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Heo RH, Wang MK, Meyre PB, Birchenough L, Park L, Vuong K, Devereaux PJ, Blum S, Lindahl B, Stone G, Conen D. Associations of Inflammatory Biomarkers With the Risk of Morbidity and Mortality After Cardiac Surgery: A Systematic Review and Meta-analysis. Can J Cardiol 2023; 39:1686-1694. [PMID: 37495205 DOI: 10.1016/j.cjca.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Although inflammatory biomarkers have been associated with cardiovascular events in nonsurgical settings, these associations have not been systematically addressed in patients undergoing cardiac surgery. This review aimed to evaluate the relationships of inflammatory markers with mortality and adverse cardiovascular events in patients undergoing cardiac surgery. METHODS Medline, Embase, and Central databases were systematically searched for studies reporting pre- or postoperative levels of inflammatory biomarkers in patients undergoing cardiac surgery. Outcomes of interest were postoperative mortality, nonfatal myocardial infarction, stroke, congestive heart failure, and major adverse cardiovascular events (MACE). Studies reporting multivariable adjusted risk estimates were included. Risk estimates were pooled with the use of random-effects models and reported as summary odds ratios (ORs). RESULTS Among 14,465 citations identified, 29 studies including 29,401 participants met the eligibility criteria. The average follow-up time after surgery was 31 months. Preoperative C-reactive protein (CRP) levels were associated with an increased risk of all-cause mortality (OR 1.88, 95% CI 1.60-2.20; I2 = 19%; 11 studies) and MACE (OR 1.73, 95% CI 1.34-2.24; I2 = 0%; 3 studies). CRP levels measured on postoperative day 6 (OR 7.4, 95% CI 2.90-18.88, 1 study) and day 10 (OR 11.8, 95% CI 3.50-39.78, 1 study) were associated with a higher risk of all-cause mortality. Less, but overall similar, information was available for other inflammatory biomarkers. CONCLUSIONS In this large meta-analysis, inflammatory biomarkers measured before or after cardiac surgery were associated with mortality and adverse cardiovascular outcomes in patients undergoing cardiac surgery.
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Affiliation(s)
- Rachel Haeeun Heo
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Michael Ke Wang
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Pascal B Meyre
- Division of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Lauren Birchenough
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Louis Park
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kiven Vuong
- Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Steffen Blum
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Division of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Uppsala, Sweden
| | - Gregg Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
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Veraar C, Schwarz S, Thanner J, Direder M, Boehm PM, Harnoncourt L, Ortmayr J, Veraar C, Mascherbauer J, Klepetko W, Dworschak M, Ankersmit HJ, Moser B. Transient perioperative inflammation following lung transplantation and major thoracic surgery with elective extracorporeal support: a prospective observational study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:385. [PMID: 33842606 PMCID: PMC8033292 DOI: 10.21037/atm-20-4771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background The clinical relevance of inflammation induced by elective perioperative extracorporeal membrane oxygenation (ECMO) usage as an integral part of modern lung transplantation (LUTX) remains elusive. The aim of this study was to determine the perioperative cytokine response accompanying major thoracic surgery employing different extracorporeal devices comprising ECMO, cardiopulmonary bypass (CPB), or no extracorporeal circulation in relation to inflammation, clinically tangible as increased sequential organ failure assessment (SOFA) score, called SOFA. Methods In this prospective, observational pilot study 42 consecutive patients with end-stage pulmonary disease undergoing LUTX; 15 patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary endarterectomy and 15 patients with lung cancer undergoing major lung resections were analysed. Cytokine serum concentrations and SOFA were determined before, at end of surgery and in the following postoperative days. Results LUTX on ECMO and pulmonary endarterectomy (PEA) on CPB triggered an immediate increase in cytokine serum concentrations at end of surgery: IL-6: 66-fold and 71-fold, IL-10: 3-fold and 2.5-fold, ST2/IL-33R: 5-fold and 4-fold and SOFA: 10.5±2.8 and 10.7±1.7, that decreased sharply to baseline levels from postoperative day 1–5. Despite low perioperative mortality (3 patients, 4.1%) extremely high SOFA ≥13 was associated with mortality after LUTX. Delta-SOFA distinguished survivors from non-survivors: −4.5±3.2 vs. −0.3±1.5 (P=0.001). Increased IL-6 serum concentrations were predictive for increased SOFA (sensitivity: 97%, specificity: 80%). Peak cytokine serum concentrations correlated with ECC duration, maximal lactate, transfusion of red-blood-cells, fresh-frozen-plasma, and catecholamine support. Conclusions LUTX and PEA on extracorporeal circulation with an excellent outcome triggered an immediate rise and concomitant fall of inflammation as observed in cytokine serum concentrations and SOFA. High absolute SOFA in the presence of an uncomplicated postoperative course may pertain to specific management strategies rather than organ failure.
