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Milne B, Gilbey T, De Somer F, Kunst G. Adverse renal effects associated with cardiopulmonary bypass. Perfusion 2024; 39:452-468. [PMID: 36794518 PMCID: PMC10943608 DOI: 10.1177/02676591231157055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction, one of the most common complications of this surgical cohort. Acute kidney injury (AKI) is associated with increased short-term morbidity and mortality and has been the focus of much research. There is increasing recognition of the role of AKI as the key pathophysiological state leading to the disease entities acute and chronic kidney disease (AKD and CKD). In this narrative review, we will consider the epidemiology of renal dysfunction after cardiac surgery on CPB and the clinical manifestations across the spectrum of disease. We will discuss the transition between different states of injury and dysfunction, and, importantly, the relevance to clinicians. The specific facets of kidney injury on extracorporeal circulation will be described and the current evidence evaluated for the use of perfusion-based techniques to reduce the incidence and mitigate the complications of renal dysfunction after cardiac surgery.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Filip De Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London British Heart Foundation Centre of Excellence, London, UK
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2
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Owens R, Loftin M, Rosten K, Fisher D, Denison B, Gottlieb E, Fraser C. Perfusion techniques for an 800 g premature neonate undergoing Arterial Switch Procedure for Transposition of the Great Arteries★. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2024; 56:16-19. [PMID: 38488714 PMCID: PMC10941837 DOI: 10.1051/ject/2023045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 10/25/2023] [Indexed: 03/17/2024]
Abstract
Early cardiac surgery in neonates and infants with congenital heart disease has been performed since the middle to late years of the twentieth century. To date, there are very few reports of successful congenital heart surgery using cardiopulmonary bypass (CPB) in premature babies less than 1000 g with serious congenital heart disease. Limited information is available in the literature describing perfusion techniques for this extremely fragile patient population. Miniaturization of the CPB circuit contributes to multiple factors that affect this population significantly. These factors include the reduction of patient-to-circuit ratios, volume of distribution of pharmacological agents, management of pressure gradients within the CPB system, and increased tactile control by the attending perfusionist. Careful management of the physiological environment of the patient is of utmost importance and can mitigate risks during CPB, including volume shifts into the interstitial space, electrolyte, and acid-base imbalance, and intracranial hemorrhage. We report perfusion techniques successfully utilized during the surgical repair of transposition of the great arteries for an 800 g, 28-week-old neonate. CPB techniques for the smallest and youngest patients may be executed safely when proper physical, chemical, and perfusion process adjustments are made and managed meticulously.
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Affiliation(s)
- Richard Owens
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Texas Center for Pediatric and Congenital Heart Disease, Dell Children’s Hospital Austin Texas USA
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Department of Surgery and Perioperative Care, University of Texas-Dell Medical School Austin Texas USA
| | - Madeline Loftin
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Texas Center for Pediatric and Congenital Heart Disease, Dell Children’s Hospital Austin Texas USA
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Department of Surgery and Perioperative Care, University of Texas-Dell Medical School Austin Texas USA
| | - Kellen Rosten
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Texas Center for Pediatric and Congenital Heart Disease, Dell Children’s Hospital Austin Texas USA
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Department of Surgery and Perioperative Care, University of Texas-Dell Medical School Austin Texas USA
| | - Douglas Fisher
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Texas Center for Pediatric and Congenital Heart Disease, Dell Children’s Hospital Austin Texas USA
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Department of Surgery and Perioperative Care, University of Texas-Dell Medical School Austin Texas USA
| | - Blake Denison
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Texas Center for Pediatric and Congenital Heart Disease, Dell Children’s Hospital Austin Texas USA
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Department of Surgery and Perioperative Care, University of Texas-Dell Medical School Austin Texas USA
| | - Erin Gottlieb
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Texas Center for Pediatric and Congenital Heart Disease, Dell Children’s Hospital Austin Texas USA
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Department of Surgery and Perioperative Care, University of Texas-Dell Medical School Austin Texas USA
| | - Charles Fraser
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Texas Center for Pediatric and Congenital Heart Disease, Dell Children’s Hospital Austin Texas USA
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Department of Surgery and Perioperative Care, University of Texas-Dell Medical School Austin Texas USA
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Tang YX, Fan ZW, Li J, Pan HD, Su WX, Matniyaz Y, Zhang HT, Luo YX, Lv ZK, Wang WZ, Gao YX, Pan T, Xu WZ, Wang DJ. Sivelestat in Patients at a High Risk of Postoperative Acute Lung Injury After Scheduled Cardiac Surgery: A Prospective Cohort Study. J Inflamm Res 2024; 17:591-601. [PMID: 38318242 PMCID: PMC10840550 DOI: 10.2147/jir.s442208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/20/2024] [Indexed: 02/07/2024] Open
Abstract
Background Sivelestat, a neutrophil elastase inhibitor, is specifically developed to mitigate the occurrence of acute lung injury (ALI) in individuals who are undergoing cardiovascular surgery. However, its impact on patients who are at a heightened risk of developing ALI after scheduled cardiac surgery has yet to be determined. In order to address this knowledge gap, we undertook a study to assess the efficacy of sivelestat in protecting the lungs of these patients. Methods We conducted a prospective cohort study involving 718 patients who were at high risk of developing postoperative acute lung injury (ALI) and underwent scheduled cardiac surgery between April 25th, 2022, and September 7th, 2023. Among them, 52 patients received sivelestat (administered at a dosage of 0.2mg/kg/h for 3 days), while 666 patients served as controls, not receiving sivelestat. The control conditions were the same for all patients, including ventilation strategy, extubating time, and fluid management. Subsequently, a propensity-score matched cohort was established, consisting of 40 patients in both the sivelestat and control groups. The primary outcome measure encompassed a composite of adverse outcomes, including 30-day mortality, ALI, acute respiratory distress syndrome (ARDS), and others. Secondary outcomes assessed included pneumonia, ventricular arrhythmias, mechanical ventilation (MV) time, and more. Results After conducting propensity matching in our study, we observed that there were no significant differences in 30-day mortality between the sivelestat and control groups (0% vs 2.5%, P=0.32). However, the use of sivelestat exhibited a significant reduction in the incidence of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) compared to the control group (0% vs 55%, P<0.01), pneumonia (0 vs 37.5%, P<0.01), MV time (median:8 hours, IQR:4-14.8 hours vs median: 15.2 hours, IQR:14-16.3 hours, P<0.01). Compared to the control group, the sivelestat could significantly decrease white cell count (P<0.01), neutrophile percentage (P<0.01) and C-reactive protein (P<0.01) in the period of postoperative 5 days. Conclusion The prophylactic administration of sivelestat has shown promising results in reducing the occurrence of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) in patients with a heightened risk of developing these conditions after elective cardiac surgery. Our study findings indicate that sivelestat may provide protective effects by suppressing inflammation triggered by neutrophil activation, thereby safeguarding pulmonary function. Registration ChiCTR2200059102, https://www.chictr.org.cn/showproj.html?proj=166643.
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Affiliation(s)
- Yu-Xian Tang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Zhi-Wei Fan
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Jing Li
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Hao-Dong Pan
- Department of Clinical Medicine, Norman Bethune Health Science Center of Jilin University, Changchun, People’s Republic of China
| | - Wen-Xin Su
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Yusanjan Matniyaz
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Hai-Tao Zhang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
| | - Yuan-Xi Luo
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
| | - Zhi-Kang Lv
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Wen-Zhe Wang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Ya-Xuan Gao
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Tuo Pan
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
| | - Wan-Zi Xu
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Dong-Jin Wang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
- Department of Clinical Medicine, Norman Bethune Health Science Center of Jilin University, Changchun, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
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4
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Ohtsubo S, Itoh T, Kawai Y, Kobayashi K, Yoshitake S, Fujimura N, Shoji Y, Ishii S. Clinical outcome of intraoperative hemodialysis using a hemoconcentrator during cardiopulmonary bypass for dialysis-dependent patients. Gen Thorac Cardiovasc Surg 2023; 71:515-524. [PMID: 36907942 DOI: 10.1007/s11748-023-01922-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/19/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVES The basic materials and structure of a hemoconcentrator incorporated into cardiopulmonary bypass (CPB) circuits are similar to those of hemodialyzers. Gravity drainage hemodiafiltration (GHDF) is an easy-to-use intraoperative renal replacement therapy (RRT) that utilizes a hemoconcentrator. This study aimed to verify whether GHDF can correct electrolyte imbalance and remove uremic toxins in dialysis-dependent patients and to evaluate the clinical outcomes of GHDF by comparing it with a conventional method of dilutional ultrafiltration (DUF). METHODS This study retrospectively compared perioperative clinical values of 41 dialysis-dependent patients (21 patients with GHDF and 20 patients with DUF) who underwent open-heart surgery. Changes in serum parameters before and after passing through the hemoconcentrator were also compared. RESULTS Compared to DUF, GHDF significantly lowered potassium, blood urea nitrogen, and creatinine levels at the outflow of the hemoconcentrator. Less catecholamine was needed to wean CPB in GHDF than in DUF. The P/F ratio (arterial blood oxygen pressure/inhaled oxygen concentration) at the end of surgery was significantly higher in GHDF than in DUF (450.8 ± 149.7 vs. 279.3 ± 153.5; p < 0.001). Postoperative intubation time was shorter in GHDF than in DUF (8.3 ± 5.9 vs. 18.7 ± 16.1 h; p = 0.006). The major morbidity and mortality rates were comparable in both groups. CONCLUSIONS GHDF removed both potassium and uremic toxins more efficiently than DUF in dialysis-dependent patients. Less catecholamine was needed to wean CPB using GHDF. It improved the immediate postoperative respiratory function and enabled earlier extubation. GHDF is a novel and effective option for intraoperative RRT in dialysis-dependent patients undergoing open-heart surgery.
