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Soliman R, Fouad E, Belghith M, Abdelmageed T. Conventional hemofiltration during cardiopulmonary bypass increases the serum lactate level in adult cardiac surgery. Ann Card Anaesth 2016; 19:45-51. [PMID: 26750673 PMCID: PMC4900403 DOI: 10.4103/0971-9784.173019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/22/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To evaluate the effect of hemofiltration during cardiopulmonary bypass on lactate level in adult patients who underwent cardiac surgery. DESIGN An observational study. SETTING Prince Sultan cardiac center, Riyadh, Saudi Arabia. PARTICIPANTS The study included 283 patients classified into two groups: Hemofiltration group (n=138), hemofiltration was done during CPB. Control group (n = 145), patients without hemofiltration. INTERVENTIONS Hemofiltration during cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Monitors included hematocrit, lactate levels, mixed venous oxygen saturation, amount of fluid removal during hemofiltration and urine output. The lactate elevated in group H than group C (P < 0.05), and the PH showed metabolic acidosis in group H (P < 0.05). The mixed venous oxygen saturation decreased in group H than group C (P < 0.05). The number of transfused packed red blood cells was lower in group H than group C (P < 0.05). The hematocrit was higher in group H than group C (P < 0.05). The urine output was lower in group H than group C (P < 0.05). CONCLUSIONS Hemofiltration during cardiopulmonary bypass leads to hemoconcentration, elevated lactate level and increased inotropic support. There are some recommendations for hemofiltration: First; Hemofiltration should be limited for patients with impaired renal function, positive fluid balance, reduced response to diuretics or prolonged bypass time more than 2 hours. Second; Minimal amount of fluids should be administered to maintain adequate cardiac output and reduction of priming volumes is preferable to maintain controlled hemodilution. Third; it should be done before weaning of or after cardiopulmonary bypass and not during the whole time of cardiopulmonary bypass.
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Affiliation(s)
- Rabie Soliman
- Department of Cardiac anesthesia, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Department of Anesthesia, Cairo University, Giza, Egypt
| | - Eman Fouad
- Department of Anesthesia, Cairo University, Giza, Egypt
| | - Makhlouf Belghith
- Department of Cardiac anesthesia, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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Kandane-Rathnayake RK, Isbister JP, Zatta AJ, Aoki NJ, Cameron P, Phillips LE. Use of recombinant activated factor VII in Jehovah's Witness patients with critical bleeding. ANZ J Surg 2012; 83:155-60. [DOI: 10.1111/j.1445-2197.2012.06285.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2012] [Indexed: 12/22/2022]
Affiliation(s)
- Rangi K. Kandane-Rathnayake
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne; Victoria; Australia
| | - James P. Isbister
- Transfusion Medicine; Royal North Shore Hospital; Sydney; New South Wales; Australia
| | - Amanda J. Zatta
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne; Victoria; Australia
| | - Naomi J. Aoki
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne; Victoria; Australia
| | | | - Louise E. Phillips
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne; Victoria; Australia
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Paone G, Brewer R, Theurer PF, Bell GF, Cogan CM, Prager RL. Preoperative predicted risk does not fully explain the association between red blood cell transfusion and mortality in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2012; 143:178-85. [DOI: 10.1016/j.jtcvs.2011.09.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 08/01/2011] [Accepted: 09/15/2011] [Indexed: 11/30/2022]
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Trethowan BA, Gilliland H, Popov AF, Varadarajan B, Phillips SA, McWhirter L, Ghent R. A case report and brief review of the literature on bilateral retinal infarction following cardiopulmonary bypass for coronary artery bypass grafting. J Cardiothorac Surg 2011; 6:154. [PMID: 22104114 PMCID: PMC3253690 DOI: 10.1186/1749-8090-6-154] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 11/21/2011] [Indexed: 11/18/2022] Open
Abstract
Postoperative visual loss is a devastating perioperative complication. The commonest aetiologies are anterior ischaemic optic neuropathy (AION), posterior ischaemic optic neuropathy (PION), and central retinal artery occlusion (CRAO). These appear to be related to certain types of operation, most commonly spinal and cardiac bypass procedures; with the rest divided between: major trauma causing excessive blood loss; head/neck and nasal or sinus surgery; major vascular procedures (aortic aneurysm repair, aorto-bifemoral bypass); general surgery; urology; gynaecology; liposuction; liver transplantation and duration of surgery. The non-surgical risk factors are multifactorial: advanced age, prolonged postoperative anaemia, positioning (supine v prone), alteration of venous drainage of the retina, hypertension, smoking, atherosclerosis, hyperlipidaemia, diabetes, hypercoagulability, hypotension, blood loss and large volume resuscitation. Other important cardiac causes are septic emboli from bacterial endocarditis and emboli caused by atrial myxomata. The majority of AION cases occur during CPB followed by head/neck surgery and prone spine surgery. CPB is used to allow coronary artery bypass grafting on a motionless heart. It has many side-effects and complications associated with its use and we report here a case of bilateral retinal infarction during routine coronary artery bypass grafting in a young male patient with multiple risk factors for developing this complication despite steps to minimise its occurrence.