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Affiliation(s)
- Cecilia Veraar
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Jürgen Thanner
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Direder
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Panja M Boehm
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Leopold Harnoncourt
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Joachim Ortmayr
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Clarence Veraar
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Dworschak
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Hendrik J Ankersmit
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.,Head FFG Project "APOSEC", FOLAB Surgery, Medical University Vienna, Vienna, Austria
| | - Bernhard Moser
- Department of Surgery, Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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Khan AI, Patidar GK, Lakshmy R, Makhija N, Talwar S, Hazarika A. Effect of leukoreduction on transfusion‐related immunomodulation in patients undergoing cardiac surgery. Transfus Med 2020; 30:497-504. [DOI: 10.1111/tme.12714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Atif Irfan Khan
- Department of Transfusion Medicine All India Institute of Medical Sciences New Delhi India
| | - Gopal Kumar Patidar
- Department of Transfusion Medicine All India Institute of Medical Sciences New Delhi India
| | - R. Lakshmy
- Department of Cardiac Biochemistry, Cardio‐Neuro (C.N) Centre All India Institute of Medical Sciences New Delhi India
| | - Neeti Makhija
- Department of Cardiac Anaesthesia, Cardio‐Neuro (C.N) Centre All India Institute of Medical Sciences New Delhi India
| | - Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, Cardio‐Neuro (C.N) Centre All India Institute of Medical Sciences New Delhi India
| | - Anjali Hazarika
- Department of Transfusion Medicine All India Institute of Medical Sciences New Delhi India
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Nelson KA, Aldea GS, Warner P, Latchman Y, Gunasekera D, Tamir A, Gernsheimer T, Bolgiano D, Slichter SJ. Transfusion‐related immunomodulation: gamma irradiation alters the effects of leukoreduction on alloimmunization. Transfusion 2019; 59:3396-3404. [DOI: 10.1111/trf.15555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/28/2022]
Affiliation(s)
| | - Gabriel S. Aldea
- Department of Surgery, Division of Cardiothoracic Surgery University of Washington Seattle Washington
| | | | - Yvette Latchman
- Bloodworks Northwest Seattle Washington
- Silverback Therapeutics Seattle Washington
| | - Devi Gunasekera
- Bloodworks Northwest Seattle Washington
- Uniformed Services University of Health Sciences Bethesda Maryland
| | | | - Terry Gernsheimer
- Bloodworks Northwest Seattle Washington
- Division of Hematology University of Washington School of Medicine Seattle Washington
- Seattle Cancer Care Alliance Seattle Washington
| | | | - Sherrill J. Slichter
- Bloodworks Northwest Seattle Washington
- Division of Hematology University of Washington School of Medicine Seattle Washington
- Seattle Cancer Care Alliance Seattle Washington
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Chan CH, Ziyadi GM, Zuhdi MA. Adverse Outcomes of Perioperative Red Blood Cell Transfusions in Coronary Artery Bypass Grafting in Hospital Universiti Sains Malaysia. Malays J Med Sci 2019; 26:49-63. [PMID: 31303850 PMCID: PMC6613466 DOI: 10.21315/mjms2019.26.3.