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Affiliation(s)
- Satoshi Ohtsubo
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan.
| | - Takahito Itoh
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Yujiro Kawai
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Kanako Kobayashi
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Shuichiro Yoshitake
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Yuta Shoji
- Department of Clinical Engineering, Saiseikai Central Hospital, Tokyo, Japan
| | - Shuichi Ishii
- Department of Clinical Engineering, Saiseikai Central Hospital, Tokyo, Japan
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5
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Pan T, Tuoerxun T, Chen X, Yang CJ, Jiang CY, Zhu YF, Li ZS, Jiang XY, Zhang HT, Zhang H, Wang YP, Chen W, Lu LC, Ge M, Cheng YQ, Wang DJ, Zhou Q. The neutrophil elastase inhibitor, sivelestat, attenuates acute lung injury in patients with cardiopulmonary bypass. Front Immunol 2023; 14:1082830. [PMID: 36761773 PMCID: PMC9902923 DOI: 10.3389/fimmu.2023.1082830] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Background The sivelestat is a neutrophil elastase inhibitor thought to have an effect against acute lung injury (ALI) in patients after scheduled cardiac surgery. However, the beneficial effect of sivelestat in patients undergoing emergent cardiovascular surgery remains unclear. We aim to evaluate the effect of sivelestat on pulmonary protection in patients with ALI after emergent cardiovascular surgery. Methods Firstly, a case-control study in 665 patients undergoing emergent cardiovascular surgery from January 1st, 2020 to October 26th, 2022 was performed. 52 patients who received sivelestat (0.2mg/kg/h for 3 days) and 613 age- and sex-matched controls. Secondly, a propensity-score matched cohort (sivelestat vs control: 50 vs 50) was performed in these 665 patients. The primary outcome was a composite of adverse outcomes, including 30-day mortality, ECMO, continuous renal replacement therapy (CRRT) and IABP, etc. The secondary outcome included pneumonia, ventricular arrhythmias and mechanical ventilation time, etc. Results In propensity-matched patients, the 30-day mortality (16% vs 24%, P=0.32), stroke (2% vs 8%, P=0.17), ECMO(6% vs 10%, P=0.46), IABP(4% vs 8%, P=0.40) and CRRT(8% vs 20%, P=0.08) had no differences between sivelestat and control group; sivelestat could significantly decrease pneumonia (40% vs 62%, P=0.03), mechanical ventilation time (median: 96hours, IQR:72-120hours vs median:148hours, IQR:110-186hours, P<0.01), bilateral pulmonary infiltrates (P<0.01), oxygen index (P<0.01), interleukin-6(P=0.02), procalcitonin(P<0.01) and C-reactive protein(P<0.01). Conclusion Administration of sivelestat might improve postoperative outcomes in patients with ALI after emergent cardiovascular surgery. Our results show that sivelestat may be considered to protect pulmonary function against inflammatory injury by CPB. Registration http://www.chictr.org.cn/showproj.aspx?proj=166643, identifier ChiCTR2200059102.
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Affiliation(s)
- Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Tayierjiang Tuoerxun
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xi Chen
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Cheng-Jin Yang
- Department of Pediatric Surgery, Sanya Women and Children's Hospital, Sanya, China
| | - Chen-Yu Jiang
- Department of Cardio-Thoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-Fan Zhu
- Department of Cardio-Thoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Xin-Yi Jiang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - He Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Ya-Peng Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Wei Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Li-Chong Lu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Min Ge
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong-Qing Cheng
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Qing Zhou
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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The effect of calcium gluconate administration during cardiopulmonary bypass on hemodynamic variables in infants undergoing open-heart surgery. Egypt Heart J 2022; 74:29. [PMID: 35416549 PMCID: PMC9006523 DOI: 10.1186/s43044-022-00266-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/05/2022] [Indexed: 11/20/2022] Open
Abstract
Background The incidence of complications after heart surgery is a critical factor in disability, deaths, lengthening hospital stays, and increasing treatment costs. The metabolic balance of certain hormones and electrolytes is necessary for proper cardiac function. In children, various biochemical conditions may cause calcium depletion during heart surgery. The purpose of this study was to determine the effect of calcium gluconate administration during cardiopulmonary bypass on hemodynamic variables and clinical outcomes in infants undergoing open-heart surgery. This study was conducted at Rajaie Cardiovascular Medical and Research Center in 2021 using a controlled randomized clinical trial. A total of 60 patients with open-heart surgery weighing up to 10 kg were included in the study. The first group received an intravenous injection of calcium gluconate 20 min after opening the aortic clamp, and the second group was monitored as a control group. Data collection tools included checklists containing demographics, surgical information, and intensive care unit measures. Results The Chi-square test or Fisher's exact test showed that the frequency distribution of gender, blood group, Rhesus factor (RH), and clinical diagnosis in the two groups of intervention and control was not statistically significant (p < 0.05). The mean and standard deviation of Ejection Fraction (EF) changes (before and after) were 13.27 ± 9.16 in the intervention group and 8.31 ± 9.80 in the control group (p = 0.065). The results of two-way repeated measures ANOVA showed that mean systolic blood pressure (p = 0.030), mean diastolic blood pressure (p = 0.021), mean heart rate (p = 0.025), mean arterial pressure (p = 0.020), mean pH (p < 0.001), and mean hemoglobin (p = 0.018) in the intervention, and control groups were statistically significant. Conclusions In the present study, unlike systolic pressure, mean diastolic blood pressure decreased, and mean arterial pressure increased significantly. As a result, the slope of changes during the study period was different in the intervention and control groups.
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7
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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8
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Stevens JS, Radhakrishnan J. Kidney Replacement Therapy for Patients Requiring Cardiopulmonary Bypass Support during Cardiac Surgery. Clin J Am Soc Nephrol 2021; 16:1898-1900. [PMID: 34706867 PMCID: PMC8729495 DOI: 10.2215/cjn.07150521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jacob S. Stevens
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jai Radhakrishnan
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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9
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Sebastian R, Ahmed MI. Blood Conservation and Hemostasis Management in Pediatric Cardiac Surgery. Front Cardiovasc Med 2021; 8:689623. [PMID: 34490364 PMCID: PMC8416772 DOI: 10.3389/fcvm.2021.689623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Pediatric cardiac surgery is associated with significant perioperative blood loss needing blood product transfusion. Transfusion carries serious risks and implications on clinical outcomes in this vulnerable population. The need for transfusion is higher in children and is attributed to several factors including immaturity of the hemostatic system, hemodilution from the CPB circuit, excessive activation of the hemostatic system, and preoperative anticoagulant drugs. Other patient characteristics such as smaller relative size of the patient, higher metabolic and oxygen requirements make successful blood transfusion management extremely challenging in this population and require meticulous planning and multidisciplinary teamwork. In this narrative review we aim to summarize risks and complications associated with blood transfusion in pediatric cardiac surgery and also to summarize perioperative coagulation management and blood conservation strategies.
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Affiliation(s)
- Roby Sebastian
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, United States
| | - M Iqbal Ahmed
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, United States
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10
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Talwar S, Sujith NS, Rajashekar P, Makhija N, Sreenivas V, Upadhyay AD, Sahu MK, Shiv Kumar C. Modified ultrafiltration and postoperative course in patients undergoing repair of tetralogy of fallot. J Card Surg 2021; 36:3679-3687. [PMID: 34324231 DOI: 10.1111/jocs.15841] [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: 11/12/2020] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Expected benefits of modified ultrafiltration (MUF) include increased hematocrit, reduction of total body water and inflammatory mediators, improved left ventricular systolic function, and improved systolic blood pressure and cardiac index (CI) following cardiopulmonary bypass (CPB). This prospective randomized trial tested this hypothesis. METHODS Seventy-nine patients undergoing intracardiac repair of tetralogy of fallot were randomized to conventional ultrafiltration (CUF) + MUF (n = 39) or only CUF group (n = 40). The primary outcome was a change in hematocrit. Secondary outcomes were changes in peak airway pressures, ventilatory support, blood transfusions, time to peripheral rewarming, mean arterial pressure, central venous pressure, inotrope score (IS), and CI. Serum inflammatory markers were measured. RESULTS Baseline hematocrit was 50.6 ± 10.02 in the only CUF group whereas it was 43.9 ± 5.55 in the CUF + MUF group (p = .36). Following MUF, the CUF + MUF group had higher hematocrit (44.7 ± 0.50 g/dl) compared to the only CUF group (37.2 ± 0.49 g/dl), p ≤ .001 after adjusting for baseline hematocrit. Central venous pressure (mmHg) immediately following sternal closure was 9.27 ± 3.12 mmHg in the CUF + MUF group and 10.52 ± 2.2 mmHg in the only CUF group (p = .04). In the intensive care unit (ICU), they were 11.52 ± 2.20 mmHg in the only CUF group and 10.84 ± 2.78 mmHg in the CUF + MUF group (p = .02). Time to peripheral rewarming was 6.30 ± 3.91 h in the CUF + MUF group and 13.67 ± 3.91 h in the only CUF group (p = .06). Peak airway pressures in ICU were 17 ± 2 mmHg versus 20.55 ± 2.97 mmHg in CUF + MUF group & only CUF group, respectively, p < .001). Duration of mechanical ventilation was 6.3 ± 2.7 h in CUF + MUF group compared to 14.7 ± 3.5 h in the only CUF group (p = .002). IS was 11.52 ± 2.20 in the only CUF group compared to 10.84 ± 2.78 in CUF + MUFs group. Eight of 39 (20.5%) patients in the CUF + MUF group had IS > 10 compared to 22 of 40 (55%) patients in the only CUF group (p = .02). Serum Troponin-T and interleukin-6 levels were lower in the CUF + MUF group; TNF-α and CPK-MB were similar. ICU and hospital stay were similar. CONCLUSION Patients undergoing a combination of CUF and MUF had higher postoperative hematocrit, decreased duration of mechanical ventilation, lower need for inotropes and lower interleukin-6 and Troponin-T levels. This group had better postoperative outcomes. This study was registered with the Clinical trials registry of India (CTRI/2017/11/010512) before commencement.
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Affiliation(s)
- Sachin Talwar
- Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Neralakere Suresha Sujith
- Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Palleti Rajashekar
- Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Neeti Makhija
- Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Manoj Kumar Sahu
- Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Choudhary Shiv Kumar
- Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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Bierer J, Henderson M, Stanzel R, Sett S, Horne D. Subzero balance - simple modified ultrafiltration (SBUF-SMUF) technique for pediatric cardiopulmonary bypass. Perfusion 2021; 37:785-788. [PMID: 34142611 PMCID: PMC9619246 DOI: 10.1177/02676591211027788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of cardiopulmonary bypass (CPB) can be associated with significant hemodilution, coagulopathy and a systemic inflammatory response for infants and children undergoing cardiac surgery. Intra-operative ultrafiltration has been used for decades to ameliorate these harmful effects. The novel combination of a continuous and non-continuous form of ultrafiltration, Subzero Balance Simple Modified Ultrafiltration (SBUF-SMUF) here described, seeks to enhance recovery from pediatric cardiac surgery and CPB.
