventricle reconstruction. Increase in PPCC and CPB duration has a strong linear association with hospital mortality. It is important to identify therapies that minimize complications associated with prolonged CPB duration in high-risk populations.
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Affiliation(s)
- Andrew Girgis
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Johnny Millar
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Warwick Butt
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Yves d'Udekem
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Siva P Namachivayam
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
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11
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Summerfield DD, Hartung KJ, Wiese CR, Wockenfus AM, Katzman BM, Donato LJ, Karon BS. Relationship between free hemoglobin (hemolysis), potassium and ionized calcium in lithium heparin blood gas samples collected intraoperatively. Clin Biochem 2019; 70:46-48. [PMID: 31059687 DOI: 10.1016/j.clinbiochem.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/12/2019] [Accepted: 05/01/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Develop sample acceptability rules by determining the relationship between free hemoglobin level (hemolysis) and potassium or ionized calcium in blood gas samples collected intraoperatively. DESIGN AND METHODS Hemolysis was assessed visually or by H index for lithium heparin blood gas samples collected intraoperatively. During periods one and three this was done using two different rules for visual assessment of centrifuged lithium heparin plasma. During period two H index was measured for all visually hemolyzed samples on a Roche Cobas c501 analyzer to determine acceptability. Potassium and ionized calcium were measured in 75 lithium heparin whole blood samples on a Radiometer ABL90 to correlate H index and potassium or ionized calcium. RESULTS During period one 35 of 5808 (0.6%) blood gas samples had visual hemolysis levels exceeding tolerance for reporting of potassium. By switching to measured H index using a laboratory-established threshold, during period 2 we estimate that 171 of 5396 (3.2%) blood gas samples exceeded the H index threshold for reporting of potassium. In 75 intraoperative blood gas samples with H index and whole blood potassium and ionized calcium measured; we observed no relationship between H index and potassium or ionized calcium. During period 3 we switched to visual assessment of hemolysis with a greater tolerance for hemolysis; with only 3 of 5345 (0.06%) samples exceeding the new visual hemolysis threshold. CONCLUSION For blood gas samples collected intraoperatively, there is no relationship between hemolysis and measured potassium or ionized calcium. The results suggest that only grossly hemolyzed intraoperative blood gas samples should be rejected for measurement of whole blood potassium and ionized calcium.
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Affiliation(s)
- Daniel D Summerfield
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Katherine J Hartung
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Cynthia R Wiese
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Amy M Wockenfus
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brooke M Katzman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Leslie J Donato
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America.
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12
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Saylor DM, Buehler PW, Brown RP, Malinauskas RA. Predicting Plasma Free Hemoglobin Levels in Patients Due to Medical Device–Related Hemolysis. ASAIO J 2019; 65:207-218. [DOI: 10.1097/mat.0000000000000801] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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13
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Huff C, Mastropietro CW, Riley C, Byrnes J, Kwiatkowski DM, Ellis M, Schuette J, Justice L. Comprehensive Management Considerations of Select Noncardiac Organ Systems in the Cardiac Intensive Care Unit. World J Pediatr Congenit Heart Surg 2018; 9:685-695. [PMID: 30322370 DOI: 10.1177/2150135118779072] [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: 11/17/2022]
Abstract
As the acuity and complexity of pediatric patients with congenital cardiac disease have increased, there are many noncardiac issues that may be present in these patients. These noncardiac problems may affect clinical outcomes in the cardiac intensive care unit and must be recognized and managed. The Pediatric Cardiac Intensive Care Society sought to provide an expert review of some of the most common challenges of the respiratory, gastrointestinal, hematological, renal, and endocrine systems in pediatric cardiac patients. This review provides a brief overview of literature available and common practices.