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/03/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Perioperative red blood cell (RBC) transfusion in coronary artery bypass grafting (CABG) has both benefits and harms. Our aim was to study the association between perioperative RBC transfusion and its adverse outcomes. METHODS This was a retrospective study of patients who underwent isolated CABG in Hospital Universiti Sains Malaysia, Kelantan, Malaysia, from 1 January 2013 until 31 December 2017. Data were collected from medical records, and comparisons were made between patients who received perioperative RBC transfusions and those who did not have adverse outcomes after CABG. RESULTS A total of 108 patients who underwent isolated CABG were included in our study, and 78 patients received perioperative RBC transfusions. Patients who received perioperative RBC transfusions compared to those who did not were significantly more likely to develop prolonged ventilatory support (21.8% versus 0%, P = 0.003), cardiac morbidity (14.1% versus 0%, P = 0.032), renal morbidity (28.2% versus 3.3%, P = 0.005) and serious infection (20.5% versus 3.3%, P = 0.037). With each unit of packed RBC transfusions, there was a significantly increased risk of prolonged ventilatory support (adjusted odds ratio [AOR] = 1.45; 95% confidence interval [CI] = 1.20-1.77; P < 0.001), cardiac morbidity (AOR =1.40; 95%CI = 1.01-1.79; P = 0.007), renal morbidity (AOR = 1.23; 95%CI = 1.03-1.45; P = 0.019) and serious infection (AOR = 1.31; 95%CI = 1.07-1.60; P = 0.009). CONCLUSION Perioperative RBC transfusion in isolated CABG patients is associated with increased risks of developing adverse events such as prolonged ventilatory support, cardiac morbidity, renal morbidity and serious infection.
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Affiliation(s)
- Choon Hua Chan
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Ghazali Mohamad Ziyadi
- Unit of Cardiothoracic Surgery, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Mamat Ahmad Zuhdi
- Unit of Cardiothoracic Surgery, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Leukodepleted Packed Red Blood Cells Transfusion in Patients Undergoing Major Cardiovascular Surgical Procedure: Systematic Review and Meta-Analysis. Cardiol Res Pract 2019; 2019:7543917. [PMID: 30931154 PMCID: PMC6410443 DOI: 10.1155/2019/7543917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/21/2018] [Accepted: 01/23/2019] [Indexed: 11/28/2022] Open
Abstract
Background Leukocytes contained in the allogeneic packed red blood cell (PRBC) are the cause of certain adverse reactions associated with blood transfusion. Leukoreduction consists of eliminating leukocytes in all blood products below the established safety levels for any patient type. In this systematic review, we appraise the clinical effectiveness of allogeneic leukodepleted (LD) PRBC transfusion for preventing infections and death in patients undergoing major cardiovascular surgical procedures. Methods We searched randomized controlled trials (RCT), enrolling patients undergoing a major cardiovascular surgical procedure and transfused with LD-PRBC. Data were extracted, and risk of bias was assessed according to Cochrane guidelines. In addition, trial sequential analysis (TSA) was used to assess the need of conducting additional trials. Quality of the evidence was assessed using the GRADE approach. Results Seven studies met the eligibility criteria. Quality of the evidence was rated as moderate for both outcomes. The risk ratio for death from any cause comparing the LD-PRBC versus non-LD-PRBC group was 0.69 (CI 95% = 0.53 to 0.90; I2 = 0%). The risk ratio for infection in the same comparison groups was 0.77 (CI 95% = 0.66 to 0.91; I2 = 0%). TSA showed a conclusive result in this outcome. Conclusions We found evidence that supports the routine use of leukodepletion in patients undergoing a major cardiovascular surgical procedure requiring PRBC transfusion to prevent death and infection. In the case of infection, the evidence should be considered sufficient and conclusive and hence indicated that further trials would not be required.