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Affiliation(s)
- Joel Bierer
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Canada
| | - Mark Henderson
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Canada
| | - Roger Stanzel
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Canada
| | - Suvro Sett
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Canada
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12
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Zero-Balance Ultrafiltration during Cardiopulmonary Bypass Is Associated with Decreased Urine Output. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:27-37. [PMID: 33814603 DOI: 10.1182/ject-2000016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 01/06/2021] [Indexed: 11/20/2022]
Abstract
Zero-balance ultrafiltration (ZBUF) during cardiopulmonary bypass (CPB) has been purported to reduce pro-inflammatory mediators during cardiac surgery. However, its clinical benefit is equivocal and its effect on renal function unknown. The purpose of this study was to examine the effect of ZBUF on urine output in adult patients undergoing CPB. Following institutional review board approval, 98,953 records from a national registry of adult patients at 215 U.S. hospitals between January 2016 and September 2019 were reviewed. Groups were stratified according to ZBUF use. Anuric patients were excluded from the study as they were patients with missing data on urine output, ultrafiltration use, or ZBUF volume. The primary endpoint was intraoperative urine output normalized to body weight and procedure duration (total operative time). Final analysis of this endpoint was carried out using a linear mixed-effects regression model adjusting for patient and procedural characteristics, as well as practice patterns associated with surgeons and perfusionists. There was a significant 16.1% reduction in median urine output for ZBUF patients (.94 [.54, 1.47] mL/kg/h) vs. the non-ZBUF group (1.12 [.70,-1.73] mL/kg/h), p < .001. After statistically adjusting for patient and procedural characteristics, each liter of ZBUF volume was associated with an estimated change in intraoperative urine output of -.03 mL/kg/h (95% CI: [-.04 to -.02], p < .001). The median ZBUF volume was 1,550 [1,000, 2,600] mL, and when ZBUF was used, conventional ultrafiltration (CUF) was more likely to be used as well (88.4% vs. 44.8%, p < .001). ZBUF patients had median asanguineous volume and crystalloid cardioplegia nearly two times more than non-ZBUF patients, and had slightly higher red blood cell transfusions (17.6% vs. 16.3%, p < .05). The application of ZBUF during CPB was associated with patients having lower urine output and significantly higher use of CUF. Further research is required to determine if these results are reproducible in prospective clinical studies.
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Burra V, Sunil PK, Praveen NB, Nagaraja PS, Singh NG, Manjunatha N, Basappanavar VS. Role of urinary PO 2 analysis during conventional versus conventional and modified ultrafiltration techniques in adult cardiac surgery. Ann Card Anaesth 2021; 23:43-47. [PMID: 31929246 PMCID: PMC7034213 DOI: 10.4103/aca.aca_2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Medullary hypoxia is the initial critical event for kidney injury during cardiopulmonary bypass, and therefore urinary PO2 with its potential of detecting medullary oxygenation for its management. Therefore, we tested the role of urinary PO2 in predicting kidney injury in those undergoing conventional versus combined (conventional and modified) ultrafiltration during cardiac surgery in adults. Methodology: We prospectively evaluated 32 adults between 18 and 65 years of age undergoing elective on-pump cardiac surgery with ejection fraction >35% by conventional (group C) versus combined ultrafiltration (group CM). Urine samples were analyzed for PO2 after induction, 30 min, 3 h, and 6 h post filtration along with blood urea and serum creatinine after induction, at 6 h, 24 h, and 48 h post filtration. Demographic variables, cardiopulmonary bypass duration, flow rates, inotropic score, ventilation duration, diuretic use, and intensive care unit (ICU) stay were assessed between two groups. Results: Both the groups (16 in each group) had comparable urinary PO2 after induction (P = 0.387) with significant decrease in group C at 30 min, 3 h, and 6 h post filtration (P < 0.05). There was a statistically significant increase in serum creatinine (mg/dL) at 48 h in group C compared with group CM (1.57 vs. 1.25, respectively; P ≤ 0.05). There was an increased diuretic usage and length of ICU stay in group C. Conclusion: Combined ultrafiltration technique had renoprotective effect in cardiac surgery analyzed by urinary PO2 levels.
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Affiliation(s)
- Vijitha Burra
- Department of Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - P K Sunil
- Department of Cardiovascular and Thoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - N B Praveen
- Department of Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - P S Nagaraja
- Department of Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - Naveen G Singh
- Department of Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - N Manjunatha
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
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American Society of ExtraCorporeal Technology: Development of Standards and Guidelines for Pediatric and Congenital Perfusion Practice (2019). THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:319-326. [PMID: 33343035 DOI: 10.1182/ject-2000045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence because of smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT member and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists, serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this article is to summarize the process of development, the content, and recommended utilization of AmSECT's Standards and Guidelines for Pediatric and Congenital Perfusion Practice. AmSECT recommends adoption of the Standards and Guidelines for Pediatric and Congenital Perfusion Practice to reduce practice variation and enhance clinical safety.
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Oldeen ME, Angona RE, Hodge A, Klein T. American Society of ExtraCorporeal Technology: Development of Standards and Guidelines for Pediatric and Congenital Perfusion Practice (2019). World J Pediatr Congenit Heart Surg 2020; 12:84-92. [PMID: 33320047 DOI: 10.1177/2150135120956938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence due to smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT membership and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists and serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this manuscript is to summarize the process of development, the content, and recommended utilization of AmSECT's Standards and Guidelines for Pediatric and Congenital Perfusion Practice.
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Affiliation(s)
- Molly Elisabeth Oldeen
- Division of Cardiovascular-Thoracic Surgery, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Ronald E Angona
- 6923University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY, USA
| | - Ashley Hodge
- Cardiothoracic Surgery, The Heart Center, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Tom Klein
- 2518Cincinnati Children's Hospital Medical Center, OH, USA
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Manning MW, Li YJ, Linder D, Haney JC, Wu YH, Podgoreanu MV, Swaminathan M, Schroder JN, Milano CA, Welsby IJ, Stafford-Smith M, Ghadimi K. Conventional Ultrafiltration During Elective Cardiac Surgery and Postoperative Acute Kidney Injury. J Cardiothorac Vasc Anesth 2020; 35:1310-1318. [PMID: 33339661 DOI: 10.1053/j.jvca.2020.11.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/08/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Conventional ultrafiltration (CUF) during cardiopulmonary bypass (CPB) serves to hemoconcentrate blood volume to avoid allogeneic blood transfusions. Previous studies have determined CUF volumes as a continuous variable are associated with postoperative acute kidney injury (AKI) after cardiac surgery, but optimal weight-indexed volumes that predict AKI have not been described. DESIGN Retrospective cohort. SETTING Single-center university hospital. PARTICIPANTS A total of 1,641 consecutive patients who underwent elective cardiac surgery between June 2013 and December 2015. INTERVENTIONS The CUF volume was removed during CPB in all participants as part of routine practice. The authors investigated the association of dichotomized weight-indexed CUF volume removal with postoperative AKI development to provide pragmatic guidance for clinical practice at the authors' institution. MEASUREMENTS AND MAIN RESULTS Primary outcomes of postoperative AKI were defined by the Kidney Disease: Improving Global Outcomes staging criteria and dichotomized, weight-indexed CUF volumes (mL/kg) were defined by (1) extreme quartiles (<Q1 v >Q3) and (2) Youden's criterion that best predicted AKI development. Multivariate logistic regression models were developed to test the association of these dichotomized indices with AKI status. Postoperative AKI occurred in 827 patients (50.4%). Higher CUF volumes were associated with AKI development by quartiles (CUF >Q3 = 32.6 v CUF < Q1 = 10.4 mL/kg; odds ratio [OR] = 1.68, 95% CI: 1.19-2.3) and Youden's criterion (CUF ≥ 32.9 v CUF <32.9 mL/kg; OR = 1.60, 95% CI: 1.21-2.13). Despite similar intraoperative nadir hematocrits among groups (p = 0.8), higher CUF volumes were associated with more allogeneic blood transfusions (p = 0.002) and longer lengths of stay (p < 0.001). CONCLUSIONS Removal of weight-indexed CUF volumes > 32 mL/kg increased the risk for postoperative AKI development. Importantly, CUF volume removal of any amount did not mitigate allogeneic blood transfusion during elective cardiac surgery. Prospective studies are needed to validate these findings.
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Affiliation(s)
- Michael W Manning
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC.
| | - Yi-Ju Li
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Dean Linder
- Oschner Medical Center, Jefferson Parish, LA
| | - John C Haney
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Mihai V Podgoreanu
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Madhav Swaminathan
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Ian J Welsby
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Mark Stafford-Smith
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
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Serial measurement of electrolyte and citrate concentrations in blood-primed continuous hemodialysis circuits during closed-circuit dialysis. Pediatr Nephrol 2020; 35:127-133. [PMID: 31372760 DOI: 10.1007/s00467-019-04318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND For continuous renal replacement therapy in small infants, due to the large extracorporeal volume involved, blood priming can be necessary to prevent hypotension and hemodilution. Because packed red blood cells (RBCs) have high levels of potassium and citrate, closed-circuit dialysis is often performed. We assessed the metrics of closed-circuit dialysis and serial citrate concentration changes. METHODS We performed dialysis of closed circuits primed with expired human packed RBC solution and 5% albumin. Blood and dialysate flow rates were 70 and 33.3 mL/min, respectively. The extracorporeal volume was 70 mL. We measured pH, electrolytes, and citrate in the closed circuit every 3 min for 15 min. We also assessed the adequacy of closed-circuit dialysis using the formula: [dialysate flow rate (mL/min) × time of dialysis (min)]/extracorporeal volume (mL) and we assessed the correlation between citrate and ionized calcium concentrations. RESULTS To reach normal concentrations of sodium, potassium, and chloride, 2.4 times as much dialysate fluid as extracorporeal volume was needed. In contrast, for ionized calcium, bicarbonate, and citrate, 3.8 times as much dialysate fluid as extracorporeal volume was required. By simple linear regression analysis, the concentration of citrate was significantly correlated with that of ionized calcium. CONCLUSIONS For closed-circuit dialysis using an RBC solution, the formula [dialysate flow rate (mL/min) × time of dialysis (min)]/extracorporeal volume (mL) would be a better parameter to estimate efficacy, compared with other metrics. Additionally, the citrate concentration can be readily estimated from the ionized calcium concentration during closed-circuit dialysis.