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Affiliation(s)
- Christin Huff
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher W Mastropietro
- 2 Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | - Jonathan Byrnes
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Misty Ellis
- 5 Department of Pediatric Critical Care, University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | | | - Lindsey Justice
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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14
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Kim-Campbell N, Gretchen C, Callaway C, Felmet K, Kochanek PM, Maul T, Wearden P, Sharma M, Viegas M, Munoz R, Gladwin MT, Bayir H. Cell-Free Plasma Hemoglobin and Male Gender Are Risk Factors for Acute Kidney Injury in Low Risk Children Undergoing Cardiopulmonary Bypass. Crit Care Med 2017; 45:e1123-e1130. [PMID: 28863013 PMCID: PMC5657595 DOI: 10.1097/ccm.0000000000002703] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To determine the relationship between the production of cell-free plasma hemoglobin and acute kidney injury in infants and children undergoing cardiopulmonary bypass for cardiac surgery. DESIGN Prospective observational study. SETTING Twelve-bed cardiac ICU in a university-affiliated children's hospital. PATIENTS Children were prospectively enrolled during their preoperative outpatient appointment with the following criteria: greater than 1 month to less than 18 years old, procedures requiring cardiopulmonary bypass, no preexisting renal dysfunction. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma and urine were collected at baseline (in a subset), the beginning and end of cardiopulmonary bypass, and 2 hours and 24 hours after cardiopulmonary bypass in 60 subjects. Levels of plasma hemoglobin increased during cardiopulmonary bypass and were associated (p < 0.01) with cardiopulmonary bypass duration (R = 0.22), depletion of haptoglobin at end and 24 hours after cardiopulmonary bypass (R = 0.12 and 0.15, respectively), lactate dehydrogenase levels at end cardiopulmonary bypass (R = 0.27), and change in creatinine (R = 0.12). Forty-three percent of patients developed acute kidney injury. There was an association between plasma hemoglobin level and change in creatinine that varied by age (overall [R = 0.12; p < 0.01]; in age > 2 yr [R = 0.22; p < 0.01]; and in < 2 yr [R = 0.03; p = 0.42]). Change in plasma hemoglobin and male gender were found to be risk factors for acute kidney injury (odds ratio, 1.02 and 3.78, respectively; p < 0.05). CONCLUSIONS Generation of plasma hemoglobin during cardiopulmonary bypass and male gender are associated with subsequent renal dysfunction in low-risk pediatric patients, especially in those older than 2 years. Further studies are needed to determine whether specific subgroups of pediatric patients undergoing cardiopulmonary bypass would benefit from potential treatments for hemolysis and plasma hemoglobin-associated renal dysfunction.
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Affiliation(s)
- Nahmah Kim-Campbell
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Catherine Gretchen
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Clifton Callaway
- Department of Emergency Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Kathryn Felmet
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| | - Timothy Maul
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Peter Wearden
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
- Nemours Cardiac Center –Florida, Orlando, FL
| | - Mahesh Sharma
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Melita Viegas
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Ricardo Munoz
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Mark T. Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA
- Division of Pulmonary, Allergy and Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Hülya Bayir
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
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15
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Jungner Å, Vallius S, Bruschettini M, Romantsik O, Gram M, Ley D. Cardiopulmonary bypass in the newborn: effects of circulatory cell-free hemoglobin and hyperoxia evaluated in a novel rat pup model. Intensive Care Med Exp 2017; 5:45. [PMID: 28980221 PMCID: PMC5628085 DOI: 10.1186/s40635-017-0153-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 08/21/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Infants with congenital heart defects (CHD) are at risk for white matter brain injury. This novel rat pup model characterizes the systemic effects of intravasal cell-free hemoglobin and hyperoxia, hypothesizing that immature endogenous scavenging systems relate to increased vulnerability to conditions present during cardiopulmonary bypass (CPB). METHODS Plasma pharmacokinetics of cell-free human hemoglobin (Hb) was determined after intraperitoneal (i.p.) administration in postnatal day 6 (P6) rat pups. Cell-free hemoglobin degradation, scavenger- and oxidative stress responses in altered oxygen environments were evaluated in P6 rat pups exposed to i.p. cell-free Hb or vehicle and subjected to hyperoxia or normoxia for 24 h. Plasma and liver were analyzed for free heme, haptoglobin, hemopexin, heme-oxygenase 1, and 8-OHdG at 3-120 h post-injection. Baseline scavenging properties were evaluated in P0-P12 rat pups. RESULTS Cell-free Hb displayed peak plasma concentrations of 3.6 ± 0.5 mg/mL (mean ± SD) at 3 h post-administration. Animals exposed to cell-free Hb demonstrated a 30-fold increase in plasma haptoglobin and a decrease in plasma hemopexin to 1/6 of concentrations observed in pups exposed to vehicle. Exposure to cell-free Hb and hyperoxia mediated increased plasma concentrations of free heme (72.7 ± 19.5 μM, mean ± SD) compared to exposure to cell-free Hb and normoxia (49.3 ± 13.1 μM) at 3 h, and an elevated hepatic mRNA expression of heme-oxygenase 1. mRNA expression of haptoglobin and hemopexin was increased in animals exposed to hemoglobin with a mitigated response in pups exposed to hemoglobin and hyperoxia. Animals exposed to hyperoxia displayed an increase in hepatic transcription of scavenger proteins at 24 h. Combined exposure to cell-free Hb and hyperoxia mediated an increased DNA-oxidation at 6 h, whereas all insults conveyed a decrease in DNA-oxidation at 120 h. CONCLUSIONS In this study, we present a novel rat pup model with scavenging characteristics and brain maturation similar to newborns with CHD. We have confirmed a distinct scavenger response after exposure to systemic cell-free hemoglobin. We have indications of an accelerated metabolism of cell-free Hb and of an altered transcription of scavenger proteins in a hyperoxic environment. We believe that this model will prove valuable in future delineation of inflammatory and oxidative end-organ damage following CPB.