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Affiliation(s)
- Brian A Trethowan
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
- Department of Cardiothoracic Transplantation & Mechanical Support, Royal Brompton & Harefield NHS Trust, Harefield, UB9 6JH, London, United Kingdom
| | - Helen Gilliland
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Aron F Popov
- Department of Cardiothoracic Transplantation & Mechanical Support, Royal Brompton & Harefield NHS Trust, Harefield, UB9 6JH, London, United Kingdom
| | - Barathi Varadarajan
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Sally-Anne Phillips
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Louise McWhirter
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
- Department of Critical Care, The Royal London Hospital, Whitechapel Road, E1 1BB, London, United Kingdom
| | - Robert Ghent
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
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Vretzakis G, Kleitsaki A, Aretha D, Karanikolas M. Management of intraoperative fluid balance and blood conservation techniques in adult cardiac surgery. Heart Surg Forum 2011; 14:E28-39. [PMID: 21345774 DOI: 10.1532/hsf98.2010111] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Blood transfusions are associated with adverse physiologic effects and increased cost, and therefore reduction of blood product use during surgery is a desirable goal for all patients. Cardiac surgery is a major consumer of donor blood products, especially when cardiopulmonary bypass (CPB) is used, because hematocrit drops precipitously during CPB due to blood loss and blood cell dilution. Advanced age, low preoperative red blood cell volume (preoperative anemia or small body size), preoperative antiplatelet or antithrombotic drugs, complex or re-operative procedures or emergency operations, and patient comorbidities were identified as important transfusion risk indicators in a report recently published by the Society of Cardiovascular Anesthesiologists. This report also identified several pre- and intraoperative interventions that may help reduce blood transfusions, including off-pump procedures, preoperative autologous blood donation, normovolemic hemodilution, and routine cell saver use.A multimodal approach to blood conservation, with high-risk patients receiving all available interventions, may help preserve vital organ perfusion and reduce blood product utilization. In addition, because positive intravenous fluid balance is a significant factor affecting hemodilution during cardiac surgery, especially when CPB is used, strategies aimed at limiting intraoperative fluid balance positiveness may also lead to reduced blood product utilization.This review discusses currently available techniques that can be used intraoperatively in an attempt to avoid or minimize fluid balance positiveness, to preserve the patient's own red blood cells, and to decrease blood product utilization during cardiac surgery.
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Affiliation(s)
- George Vretzakis
- Cardiac Anaesthesia Unit, University Hospital of Larissa, Greece
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Perez-Valdivieso JR, Monedero P, Vives M, Garcia-Fernandez N, Bes-Rastrollo M. Cardiac-surgery associated acute kidney injury requiring renal replacement therapy. A Spanish retrospective case-cohort study. BMC Nephrol 2009; 10:27. [PMID: 19772621 PMCID: PMC2759914 DOI: 10.1186/1471-2369-10-27] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 09/22/2009] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury is among the most serious complications after cardiac surgery and is associated with an impaired outcome. Multiple factors may concur in the development of this disease. Moreover, severe renal failure requiring renal replacement therapy (RRT) presents a high mortality rate. Consequently, we studied a Spanish cohort of patients to assess the risk factors for RRT in cardiac surgery-associated acute kidney injury (CSA-AKI). Methods A retrospective case-cohort study in 24 Spanish hospitals. All cases of RRT after cardiac surgery in 2007 were matched in a crude ratio of 1:4 consecutive patients based on age, sex, treated in the same year, at the same hospital and by the same group of surgeons. Results We analyzed the data from 864 patients enrolled in 2007. In multivariate analysis, severe acute kidney injury requiring postoperative RRT was significantly associated with the following variables: lower glomerular filtration rates, less basal haemoglobin, lower left ventricular ejection fraction, diabetes, prior diuretic treatment, urgent surgery, longer aortic cross clamp times, intraoperative administration of aprotinin, and increased number of packed red blood cells (PRBC) transfused. When we conducted a propensity analysis using best-matched of 137 available pairs of patients, prior diuretic treatment, longer aortic cross clamp times and number of PRBC transfused were significantly associated with CSA-AKI. Patients requiring RRT needed longer hospital stays, and suffered higher mortality rates. Conclusion Cardiac-surgery associated acute kidney injury requiring RRT is associated with worse outcomes. For this reason, modifiable risk factors should be optimised and higher risk patients for acute kidney injury should be identified before undertaking cardiac surgery.
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Affiliation(s)
- Jose Ramon Perez-Valdivieso
- Department of Anesthesia and Critical Care, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain.
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Lichtman AD, Carullo V, Minhaj M, Karkouti K. Case 6—2007 Massive Intraoperative Thrombosis and Death After Recombinant Activated Factor VII Administration. J Cardiothorac Vasc Anesth 2007; 21:897-902. [DOI: 10.1053/j.jvca.2007.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Indexed: 11/11/2022]
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The Critically III Red Blood Cell. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- Bruce D Spiess
- VCURES Shock Center, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0695, USA.
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Ferraris VA, Ferraris SP, Saha SP, Hessel EA, Haan CK, Royston BD, Bridges CR, Higgins RSD, Despotis G, Brown JR, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27-86. [PMID: 17462454 DOI: 10.1016/j.athoracsur.2007.02.099] [Citation(s) in RCA: 543] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 01/21/2007] [Accepted: 02/08/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes. METHODS We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme. RESULTS Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions. CONCLUSIONS Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.
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Lerner AB. Pro: Antifibrinolytics are safe and effective in patients undergoing liver transplantation. J Cardiothorac Vasc Anesth 2006; 20:888-90. [PMID: 17138101 DOI: 10.1053/j.jvca.2006.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Adam B Lerner
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Stafford-Smith M, Newman MF. What effects do hemodilution and blood transfusion during cardiopulmonary bypass have on renal outcomes? ACTA ACUST UNITED AC 2006; 2:188-9. [PMID: 16932421 DOI: 10.1038/ncpneph0128] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2005] [Accepted: 01/16/2006] [Indexed: 11/08/2022]
Affiliation(s)
- Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Ball J. Recently published papers: what not to do and how not to do it? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:419-21. [PMID: 16277724 PMCID: PMC1297633 DOI: 10.1186/cc3812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Controversies abound in the areas of blood transfusion, albumin, lipoproteins in sepsis and pulmonary artery catheters. We are also making too many errors, but at least there is a new nitric oxide therapy in the offing.
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