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Bierer J, Stanzel R, Henderson M, Sett S, Horne D. Ultrafiltration in Pediatric Cardiac Surgery Review. World J Pediatr Congenit Heart Surg 2019; 10:778-788. [DOI: 10.1177/2150135119870176] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: The use of cardiopulmonary bypass in pediatric cardiac surgery is associated with significant inflammation, fluid overload, and end-organ dysfunction yielding morbidity and mortality. For decades, various intraoperative ultrafiltration techniques such as conventional ultrafiltration, modified ultrafiltration (MUF), zero-balance ultrafiltration (ZBUF), and combination techniques (ZBUF-MUF) have been used to mitigate these toxicities and promote improved postoperative outcomes. However, there is currently no consensus on the ultrafiltration technique or strategy that yields the most benefit for infants and children undergoing open heart surgery. Methods: A librarian-conducted PubMed literature search from 1990 to 2018 yielded 90 clinical studies or publications on the various forms of ultrafiltration and the impact on physiologic markers and clinical outcomes. All publications were reviewed, summarized, and conclusions synthesized. The data sets were not combined for systematic or meta-analysis due to significant heterogeneity in study protocols and patient populations. Results: Modified ultrafiltration significantly promotes improved myocardial function, reduction in fluid overload, and reduced bleeding and transfusion complications. Furthermore, ZBUF has shown a consistent reduction in inflammatory cytokines and improved pulmonary function and compliance. There is conflicting evidence that MUF, ZBUF, and ZBUF-MUF culminate in reduced ventilation time and intensive care unit stay. Conclusion: Various modes of ultrafiltration have been shown to be associated with improved physiologic function or clinical outcomes in pediatric cardiac surgery. There are some inconsistent trial results that can be explained by heterogeneity in ultrafiltration, clinical staff preferences, and institution protocols. Ultrafiltration has some essential benefit as it is ubiquitously used at pediatric heart centers; however, the optimal protocol could be yet identified.
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Affiliation(s)
- Joel Bierer
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roger Stanzel
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Mark Henderson
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Suvro Sett
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Gholampour Dehaki M, Niknam S, Bakhshandeh H, Azarfarin R. Zero‐balance ultrafiltration of the priming blood modifies the priming components and improves the clinical outcome in infants undergoing cardiopulmonary bypass: A randomized controlled trial. Artif Organs 2019; 44:288-295. [DOI: 10.1111/aor.13559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 07/09/2019] [Accepted: 08/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Maziar Gholampour Dehaki
- Department of Pediatric Cardiac Surgery Rajaei Cardiovascular Medical and Research Center Tehran Iran
| | - Sana Niknam
- Department of Clinical Research Development Unit of Besat Hospital Hamadan University of Medical Sciences Medical School Hamadan Iran
| | - Hooman Bakhshandeh
- Department of Epidemiology and Biostatistics Rajaei Cardiovascular Medical and Research Center Tehran Iran
| | - Rasoul Azarfarin
- Department of Cardiac Anesthesia Rajaei Cardiovascular Medical and Research Center Tehran Iran
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Akt is a critical node of acute myocardial insulin resistance and cardiac dysfunction after cardiopulmonary bypass. Life Sci 2019; 234:116734. [PMID: 31394126 DOI: 10.1016/j.lfs.2019.116734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/04/2019] [Accepted: 08/04/2019] [Indexed: 10/26/2022]
Abstract
AIMS Acute myocardial insulin resistance is an independent risk factor for patients who undergo cardiac surgery with cardiopulmonary bypass (CPB). However, the underlying mechanism of insulin resistance during CPB has not been fully investigated. MATERIALS AND METHODS To explore the role of myocardial insulin resistance on the cardiac function and its underlying mechanism, CPB operation and pharmacological intervention were applied in mini pigs, and myocardial insulin signaling, glucose uptake, ATP production and cardiac function were examined. KEY FINDINGS Our data showed that CPB elicited not only hyperglycemia and hyperinsulinemia, but also inactivated Akt, and impaired the transposition of membrane glucose transporter-4 (GLUT-4), reduced glucose uptake and ATP production in the myocardium as well, which in turn was accompanied with cardiac dysfunction. Meanwhile, linear correlations were established among reduced myocardial glucose uptake, ATP production, and depressed cardiac systolic or diastolic function. Reactivation of Akt by SC79, an Akt agonist, partially alleviated myocardial insulin resistance and restored post CPB cardiac function via augmenting myocardial glucose uptake and ATP production. SIGNIFICANCE These findings revealed that acute myocardial insulin resistance due to inactivation of Akt played a key role in cardiac dysfunction post CPB via suppressing glucose metabolism related energy supply.
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Borisov AS, Malov AA, Kolesnikov SV, Lomivorotov VV. Renal Replacement Therapy in Adult Patients After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2273-2286. [PMID: 30871949 DOI: 10.1053/j.jvca.2019.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/04/2019] [Accepted: 02/08/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Alexander S Borisov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Andrey A Malov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Sergey V Kolesnikov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir V Lomivorotov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia.
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Ames WA. Pro: The Value of Modified Ultrafiltration in Children After Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2019; 33:866-869. [DOI: 10.1053/j.jvca.2018.10.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Indexed: 11/11/2022]
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Medikonda R, Ong CS, Wadia R, Goswami D, Schwartz J, Wolff L, Hibino N, Vricella L, Nyhan D, Barodka V, Steppan J. Trends and Updates on Cardiopulmonary Bypass Setup in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2804-2813. [PMID: 30738750 DOI: 10.1053/j.jvca.2019.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Indexed: 02/07/2023]
Abstract
Perfusion strategies for cardiopulmonary bypass have direct consequences on pediatric cardiac surgery outcomes. However, inconsistent study results and a lack of uniform evidence-based guidelines for pediatric cardiopulmonary bypass management have led to considerable variability in perfusion practices among, and even within, institutions. Important aspects of cardiopulmonary bypass that can be optimized to improve clinical outcomes of pediatric patients undergoing cardiac surgery include extracorporeal circuit components, priming solutions, and additives. This review summarizes the current literature on circuit components and priming solution composition with an emphasis on crystalloid, colloid, and blood-based primes, as well as mannitol, bicarbonate, and calcium.
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Affiliation(s)
| | - Chin Siang Ong
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Rajeev Wadia
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jamie Schwartz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Larry Wolff
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Luca Vricella
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Daniel Nyhan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Viachaslau Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
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José Curi-Curi P, Aguilar Alanis E, Calderón- Colmenero J, Luis Cervantes-Salazar J, Reyes Pavón R, Ramírez-Marroquín S. Impact of Modified Ultrafiltration in Congenital Heart Disease Patients Treated with Cardiopulmonary Bypass. CONGENIT HEART DIS 2018. [DOI: 10.5772/intechopen.80599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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25
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Medikonda R, Ong CS, Wadia R, Goswami D, Schwartz J, Wolff L, Hibino N, Vricella L, Barodka V, Steppan J. A Review of Goal-Directed Cardiopulmonary Bypass Management in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:565-572. [PMID: 30157729 DOI: 10.1177/2150135118775964] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiopulmonary bypass perfusion management significantly affects postoperative outcomes. In recent years, the principles of goal-directed therapy have been applied to the field of cardiothoracic surgery to improve patient outcomes. Goal-directed therapy involves continuous peri- and postoperative monitoring of vital clinical parameters to tailor perfusion to each patient's specific needs. Closely measured parameters include fibrinogen, platelet count, lactate, venous oxygen saturation, central venous oxygen saturation, mean arterial pressure, perfusion flow rate, and perfusion pulsatility. These parameters have been shown to influence postoperative fresh frozen plasma transfusion rate, coagulation state, end-organ perfusion, and mortality. In this review, we discuss the recent paradigm shift in pediatric perfusion management toward goal-directed perfusion.
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Affiliation(s)
| | - Chin Siang Ong
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Rajeev Wadia
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dheeraj Goswami
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jamie Schwartz
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Larry Wolff
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Narutoshi Hibino
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Luca Vricella
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viachaslau Barodka
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jochen Steppan
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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26
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Luo Y, Sun G, Zheng C, Wang M, Li J, Liu J, Chen Y, Zhang W, Li Y. Effect of high-volume hemofiltration on mortality in critically ill patients: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12406. [PMID: 30235713 PMCID: PMC6160258 DOI: 10.1097/md.0000000000012406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/24/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND High-volume hemofiltration (HVHF) is widely used for blood purification in critically ill patients with systemic inflammatory syndromes. The purpose of this study was to evaluate the effect of HVHF on mortality at different follow-up periods in critically ill patients. METHODS We systematically searched PubMed, Embase, and the Cochrane Library through April 2017 to identify trials that evaluated the effect of HVHF on mortality in critically ill patients. Summary relative risks (RRs) and 95% confidence intervals (CIs) were employed to calculate the treatment effect using a random effects model. Eleven trials involving 1048 critically ill patients were included in this study. RESULTS The summary results indicated no significant differences between HVHF and usual care for the incidence of 28-day mortality (RR: 0.93; 95%CI: 0.80-1.08; P = .321), 7-day mortality (RR: 0.72; 95%CI: 0.50-1.03; P = .072), 60-day mortality (RR: 1.00; 95%CI: 0.86-1.16; P = .997), and 90-day mortality (RR: 1.01; 95%CI: 0.88-1.16; P = .927). Subgroup analysis suggested HVHF significantly reduced the risk of 28-day mortality (RR: 0.64; 95%CI: 0.42-0.97; P = .035) if pooled the study sample size < 100. CONCLUSION Our findings suggest HVHF significantly reduced the incidence of 28-day mortality when pooled the study sample size < 100. Further, HVHF had a marginal effect on the incidence of 7-day mortality.