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Oxidation Reduction Potential (ORP) is Predictive of Complications Following Pediatric Cardiac Surgery. Pediatr Cardiol 2018; 39:299-306. [PMID: 29090352 DOI: 10.1007/s00246-017-1755-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/23/2017] [Indexed: 01/24/2023]
Abstract
Oxidation reduction potential (ORP) or Redox is the ratio of activity between oxidizers and reducers. Oxidative stress (OS) can cause cellular injury and death, and is important in the regulation of immune response to injury or disease. In the present study, we investigated changes in the redox system as a function of cardiopulmonary bypass (CPB) in pediatric patients. 664 plasma samples were collected from 162 pediatric patients having cardiac surgery of various CPB times. Lower ORP values at 12 h post-CPB were associated with poor survival rate (mean ± SD 167 ± 20 vs. 138 ± 19, p = 0.005) and higher rate of thrombotic complications (153 ± 21 vs. 168 ± 20, p < 0.008). Similarly, patients who developed infections had lower ORP values at 6 h (149 ± 19 vs. 160 ± 22, p = 0.02) and 12 h (156 ± 17 vs. 168 ± 21, p = 0.004) post-CPB. Patients that developed any post-operative complication also had lower 6 h (149 ± 17 vs. 161 ± 23, p = 0.002) and 12 h (157 ± 18 vs. 170 ± 21, p = 0.0007) post-CPB ORP values. Free hemoglobin and IL-6, IL-10, and CRP were not associated with ORP levels. However, higher haptoglobin levels preoperatively were protective against decreases in ORP. Decreased ORP is a marker for poor outcome and predictive of post-operative thrombosis, infection, and other complications in critically ill pediatric cardiac surgery patients. These results suggest that redox imbalance and OS may contribute to the risk of complications and poor outcome in pediatric CBP patients. Haptoglobin may be a marker for increased resilience to OS in this population.
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8
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Schwarz C, Fitschek F, Bar-Or D, Klaus DA, Tudor B, Fleischmann E, Roth G, Tamandl D, Wekerle T, Gnant M, Bodingbauer M, Kaczirek K. Inflammatory response and oxidative stress during liver resection. PLoS One 2017; 12:e0185685. [PMID: 29045432 PMCID: PMC5646773 DOI: 10.1371/journal.pone.0185685] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/18/2017] [Indexed: 12/15/2022] Open
Abstract
Background Postoperative complications are still a major concern after liver resection (LR). Systemic inflammation and deregulated reactive oxygen species during major abdominal surgery may impair outcome after hepatectomy. Methods Patients undergoing LR were included in this study (n = 40). Oxidative stress (OS) was measured peri- and post-operatively as static oxidation-reduction potential markers (sORP) and antioxidant capacity ORP (cORP) by using the RedoxSYS Diagnostic system. Furthermore, Th1- and Th2-specific cytokines were assessed. Results Whereas there was no significant change in systemic sORP during LR and in the early postoperative course, there was a substantial decrease of cORP immediately post-surgery, and on postoperative days 1 and 3 (p<0.001). OS response was tightly regulated, as there was a significant correlation between sORP and cORP (p<0.0001; R2:0.457). An increase of OS (sORP) after LR of more than 3 mV was predictive for severe postoperative complications (53.8% vs. 12.5; p = 0.017). There was a significantly higher IL-2 (p = 0.006) and IL-5 (p = 0.001) increase during hepatectomy in patients who developed a severe morbidity. Conclusion Antioxidant capacity remained stable during LR but dropped during the post-surgical period, suggesting a consumption of antioxidants to maintain OS within healthy range. Severe postoperative complications were associated with a pronounced inflammatory response during surgery.