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Affiliation(s)
- Åsa Jungner
- Department of Clinical Sciences Lund, Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Pediatric Surgery and Neonatal Care, Skane University Hospital, Lund University, Lund, Sweden
- Pediatric Intensive Care Unit (BIVA), Skane University Hospital, Lund, Sweden
| | - Suvi Vallius
- Department of Clinical Sciences Lund, Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Pediatric Surgery and Neonatal Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Pediatric Surgery and Neonatal Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Magnus Gram
- Department of Clinical Sciences Lund, Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, Lund, Sweden
| | - David Ley
- Department of Clinical Sciences Lund, Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Pediatric Surgery and Neonatal Care, Skane University Hospital, Lund University, Lund, Sweden
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16
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De Villiers WL, Murray AA, Levin AI. Expediting red blood cell transfusions by syringing causes significant hemolysis. Transfusion 2017; 57:2747-2751. [PMID: 28833178 DOI: 10.1111/trf.14283] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/17/2017] [Accepted: 06/20/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Techniques commonly used to expedite blood transfusions include pneumatically pressurizing red blood cell (RBC) bags or manual syringing its contents. We compared these techniques on RBC hemolysis using a simulated transfusion model. STUDY DESIGN AND METHODS Fifteen warmed RBC units that were 12.3 ± 4.3 (95% confidence interval [CI], 10.1-14.5) days old were each subjected to two experimental rapid transfusion techniques. RBCs from each technique were directed through 18- and 22-gauge cannulas attached to blood administration sets. One technique involved RBC bag pressurization to 300 mmHg. The other employed a 20-mL syringe to effect forceful, manual aspiration from the RBC bag followed by forceful, manual RBC injection. The control group was gravity driven without cannulas. Free hemoglobin (Hb) concentrations were measured and percent hemolysis was calculated. RESULTS Free Hb concentrations and percent hemolysis (median [95% CI]) were similar in the control (0.05 [0.03-0.08] g/dL and 0.13% [0.09%-0.17%], respectively) and pressurized experiments (0.06 [0.05-0.09] g/dL; 0.14% [0.12%-0.22%]), respectively. Syringing resulted in 10-fold higher free Hb concentrations (0.55 [0.38-0.92] g/dL) and percent hemolysis (1.28% [1.03%-2.15%]) than when employing the control (p < 0.0001) or pressurization (p < 0.0001) techniques. Cannula sizes studied did not affect hemolysis. CONCLUSION Forceful manual syringing caused significant hemolysis and high free Hb concentrations. Pressurizing RBC bags induced no more hemolysis than after gravity-facilitated transfusions. Syringing to expedite RBC transfusions should be avoided in favor of pneumatic RBC bag pressurization.
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Affiliation(s)
- Willem Lambertus De Villiers
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Tygerberg, South Africa
| | - Adriaan Albertus Murray
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Tygerberg, South Africa
| | - Andrew Ian Levin
- Department of Anesthesiology and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Tygerberg, South Africa
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17
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Riley A, Gebhard DJ, Akcan-Arikan A. Acute Kidney Injury in Pediatric Heart Failure. Curr Cardiol Rev 2016; 12:121-31. [PMID: 26585035 PMCID: PMC4861941 DOI: 10.2174/1573403x12666151119165628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/15/2015] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) is very common in pediatric medical and surgical cardiac patients. Not only is it an independent risk factor for increased morbidity and mortality in the short run, but repeated episodes of AKI lead to chronic kidney disease (CKD) especially in the most vulnerable hosts with multiple risk factors, such as heart transplant recipients. The cardiorenal syndrome, a term coined to emphasize the bidirectional nature of simultaneous or sequential cardiac-renal dysfunction both in acute and chronic settings, has been recently described in adults but scarcely reported in children. Despite the common occurrence and clinical and financial impact, AKI in pediatric heart failure outside of cardiac surgery populations remains poorly studied and there are no large-scale pediatric specific preventive or therapeutic studies to date. This article will review pediatric aspects of the cardiorenal syndrome in terms of pathophysiology, clinical impact and treatment options.