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Affiliation(s)
| | | | | | - Mei Wang
- Department of Intensive Care Medicine
| | - Juan Li
- Department of Intensive Care Medicine
| | - Jie Liu
- Department of Intensive Care Medicine
| | | | | | - Yanling Li
- Nursing Department, Tangshan Caofeidian-District Hospital, Tang Shan, Hebei, PR China
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27
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Delanaye P, Lambermont B, Dogné JM, Dubois B, Ghuysen A, Janssen N, Desaive T, Kolh P, D'Orio V, Krzesinski JM. Confirmation of High Cytokine Clearance by Hemofiltration with a Cellulose Triacetate Membrane with Large Pores: An in vivo Study. Int J Artif Organs 2018; 29:944-8. [PMID: 17211815 DOI: 10.1177/039139880602901004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To confirm in vivo the hypothesis that hemofiltration with a large pore membrane can achieve significant cytokine clearance. Method We used a well-known animal model of endotoxinic shock (0.5 mg/kg of lipopolysaccharide from Escherichia Coli over a period of 30 mins). Six pigs were hemofiltrated for 3 hours with a large pore membrane (78 Å pore, 80 kDa cut off) (Sureflux FH 70, Nipro, Osaka, Japan). The ultrafiltration rate was 45 ml/kg/min. Samples were taken from arterial, venous line and in the ultrafiltrate at T120 and T240. We measured concentrations of interleukin 6, interleukin 10 and albumin. Results At T120 and T240, the IL-6 clearances were 22 ± 7 and 15 ± 3 ml/min, respectively. The IL-6 sieving coefficients were 0.97 and 0.7 at T120 and T240, respectively. At T120 and T240, the IL-10 clearances were 14 ± 4 and 10 ± 7 ml/min, respectively. The sieving coefficients were 0.63 and 0.45 at T120 and T240, respectively. The concentrations of IL-6 and IL-10 were the same at T0 and T240. At T60 and T240, the plasmatic albumin concentrations were 24 ± 4 g/L and 23 ± 4 g/L, respectively (p = 0.13). Conclusions In this animal model of endotoxinic shock, we confirm the high cytokine clearance observed when hemofiltration is applied to a large pore membrane. The loss of albumin seems negligible. The impact of such clearances on hemodynamic stability and survival remains to be proved.
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Affiliation(s)
- P Delanaye
- Department of Nephrology, University of Liege, Liege - Belgium.
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28
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Ricci Z, Polito A, Giorni C, Di Chiara L, Ronco C, Picardo S. Continuous Hemofiltration dose Calculation in a Newborn Patient with Congenital Heart Disease and Preoperative Renal Failure. Int J Artif Organs 2018; 30:258-61. [PMID: 17417766 DOI: 10.1177/039139880703000312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To report a case of a newborn patient with renal failure due to polycystic kidneys requiring renal replacement therapy, and total anomalous pulmonary venous return requiring major cardiosurgical intervention. Setting Pediatric cardiosurgery operatory room and pediatric cardiologic intensive care. Patient: A 6-day-old newborn child weighing 3.1 kg. Results Renal function (creatinine value and urine output) was monitored during the course of the operation and intraoperative renal replacement therapy was not initiated. Serum creatinine concentration decreased from 4.4 to 3 mg/dL at cardiopulmonary bypass (CPB) start and to 1.5 at the end of surgery: the creatinine decrease was provided by the dilutional effect of CPB priming and the infusion of fresh blood from transfusions together with an adequate filtration rate (800 m/L in about 120 minutes). After the operation, extracorporeal membrane oxygenation (ECMO) for ventricular dysfunction and continuous hemofiltration for anuria refractory to medical therapy were prescribed. The hemofiltration machine was set in parallel with the ECMO machine at a blood flow rate of 60 ml/min and a predilution replacement solution infusion of 600 ml/h (4.5 ml/min of creatinine clearance once adjusted on extracorporeal circuits; 3000 mL/m2 hemofiltration): after a single hemofiltration session lasting 96 hours, serum creatinine reached optimal steady state levels around 0.5 mg/dL on postoperative day 2 and 3. Conclusion Administration of intraoperative continuous hemofiltration is not mandatory in the case of a 3-kg newborn patient with established renal failure needing major cardiosurgery: hemodilution secondary to CPB, transfusion of hemoderivates, and optimal UF rate appear to be effective methods for achieving solute removal. If postoperative continuous hemofiltration is started, however, a “dialytic dose” of 4.5 ml/min allows an adequate creatinine clearance, quick achievement of a steady state of serum creatinine concentration and an eventual acceptable rate of inflammatory mediator removal.
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Affiliation(s)
- Z Ricci
- Department of Pediatric Cardiosurgery, Bambino Gesù Hospital, Rome, Italy.
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29
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Effects of Early Continuous Venovenous Hemofiltration on E-Selectin, Hemodynamic Stability, and Ventilatory Function in Patients with Septic-Shock-Induced Acute Respiratory Distress Syndrome. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7463130. [PMID: 28044135 PMCID: PMC5156784 DOI: 10.1155/2016/7463130] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/12/2016] [Accepted: 09/15/2016] [Indexed: 12/29/2022]
Abstract
Objective. To investigate the effects of 72-hour early-initiated continuous venovenous hemofiltration (ECVVH) treatment in patients with septic-shock-induced acute respiratory distress syndrome (ARDS) (not acute kidney injury, AKI) with regard to serum E-selectin and measurements of lung function and hemodynamic stability. Methods. This prospective nonblinded single institutional randomized study involved 51 patients who were randomly assigned to receive or not receive ECVVH, an ECVVH group (n = 24) and a non-ECVVH group (n = 27). Besides standard therapies, patients in ECVVH group underwent CVVH for 72 h. Results. At 0 and 24 h after initiation of treatment, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, extravascular lung water index (EVLWI), and E-selectin level were not significantly different between groups (all P > 0.05). Compared to non-ECVVH group, PaO2/FiO2 is significantly higher and EVLWI and E-selectin level are significantly lower in ECVVH group (all P < 0.05) at 48 h and 72 h after initiation of treatment. The lengths of mechanical ventilation and stay in intensive care unit (ICU) were shorter in ECVVH group (all P < 0.05), but there was no difference in 28-day mortality between two groups. Conclusions. In patients with septic-shock-induced ARDS (not AKI), treatment with ECVVH in addition to standard therapies improves endothelial function, lung function, and hemodynamic stability and reduces the lengths of mechanical ventilation and stay in ICU.
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30
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Chew MS. Does modified ultrafiltration reduce the systemic inflammatory response to cardiac surgery with cardiopulmonary bypass? Perfusion 2016; 19 Suppl 1:S57-60. [PMID: 15161065 DOI: 10.1191/0267659104pf719oa] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiopulmonary bypass (CPB) is associated with an accumulation of total body water and a systemic inflammatory response syndrome (SIRS), which, in turn, is associated with organ dysfunction and postoperative morbidity. It has been suggested that modified ultrafiltration (MUF) may be capable of reducing SIRS and improving clinical outcome by filtering out the inflammatory mediators generated during CPB. This paper reviews the data regarding the use of MUF in paediatric and adult settings. Specifically, three issues will be considered: 1) Does MUF improve clinical outcome? 2) Does MUF reduce the systemic inflammatory response to cardiac surgery with CPB? 3) Is MUF more effective than conventional ultrafiltration in improving clinical outcome?
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Affiliation(s)
- Michelle S Chew
- Department of Anaesthesia and Intensive Care, Lund University Hospital, Lund, Sweden.
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31
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Ziyaeifard M, Alizadehasl A, Aghdaii N, Rahimzadeh P, Masoumi G, Golzari SE, Fatahi M, Gorjipur F. The effect of combined conventional and modified ultrafiltration on mechanical ventilation and hemodynamic changes in congenital heart surgery. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:113. [PMID: 28255321 PMCID: PMC5331766 DOI: 10.4103/1735-1995.193504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 06/29/2016] [Accepted: 08/20/2016] [Indexed: 11/06/2022]
Abstract
Background: Cardiopulmonary bypass is associated with increased fluid accumulation around the heart which influences pulmonary and cardiac diastolic function. The aim of this study was to compare the effects of modified ultrafiltration (MUF) versus conventional ultrafiltration (CUF) on duration of mechanical ventilation and hemodynamic status in children undergoing congenital heart surgery. Materials and Methods: A randomized clinical trial was conducted on 46 pediatric patients undergoing cardiopulmonary bypass throughout their congenital heart surgery. Arteriovenous MUF plus CUF was performed in 23 patients (intervention group) and sole CUF was performed for other 23 patients (control group). In MUF group, arterial cannula was linked to the filter inlet through the arterial line, and for 10 min, 10 ml/kg/min of blood was filtered and returned via cardioplegia line to the right atrium. Different parameters including hemodynamic variables, length of mechanical ventilation, Intensive Care Unit (ICU) stay, and inotrope requirement were compared between the two groups. Results: At immediate post-MUF phase, there was a statistically significant increase in the mean arterial pressure, systolic blood pressure, and diastolic blood pressure (P < 0.05) only in the study group. Furthermore, there was a significant difference in time of mechanical ventilation (P = 0.004) and ICU stay (P = 0.007) between the two groups. Inotropes including milrinone (P = 0.04), epinephrine (P = 0.001), and dobutamine (P = 0.002) were used significantly less frequently for patients in the intervention than the control group. Conclusion: Administration of MUF following surgery improves hemodynamic status of patients and also significantly decreases the duration of mechanical ventilation and inotrope requirement within 48 h after surgery.
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Affiliation(s)
- Mohsen Ziyaeifard
- Department of Cardiac Anesthesiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azin Alizadehasl
- Department of Cardiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Aghdaii
- Department of Cardiac Anesthesiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Poupak Rahimzadeh
- Department of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Masoumi
- Department of Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Samad Ej Golzari
- Department of Anesthesiology and Intensive Care Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mostafa Fatahi
- Department of Perfusion, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farhad Gorjipur
- Department of Perfusion, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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32
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Abstract
Pediatric cardiopulmonary bypass (CPB) results in increased total body water and capillary permeability. Ultrafiltration has been effective in removing this excess water. The con ventional method of ultrafiltration is restricted by the vol ume in the venous reservoir and therefore is inefficient in smaller children and neonates, whose blood volume is dis proportionately smaller than the circuit volume. Modified ultrafiltration, performed in the immediate post-CPB period, is more effective in these patients. Blood from the aorta is pumped through the ultrafilter, and warm concentrated blood is returned to the right atrium. This removes excess water from the patient and provides a method of salvaging volume from the circuit. Modified ultrafiltration results in consistent improvements in systolic blood pressure, cardiac index, and lung compliance, as well as a reduction in pul monary vascular resistance. Removal of various inflamma tory mediators, such as tumor necrosis factor a, interleu kin-6, and interieukin-8, has been reported after modified ultrafiltration. Other advantages include an increase in he matocrit, colloid osmotic pressure, and coagulation factors, resulting in decreased bleeding and a decreased need for transfusions. In the animal model, improvement in cerebral recovery after deep hypothermic circulatory arrest has been reported. The disadvantages of this technique include the risk of air entrapment, delay in heparin reversal, and poten tial for cooling.
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Affiliation(s)
- Susan T. Verghese
- Departments of Anesthesiology and Pediatrics, George Washington University Medical Center, and the Children's National Medical Center, Washington, DC
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33
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Song L, Yinglong L, Jinping L. Effects of zero-balanced ultrafiltration on procalcitonin and respiratory function after cardiopulmonary bypass. Perfusion 2016; 22:339-43. [PMID: 18416220 DOI: 10.1177/0267659107086726] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The abnormal conditions to which blood is subjected during cardiopulmonary bypass (CPB) trigger an activation of the inflammatory response and cause pulmonary dysfunction. It has been suggested that high-volume, zero-balanced ultrafiltration (ZBUF) facilitates clearance of inflammatory mediators and improves post-operative pulmonary function. Procalcitonin, a newly discovered inflammatory mediator, has been found to be increased after CPB and has been proven to be an appropriate parameter for predicting pulmonary dysfunction secondary to CPB. The aim of this study was to investigate the effects of zero-balanced ultrafiltration (ZBUF) on procalcitonin (PCT) and respiratory function of infants with Tetralogy of Fallot (TOF) after CPB. Twenty infants with TOF undergoing open-heart total surgical correction were randomly assigned to two groups. The trial group was given ZBUF (50 ml/kg) and conventional ultrafiltration (CUF), while the control group was given CUF only. Plasma PCT and pulmonary function were monitored and compared between the two groups before the operation (T1), before rewarming (T2), at the end of the operation (T3), and at 12 h, 24 h and 48 h after the operation (T4-T6). PCT was decreased in the trial group between 12 h and 48 h post-operatively, but the differences did not reach statistical significance. The trial group's pulmonary compliance was higher at 12 h post-operatively ( p < 0.05). Oxygenation index was increased in the trial group at the end of the operation and 12 h post-operatively ( p > 0.05). Intubation time was shorter in the trial group ( P < 0.01). A positive correlation was found between peak PCT concentration and intubation time. ZBUF appeared to improve ventilation and shorten intubation time. The improved respiratory function may be due to the lower plasma PCT. Perfusion (2007) 22, 339—343.
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Affiliation(s)
- Lou Song
- Department of Congenital Defect, Cardiovascular Institute and Fu Wai Hospital, CAMS & PUMC, Beijing, P.R. China
| | - Liu Yinglong
- Department of Congenital Defect, Cardiovascular Institute and Fu Wai Hospital, CAMS & PUMC, Beijing, P.R. China
| | - Liu Jinping
- Department of Congenital Defect, Cardiovascular Institute and Fu Wai Hospital, CAMS & PUMC, Beijing, P.R. China
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34
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Curi-Curi PJ, Springall del Villar MR, Gómez-García L, González Vergara B, Calderón-Colmenero J, Ramírez-Marroquín S, Cervantes-Salazar JL. Impacto intraoperatorio de la ultrafiltración modificada en pacientes pediátricos sometidos a cirugía cardíaca con circulación extracorpórea. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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35
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Abstract
Suboptimal neurodevelopmental outcome is common in children who have congenital heart disease. Its aetiology is often multifactorial. This review focuses on the role of cardiopulmonary bypass. Hypothermia is the mainstay of cerebral protection. Low flow and regional low flow are preferred to deep hypothermic circulatory arrest in many situations. Cooling and rewarming, aortopulmonary collaterals, pH, air emboli, the systemic inflammatory response, haematocrit, oxygenation, glucose and ultrafiltration can influence neurodevelopmental outcome. Although no pharmacological agents have been shown to have a beneficial effect on neurodevelopmental outcome in clinical practice in children, animal work on the use of steroids several hours before surgery is encouraging.
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Chew MS, Brix-Christensen V, Ravn HB, Brandslund I, Ditlevsen E, Pedersen J, Hjortholm K, Hansen OK, Tønnesen E, Hjortdal VE. Effect of modified ultrafiltration on the inflammatory response in paediatric open-heart surgery: a prospective, randomized study. Perfusion 2016; 17:327-33. [PMID: 12243435 DOI: 10.1191/0267659102pf595oa] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Modified ultrafiltration (MUF) is often used in conjunction with paediatric cardiac surgery with cardiopulmonary bypass (CPB) and is thought to improve clinical outcome. It is unclear whether these improvements (if any) are due to the removal of inflammatory mediators. In this prospective study, 18 children aged 12-24 months undergoing uncomplicated cardiac surgery with methylprednisolone added in the pump prime were randomized to receive CPB with ( n= 10) and without ( n= 8) MUF. Cytokines (TNFα, IL-6, IL- 1β, IL-10, IL-1ra), complement split products (C3d, C4d) and coagulation system activation (F1+ 2, ATIII) were measured pre-, peri- and up to 48 h postoperatively. For clinical outcome, the alveolar-arterial oxygen (A-a) gradient, transfusion requirement, drain loss, mean blood pressure and requirement for inotropic support were registered up to 24 h postoperatively. Our results show an improvement in postoperative oxygenation as well as a tendency towards decreased drain loss and improved haemodynamics in the MUF group. There were no intergroup differences detectable for TNFα, IL-1β, IL-1ra, complement and coagulation markers. We conclude that MUF in itself does not significantly influence TNFα, IL-1β, IL-1ra and the complement and coagulation profiles in children undergoing cardiac surgerywith CPB. Despite this, there was some evidence for improved clinical outcome. Our results do not support that MUF improves postoperative organ function by modulation of the measured markers of inflammation.
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Affiliation(s)
- Michelle S Chew
- Department of Anaesthesia and Intensive Care, Institute of Experimental Clinical Research, Aarhus University Hospital, Denmark.
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Raja SG, Yousufuddin S, Rasool F, Nubi A, Danton M, Pollock J. Impact of Modified Ultrafiltration on Morbidity after Pediatric Cardiac Surgery. Asian Cardiovasc Thorac Ann 2016; 14:341-50. [PMID: 16868113 DOI: 10.1177/021849230601400417] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiopulmonary bypass is a double-edged sword. Without it, corrective cardiac surgery would not be possible in the majority of children with congenital heart disease. However, much of the perioperative morbidity that occurs after cardiac surgery can be attributed to a large extent to pathophysiologic processes engendered by extracorporeal circulation. One of the challenges that has confronted pediatric cardiac surgeons has been to minimize the consequences of cardiopulmonary bypass. Ultrafiltration is a strategy that has been used for many years in an effort to attenuate the effects of hemodilution that occur when small children undergo surgery with cardiopulmonary bypass. Over the past several years, a modified technique of ultrafiltration, commonly known as modified ultrafiltration, has been used with increasing enthusiasm. Multiple studies have been undertaken to assess the effects of modified ultrafiltration on organ function and postoperative morbidity following repair of congenital heart defects. This review attempts to evaluate current available scientific evidence on the impact of modified ultrafiltration on organ function and morbidity after pediatric cardiac surgery.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair Street, Glasgow G3 8SJ, United Kingdom.
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38
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Tirilomis T, Friedrich M, Sîrbu H, Aleksic I, Busch T. Intraoperative Hemofiltration in Adults: Prevention of Hypercirculatory Syndrome? Asian Cardiovasc Thorac Ann 2016; 13:17-9. [PMID: 15793044 DOI: 10.1177/021849230501300104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypercirculatory syndrome (HCS) after cardiac surgery may be a sequela of extracorporeal circulation due to hemodilution and release of inflammatory mediators. The aim of this study was to investigate the influence of intraoperative hemofiltration (HF) on the incidence of HCS. A prospective cohort study of 80 patients scheduled for elective coronary bypass was performed. The patients were randomized to two groups: in the conventional (CONV) group 40 patients were treated conventionally and in the HF group 40 patients underwent intraoperative HF. There was no perioperative mortality. The incidence of HCS was comparable in both groups (32% in CONV group versus 40% in HF group; n.s.). Mean cardiac output was higher and systemic vascular resistance lower in CONV group patients than in HF group patients, however these differences did not reach statistical significance. According to this data intraoperative HF does not prevent postoperative HCS induced by cardiopulmonary bypass. Further studies are required to identify the etiology of HCS, and to prevent it occurring after open-heart surgery.
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Affiliation(s)
- Theodor Tirilomis
- Department of Thoracic, Cardiac and Vascular Surgery, University of Göttingen. Robert-Koch-Str. 40, Göttingen D-37075, Germany.
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Quenot JP, Binquet C, Vinsonneau C, Barbar SD, Vinault S, Deckert V, Lemaire S, Hassain AA, Bruyère R, Souweine B, Lagrost L, Adrie C. Very high volume hemofiltration with the Cascade system in septic shock patients. Intensive Care Med 2015; 41:2111-20. [PMID: 26431720 DOI: 10.1007/s00134-015-4056-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/06/2015] [Indexed: 12/22/2022]
Abstract
PURPOSE We compared hemodynamic and biological effects of the Cascade system, which uses very high volume hemofiltration (HVHF) (120 mL kg(-1) h(-1)), with those of usual care in patients with septic shock. METHODS Multicenter, prospective, randomized, open-label trial in three intensive care units (ICU). Adults with septic shock with administration of epinephrine/norepinephrine were eligible. Patients were randomized to usual care plus HVHF (Cascade group), or usual care alone (control group). Primary end point was the number of catecholamine-free days up to 28 days after randomization. Secondary end points were number of days free of mechanical ventilation, renal replacement therapy (RRT) or ICU up to 90 days, and 7-, 28-, and 90-day mortality. RESULTS We included 60 patients (29 Cascade, 31 usual care). Baseline characteristics were comparable. Median number of catecholamine-free days was 22 [IQR 11-23] vs 20 [0-25] for Cascade vs control; there was no significant difference even after adjustment. There was no significant difference in number of mechanical ventilation-free days or ICU requirement. Median number of RRT-free days was 85 [46-90] vs 74 [0-90] for Cascade vs control groups, p = 0.42. By multivariate analysis, the number of RRT-free days was significantly higher in the Cascade group (up to 25 days higher after adjustment). There was no difference in mortality at 7, 28, or 90 days. CONCLUSION Very HVHF using the Cascade system can safely be used in patients presenting with septic shock, but it was not associated with a reduction in the need for catecholamines during the first 28 days.