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Affiliation(s)
| | | | - Ayse Akcan-Arikan
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
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18
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Mazzone AL, Baker RA, Gleadle JM. Mending a broken heart but breaking the kidney. Nephrology (Carlton) 2016; 21:812-20. [DOI: 10.1111/nep.12799] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/05/2016] [Accepted: 04/09/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Annette L Mazzone
- Department of Cardiac Surgery Research and Perfusion, Cardiac and Thoracic Surgical Unit; Flinders Medical Centre; Adelaide South Australia Australia
- School of Medicine; Flinders University; Adelaide South Australia Australia
| | - Robert A Baker
- Department of Cardiac Surgery Research and Perfusion, Cardiac and Thoracic Surgical Unit; Flinders Medical Centre; Adelaide South Australia Australia
- School of Medicine; Flinders University; Adelaide South Australia Australia
| | - Jonathan M Gleadle
- School of Medicine; Flinders University; Adelaide South Australia Australia
- Department of Renal Medicine; Flinders Medical Centre; Adelaide South Australia Australia
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19
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The Complex Relationship of Extracorporeal Membrane Oxygenation and Acute Kidney Injury: Causation or Association? BIOMED RESEARCH INTERNATIONAL 2016; 2016:1094296. [PMID: 27006941 PMCID: PMC4783537 DOI: 10.1155/2016/1094296] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 01/29/2016] [Accepted: 01/31/2016] [Indexed: 12/23/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass (CPB) circuit capable of providing prolonged cardiorespiratory support. Recent advancement in ECMO technology has resulted in increased utilisation and clinical application. It can be used as a bridge-to-recovery, bridge-to-bridge, bridge-to-transplant, or bridge-to-decision. ECMO can restitute physiology in critically ill patients, which may minimise the risk of progressive multiorgan dysfunction. Alternatively, iatrogenic complications of ECMO clearly contribute to worse outcomes. These factors affect the risk : benefit ratio of ECMO which ultimately influence commencement/timing of ECMO. The complex interplay of pre-ECMO, ECMO, and post-ECMO pathophysiological processes are responsible for the substantial increased incidence of ECMO-associated acute kidney injury (EAKI). The development of EAKI significantly contributes to morbidity and mortality; however, there is a lack of evidence defining a potential benefit or causative link between ECMO and AKI. This area warrants investigation as further research will delineate the mechanisms involved and subsequent strategies to minimise the risk of EAKI. This review summarizes the current literature of ECMO and AKI, considers the possible benefits and risks of ECMO on renal function, outlines the related pathophysiology, highlights relevant investigative tools, and ultimately suggests an approach for future research into this under investigated area of critical care.
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20
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Lehle K, Philipp A, Zeman F, Lunz D, Lubnow M, Wendel HP, Göbölös L, Schmid C, Müller T. Technical-Induced Hemolysis in Patients with Respiratory Failure Supported with Veno-Venous ECMO - Prevalence and Risk Factors. PLoS One 2015; 10:e0143527. [PMID: 26606144 PMCID: PMC4659553 DOI: 10.1371/journal.pone.0143527] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/05/2015] [Indexed: 11/18/2022] Open
Abstract
The aim of the study was to explore the prevalence and risk factors for technical-induced hemolysis in adults supported with veno-venous extracorporeal membrane oxygenation (vvECMO) and to analyze the effect of hemolytic episodes on outcome. This was a retrospective, single-center study that included 318 adult patients (Regensburg ECMO Registry, 2009–2014) with acute respiratory failure treated with different modern miniaturized ECMO systems. Free plasma hemoglobin (fHb) was used as indicator for hemolysis. Throughout a cumulative support duration of 4,142 days on ECMO only 1.7% of the fHb levels were above a critical value of 500 mg/l. A grave rise in fHb indicated pumphead thrombosis (n = 8), while acute oxygenator thrombosis (n = 15) did not affect fHb. Replacement of the pumphead normalized fHb within two days. Neither pump or cannula type nor duration on the first system was associated with hemolysis. Multiple trauma, need for kidney replacement therapy, increased daily red blood cell transfusion requirements, and high blood flow (3.0–4.5 L/min) through small-sized cannulas significantly resulted in augmented blood cell trauma. Survivors were characterized by lower peak levels of fHb [90 (60, 142) mg/l] in comparison to non-survivors [148 (91, 256) mg/l, p≤0.001]. In conclusion, marked hemolysis is not common in vvECMO with modern devices. Clinically obvious hemolysis often is caused by pumphead thrombosis. High flow velocity through small cannulas may also cause technical-induced hemolysis. In patients who developed lung failure due to trauma, fHb was elevated independantly of ECMO. In our cohort, the occurance of hemolysis was associated with increased mortality.
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Affiliation(s)
- Karla Lehle
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
- * E-mail:
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Peter Wendel
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Laszlo Göbölös
- Department of Cardiothoracic Surgery, Southampton University Hospital Trust, Southampton, United Kingdom
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
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Bockeria LA, Kupryashov AA. eComment. Haemolysis in cardiac surgery: a well-known problem with no solution. Interact Cardiovasc Thorac Surg 2014; 19:188. [PMID: 25035501 DOI: 10.1093/icvts/ivu223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Leo A Bockeria
- Bakoulev Scientific Centre for Cardiovascular Surgery, Moscow, Russian Federation
| | - Alexey A Kupryashov
- Bakoulev Scientific Centre for Cardiovascular Surgery, Moscow, Russian Federation
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