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Affiliation(s)
- Jean-Pierre Quenot
- Intensive Care Unit, University Hospital of Dijon, Dijon, France. .,Clinical Epidemiology Unit, INSERM, CIC1432, Dijon, France. .,Lipness Team, INSERM, Research Center UMR866 and LabEx LipSTIC, Université de Bourgogne, Dijon, France.
| | - Christine Binquet
- Clinical Epidemiology Unit, INSERM, CIC1432, Dijon, France.,Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, Dijon University Hospital, Dijon, France
| | | | | | - Sandrine Vinault
- Clinical Epidemiology Unit, INSERM, CIC1432, Dijon, France.,Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, Dijon University Hospital, Dijon, France
| | - Valerie Deckert
- Lipness Team, INSERM, Research Center UMR866 and LabEx LipSTIC, Université de Bourgogne, Dijon, France.,Clinical Research Department, University Hospital of Dijon, Dijon, France
| | - Stéphanie Lemaire
- Lipness Team, INSERM, Research Center UMR866 and LabEx LipSTIC, Université de Bourgogne, Dijon, France.,Clinical Research Department, University Hospital of Dijon, Dijon, France
| | - Ali Ait Hassain
- Intensive Care Unit, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Rémi Bruyère
- Intensive Care Unit, University Hospital of Dijon, Dijon, France
| | - Bertrand Souweine
- Intensive Care Unit, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurent Lagrost
- Lipness Team, INSERM, Research Center UMR866 and LabEx LipSTIC, Université de Bourgogne, Dijon, France.,Clinical Research Department, University Hospital of Dijon, Dijon, France
| | - Christophe Adrie
- Intensive Care Unit, Hospital of Melun, Melun, France.,Physiology Department, Cochin Hospital, Paris, France
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40
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Han SS, Kim HJ, Lee SJ, Kim WJ, Hong Y, Lee HY, Song SY, Jung HH, Ahn HS, Ahn IM, Baek H. Effects of Renal Replacement Therapy in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis. Ann Thorac Surg 2015; 100:1485-95. [PMID: 26341602 DOI: 10.1016/j.athoracsur.2015.06.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
Abstract
The use of renal replacement therapy (RRT) in patients receiving extracorporeal membrane oxygenation (ECMO) is increasing, but the effect of RRT on ECMO is controversial. We performed a meta-analysis to determine whether RRT is related to higher mortality in patients receiving ECMO. We searched MEDLINE, EMBASE, the Cochrane Library, and KoreaMed and found 43 observational studies with 21,624 patients receiving ECMO and then compared inpatient mortality rates of patients receiving ECMO both with and without RRT. The risk ratio (RR) of mortality between patients receiving RRT and those not receiving RRT tended to decrease as the mortality of the group not receiving RRT increased. Among patients with RRT use rates of 30% and higher, the overall mortality rates for all patients receiving ECMO tended to decrease. We found that the increase in the RR for RRT tended to be greater the longer the initiation of RRT was delayed. We suggest that in patients receiving ECMO who have high RRT use rates, RRT may decrease mortality rates.
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Affiliation(s)
- Seon-Sook Han
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seung Joon Lee
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Woo Jin Kim
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Youngi Hong
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hui-Young Lee
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Seo-Young Song
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hae Hyuk Jung
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Division of Nephrology, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Il Min Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea; Department of Literary Arts, Brown University, Providence, Rhode Island
| | - Hyunjeong Baek
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Division of Nephrology, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea.
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Arriagada S D, Donoso F A, Cruces R P, Díaz R F. [Septic shock in intensive care units. Current focus on treatment]. ACTA ACUST UNITED AC 2015; 86:224-35. [PMID: 26323988 DOI: 10.1016/j.rchipe.2015.07.013] [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: 04/22/2014] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
Essential therapeutic principles in children with septic shock persist over time, although some new concepts have been recently incorporated, and fully awareness of pediatricians and intensivists is essential. Fluid resuscitation is a fundamental intervention, but the kind of ideal fluid has not been established yet, as each of these interventions has specific limitations and there is no evidence supportive of the superiority of one type of fluid. Should septic shock persists despite adequate fluid resuscitation, the use of inotropic medication and/or vasopressors is indicated. New vasoactive drugs can be used in refractory septic shock caused by vasopressors, and the use of hydrocortisone should be considered in children with suspected adrenal insufficiency, as it reduces the need for vasopressors. The indications for red blood cells transfusion or the optimal level of glycemia are still controversial, with no consensus on the threshold value for the use of these blood products or the initiation of insulin administration, respectively. Likewise, the use of high-volume hemofiltration is a controversial issue and further study is needed on the routine recommendation in the course of septic shock. Nutritional support is crucial, as malnutrition is a serious complication that should be properly prevented and treated. The aim of this paper is to provide update on the most recent advances as concerns the treatment of septic shock in the pediatric population.
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Affiliation(s)
- Daniela Arriagada S
- Programa de Medicina Intensiva en Pediatría, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Alejandro Donoso F
- Programa de Medicina Intensiva en Pediatría, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile; Área de Cuidados Críticos, Unidad de Gestión Clínica de Niño, Hospital Padre Hurtado, Santiago, Chile.
| | - Pablo Cruces R
- Área de Cuidados Críticos, Unidad de Gestión Clínica de Niño, Hospital Padre Hurtado, Santiago, Chile; Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andrés Bello, Santiago, Chile
| | - Franco Díaz R
- Área de Cuidados Críticos, Unidad de Gestión Clínica de Niño, Hospital Padre Hurtado, Santiago, Chile
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42
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Seo DJ, Yoo JS, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Venovenous Extracorporeal Membrane Oxygenation for Postoperative Acute Respiratory Distress Syndrome. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 48:180-6. [PMID: 26078924 PMCID: PMC4463224 DOI: 10.5090/kjtcs.2015.48.3.180] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 01/11/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has recently attracted interest as a treatment for severe acute respiratory distress syndrome (ARDS). However, the outcomes of this procedure in post-surgical settings have not yet been characterized. In this study, we evaluated the outcomes of ECMO in patients with severe postoperative ARDS. Methods From January 2007 to December 2012, a total of 69 patients (aged 58.3±11.5 years, 23 females) who underwent venovenous ECMO to treat severe postoperative ARDS were reviewed. Of these patients, 22 (31.9%) had undergone cardiothoracic surgery, 32 (46.4%) had undergone liver transplantation, and 15 (21.7%) had undergone other procedures. Results Thirty-four patients (49.3%) were successfully weaned from ECMO, while the other 35 patients (50.7%) died on ECMO support. Among the 34 patients who were successfully weaned from ECMO, 21 patients (30.4%) eventually died before discharge from the hospital, resulting in 13 hospital survivors (18.8%). Multivariable analysis showed that the duration of pre-ECMO ventilation was a significant independent predictor of death (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.29 to 3.90; p=0.004), whereas the concomitant use of continuous venovenous hemodialysis (CVVHD) was associated with improved survival (OR, 0.55; 95% CI, 0.31 to 0.97; p=0.038). Conclusion Although the overall survival rate of patients treated with ECMO for postoperative ARDS was unfavorable, ECMO offered an invaluable opportunity for survival to patients who would not have been expected to survive using conventional therapy. CVVHD may be beneficial in improving the outcomes of such patients, whereas a prolonged duration of pre-ECMO ventilator support was associated with poor survival.
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Affiliation(s)
- Dong Ju Seo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
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43
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History of cardiopulmonary bypass (CPB). Best Pract Res Clin Anaesthesiol 2015; 29:99-111. [PMID: 26060023 DOI: 10.1016/j.bpa.2015.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/04/2015] [Accepted: 04/14/2015] [Indexed: 11/21/2022]
Abstract
The development of cardiopulmonary bypass (CPB), thereby permitting open-heart surgery, is one of the most important advances in medicine in the 20th century. Many currently practicing cardiac anesthesiologists, cardiac surgeons, and perfusionists are unaware of how recently it came into use (60 years) and how much the practice of CPB has changed during its short existence. In this paper, the development of CPB and the many changes and progress that has taken place over this brief period of time, making it a remarkably safe endeavor, are reviewed. The many as yet unresolved questions are also identified, which sets the stage for the other papers in this issue of this journal.
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44
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Heath M, Barbeito A, Welsby I, Maxwell C, Iribarne A, Raghunathan K. Using Zero-Balance Ultrafiltration With Dialysate as a Replacement Solution for Toxin and Eptifibatide Removal on a Dialysis-Dependent Patient During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 30:162-8. [PMID: 25857672 DOI: 10.1053/j.jvca.2014.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | - Atilio Barbeito
- Durham VA Medical Center; Duke University Hospital, Durham, NC
| | - Ian Welsby
- Durham VA Medical Center; Duke University Hospital, Durham, NC
| | - Cory Maxwell
- Durham VA Medical Center; Duke University Hospital, Durham, NC
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Kapitein B, van Saet AW, Golab HD, de Hoog M, de Wildt S, Tibboel D, Bogers AJJC. Does pharmacotherapy influence the inflammatory responses during cardiopulmonary bypass in children? J Cardiovasc Pharmacol 2015; 64:191-7. [PMID: 24949583 DOI: 10.1097/fjc.0000000000000098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cardiopulmonary bypass (CPB) induces a systemic inflammatory response syndrome (SIRS) by factors such as contact of the blood with the foreign surface of the extracorporeal circuit, hypothermia, reduction of pulmonary blood flow during CPB and endotoxemia. SIRS is maintained in the postoperative phase, co-occurring with a counter anti-inflammatory response syndrome. Research on the effects of drugs administered before the surgery, especially in the induction phase of anesthesia, as well as drugs used during extracorporeal circulation, has revealed that they greatly influence these postoperative inflammatory responses. A better understanding of these processes may not only improve postoperative recovery but also enable tailor-made pharmacotherapy, with both health and economic benefits. In this review, we describe the pathophysiology of SIRS and counter anti-inflammatory response syndrome in the light of CPB in children and the influence of drugs used on these syndromes.
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Affiliation(s)
- Berber Kapitein
- *Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; †Department of Anesthesiology, Intensive Care Unit, Erasmus MC, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; and ‡Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, the Netherlands
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46
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Matata BM, Scawn N, Morgan M, Shirley S, Kemp I, Richards S, Lane S, Wilson K, Stables R, Jackson M, Haycox A, Mediratta N. A Single-Center Randomized Trial of Intraoperative Zero-Balanced Ultrafiltration During Cardiopulmonary Bypass for Patients With Impaired Kidney Function Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1236-47. [PMID: 26119403 DOI: 10.1053/j.jvca.2015.02.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The authors investigated whether zero-balance ultrafiltration (Z-BUF) during bypass significantly improves clinical and cost outcomes or biomarkers of kidney injury for patients with preoperative kidney impairment (estimated glomerular filtration rate [eGFR]<60 mL/minute) undergoing cardiac surgery. DESIGN A single-center randomized controlled trial recruited, patients between 2010 and 2013, with a 12-months follow-up. SETTING Hospital. PARTICIPANTS One hundred ninety-nine patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). INTERVENTIONS Patients were assigned randomly to receive zero-balance ultrafiltration (Z-BUF) or not, with stratification for degree of kidney dysfunction and diabetes. MEASUREMENTS AND MAIN RESULTS The authors assessed clinical efficacy and kidney function biomarkers. Cumulative probability of discharge from the intensive care unit (ICU) was assessed by Kaplan-Meier plots and was found not to be significantly different between the two trial arms (p = 0.61). After adjusting for EuroSCORE, diabetes, eGFR, cardioplegia types and type of surgery in a Cox proportional hazard model, hazard ratios (HR) for ICU length of stay between the Z-BUF and no-Z-BUF groups was not significantly different: HR (95% CI): 0.89 (0.66, 1.20; p = 0.44). In contrast, significant reductions in postoperative chest infections and the composite of clinical endpoints (death, strokes, and myocardial infarctions) in the Z-BUF group were observed. In addition, Z-BUF significantly abrogated the rise in the kidney damage markers urinary NGAL/creatinine ratio, urea, creatinine and eGFR during CPB and adverse events risks. CONCLUSIONS Z-BUF during bypass surgery is associated with significant reductions in morbidity and biomarkers of CPB-induced acute kidney injury soon after CPB, which are indicative of clearance of inflammatory/immune mediators from the circulation.
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Affiliation(s)
| | - Nigel Scawn
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | | | - Sarah Shirley
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | - Ian Kemp
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | | | - Steven Lane
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Keith Wilson
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | | | - Mark Jackson
- Liverpool Heart and Chest Hospital NHS Foundation Trust
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Abstract
OBJECTIVES High-volume hemofiltration has shown beneficial effects in severe sepsis and multiple organ failure, improving hemodynamics and fluid balance. Recent studies suggest that acute liver failure shares many pathophysiologic similarities with sepsis. Therefore, we assessed the systemic effects of high-volume hemofiltration in children with acute liver failure. DESIGN Retrospective observational cohort study. PATIENTS Twenty-two children. SETTING Forty-two-bed multidisciplinary pediatric and neonatal ICUs in a tertiary university hospital. INTERVENTION We evaluated high-volume hemofiltration therapy as part of standard management of 22 children admitted in our unit for acute liver failure. Fifteen patients had fulminant hepatic failure, three had acute-on-chronic liver disease, and four had primary nonfunction. High-volume hemofiltration was initiated in patients requiring emergency liver transplantation and when hepatic encephalopathy grade higher than 2 and/or hemodynamic instability requiring vasopressors occurred. High-volume hemofiltration was defined by a flow of ultrafiltrate of more than 80 mL/kg/hr. Clinical and biological variables were assessed before and 24 and 48 hours after initiation of high-volume hemofiltration therapy. MEASUREMENTS AND MAIN RESULTS High-volume hemofiltration was initiated with a median grade III of hepatic encephalopathy. The median flow of ultrafiltrate was 119 mL/kg/hr (range, 80-384). After 24 hours of high-volume hemofiltration treatment, we observed an increase in mean arterial pressure (p = 0.0002) and a decrease in serum creatinine (p = 0.0002). In half of the patients, the encephalopathy grade decreased. After 48 hours of treatment, mean arterial pressure (p = 0.0005), grade of hepatic encephalopathy (p = 0.04), and serum creatinine (p = 0.0002) improved. Overall mortality was 45.4% (n = 10). Emergency liver transplantation was performed in eight children. Five patients spontaneously recovered liver function. CONCLUSIONS High-volume hemofiltration therapy significantly improves hemodynamic stability and neurological status in children with acute liver failure awaiting for emergency liver transplantation.
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48
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Abstract
Perioperative period is very likely to lead to acute renal failure because of anesthesia (general or perimedullary) and/or surgery which can cause acute kidney injury. Characterization of acute renal failure is based on serum creatinine level which is imprecise during and following surgery. Studies are based on various definitions of acute renal failure with different thresholds which skewed their comparisons. The RIFLE classification (risk, injury, failure, loss, end stage kidney disease) allows clinicians to distinguish in a similar manner between different stages of acute kidney injury rather than using a unique definition of acute renal failure. Acute renal failure during the perioperative period can mainly be explained by iatrogenic, hemodynamic or surgical causes and can result in an increased morbi-mortality. Prevention of this complication requires hemodynamic optimization (venous return, cardiac output, vascular resistance), discontinuation of nephrotoxic drugs but also knowledge of the different steps of the surgery to avoid further degradation of renal perfusion. Diuretics do not prevent acute renal failure and may even push it forward especially during the perioperative period when venous retourn is already reduced. Edema or weight gain following surgery are not correlated with the vascular compartment volume, much less with renal perfusion. Treatment of perioperative acute renal failure is similar to other acute renal failure. Renal replacement therapy must be mastered to prevent any additional risk of hemodynamic instability or hydro-electrolytic imbalance.
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Affiliation(s)
- Vibol Chhor
- Service d'anesthésie-réanimation chirurgicale, hôpital européen Georges Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, 75015 Paris, France
| | - Didier Journois
- Service d'anesthésie-réanimation chirurgicale, hôpital européen Georges Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, 75015 Paris, France.
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Mohanlall R, Adam J, Nemlander A. Venoarterial modified ultrafiltration versus conventional arteriovenous modified ultrafiltration during cardiopulmonary bypass surgery. Ann Saudi Med 2014; 34:18-30. [PMID: 24658550 PMCID: PMC6074936 DOI: 10.5144/0256-4947.2014.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Different types of modified ultrafiltration (MUF) systems evaluated showed that none of the MUF techniques adhered to the normal venous to arterial blood flow dynamics. This study compared a conventional arteriovenous modified ultrafiltration (AVMUF) system to a custom- designed venoarterial modified ultrafiltration (VAMUF) system. DESIGN AND SETTINGS Randomized, controlled clinical study conducted at the Northwest Armed Forces Military hospital in Tabuk, Saudi Arabia. PATIENTS AND METHODS Sixty patients who underwent MUF during the years 2007 and 2009 were divided into 2 groups: the AVMUF (n=30) and the VAMUF (n=30) groups. MUF was performed for a mean time of 12 minutes in both groups. In AVMUF, blood was removed from the aorta, hemoconcentrated, and infused into the right atrium (RA). In VAMUF, blood flow was from the RA through a hemoconcentrator and re-infused into the aorta. RESULTS Results of the study showed that the VAMUF group required a shorter ventilation time (P < .001), in.tensive care unit (ICU) (P=.003), and hospital stay (P=.007) than the AVMUF group. Results also demonstrated a lower percentage of fluid balance (P=.008) in the VAMUF group. The systolic (P < .001) and mean blood pres.sures (P < .001) were significantly higher after VAMUF, with a decrease in heart rate (P < .001) and central venous pressure (P=.002). The VAMUF group showed a significantly greater decrease of creatinine (P < .001), serum lactacte (P < .001), and uric acid (P < .027) over time with no significant differences in oximetry. CONCLUSION Results prove that VAMUF is a more physiological technique than AVMUF.
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Affiliation(s)
| | - Jamila Adam
- Prof. Jamila Adam, Department of Biomedical Clinical Technology,, Faculty of Health Sciences Biomedical and Clinical Technology,, Durban University of Technology,, Durban, KZN 1334 South Africa, T: +27-373-5291, F: +27-373-5295,
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50
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Shi J, Chen Q, Yu W, Shen J, Gong J, He C, Hu Y, Zhang J, Gao T, Xi F, Li J. Continuous renal replacement therapy reduces the systemic and pulmonary inflammation induced by venovenous extracorporeal membrane oxygenation in a porcine model. Artif Organs 2013; 38:215-23. [PMID: 24329567 DOI: 10.1111/aor.12154] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary changes in veno-venous extracorporeal membrane oxygenation (VV-ECMO) are rarely determined. We compared the contribution of VV-ECMO and cannulation based on the observation of pulmonary inflammatory reaction and parenchymal construction in a porcine model of low tidal volume (VT ) ventilation. We also evaluated the effect of adding continuous renal replacement therapy (CRRT) to the ECMO circuit, because CRRT is known to reduce systemic cytokine release induced by VV-ECMO. A total of 18 pigs undergoing low-VT ventilation were randomly divided into three groups (group 1, cannulation; group 2, VV-ECMO; group 3, VV-ECMO + CRRT) and studied for 24 h. Hemodynamic and ventilation parameters were recorded. We assessed plasma and alveolar cytokines, expression of pulmonary inflammatory genes, histopathological grading, and ultrastructural changes of the lungs. During the process, inspiratory volume increased and PaO2 decreased in group 1. Systemic tumor necrosis factor-α (TNF-α) and interleukin 6 (IL-6) levels increased at 2 h in group 2 and partly decreased in group 3. At 24 h, the levels of bronchoalveolar lavage fluid, TNF-α, and IL-6 in group 2 were remarkably higher than those in groups 1 and 3. Pulmonary mRNA expression of cytokines did not differ between the groups. We observed an increased score of pulmonary pathological findings in pro-inflammatory cell infiltration and interstitial thickening of the lungs in group 2. The epithelium of the blood-air barrier after VV-ECMO was swollen. In group 3, the pulmonary parenchyma and blood-air barrier were well preserved. We concluded that in a porcine model of low-VT ventilation, both VV-ECMO and VV-ECMO in combination with CRRT provided adequate oxygenation and carbon dioxide removal. Compared with VV-ECMO alone, VV-ECMO in combination with CRRT better preserved the lung parenchyma by eliminating systemic cytokines.
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Affiliation(s)
- Jialiang Shi
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China
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