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Affiliation(s)
- Christoph Schwarz
- Department of Surgery and Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
- Section of Transplantation Immunology, Department of Surgery; Medical University of Vienna, Vienna, Austria
| | - Fabian Fitschek
- Department of Surgery and Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - David Bar-Or
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado, United States of America
- Trauma Research Department, Swedish Medical Center, Englewood, Colorado, United States of America
- Trauma Research Department, Medical Center of Plano, Plano, Texas, United States of America
- AYTU BioScience, Inc., Englewood, Colorado, United States of America
| | - Daniel A. Klaus
- Dept. of Anesthesiology, General Intensive Care and Pain Medicine; Medical University of Vienna, Vienna, Austria
| | - Bianca Tudor
- Dept. of Anesthesiology, General Intensive Care and Pain Medicine; Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- Dept. of Anesthesiology, General Intensive Care and Pain Medicine; Medical University of Vienna, Vienna, Austria
| | - Georg Roth
- Dept. of Anesthesiology, General Intensive Care and Pain Medicine; Medical University of Vienna, Vienna, Austria
| | - Dietmar Tamandl
- Department of Biomedical Imaging and Image Guided Therapy; Medical University of Vienna, Vienna, Austria
| | - Thomas Wekerle
- Section of Transplantation Immunology, Department of Surgery; Medical University of Vienna, Vienna, Austria
| | - Michael Gnant
- Department of Surgery and Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin Bodingbauer
- Department of Surgery and Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
| | - Klaus Kaczirek
- Department of Surgery and Center for Perioperative Medicine, Medical University of Vienna, Vienna, Austria
- * E-mail:
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Grände PO. Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction. Front Neurol 2017; 8:315. [PMID: 28725211 PMCID: PMC5495987 DOI: 10.3389/fneur.2017.00315] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/16/2017] [Indexed: 12/24/2022] Open
Abstract
When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.
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Affiliation(s)
- Per-Olof Grände
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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Lio CF, Lee YH, Chan HY, Yu CC, Peng NJ, Chan HP. Posterior reversible encephalopathy syndrome in a postpartum hemorrhagic woman without hypertension: A case report. Medicine (Baltimore) 2017; 96:e6690. [PMID: 28422884 PMCID: PMC5406100 DOI: 10.1097/md.0000000000006690] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
RATIONALE Posterior reversible encephalopathy syndrome (PRES), which diagnosis is based on clinical symptoms and radiological features, is a neurotoxic disease characterized by a set of clinical manifestations, such as seizure, headache, visual, and/or consciousness disturbance. It is the first case of PRES followed by postpartum hemorrhage (PPH) without underlying disease. PATIENT CONCERNS A 37-year-old healthy woman had PPH after caesarean section. Six days after delivery, headache occurred suddenly, followed by episodes of clonus seizure. DIAGNOSES Brain computed tomography showed ischemic stroke. However, magnetic resonance imaging revealed characteristics consistent with PRES. INTERVENTIONS The patient received phenytoin for seizure control. OUTCOMES Seizure was under good control over the following days. Three months later, repeated magnetic resonance imaging showed complete remission. LESSONS PRES may be triggered by PPH and is not necessarily secondary to typical predisposing factors such as hypertension or pre/eclampsia. Hormone fluctuation, increased blood pressure variation, and massive blood transfusion may be contributed to the development of PRES in our case. Also, it is necessary to rule out those life-threatening diseases, such as cavernoma hemorrhage, cerebral venous thrombosis, and ischemic stroke before the diagnosis of PRES.
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Affiliation(s)
- Chon-Fu Lio
- Centro Hospitalar Conde de São Januário, Macao, China
| | - Ying-Hua Lee
- Department of Medicine, National Defense Medical Center, Taipei City
| | - Hung-Yen Chan
- Department of Emergency, E-Da Hospital, Kaohsiung City
| | - Chang-Ching Yu
- Department of Nuclear Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Nan-Jing Peng
- Department of Nuclear Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
- School of Medicine, National Yang-Ming University, Taipei City, Taiwan
| | - Hung-Pin Chan
- Department of Nuclear Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
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Vamvakas EC. Transfusion-Related Immunomodulation (TRIM): From Renal Allograft Survival to Postoperative Mortality in Cardiac Surgery. Respir Med 2017. [DOI: 10.1007/978-3-319-41912-1_13] [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: 11/30/2022]
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12
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Henke PK, Park YJ, Hans S, Bove P, Cuff R, Kazmers A, Schreiber T, Gurm HS, Grossman PM. The Association of Peri-Procedural Blood Transfusion with Morbidity and Mortality in Patients Undergoing Percutaneous Lower Extremity Vascular Interventions: Insights from BMC2 VIC. PLoS One 2016; 11:e0165796. [PMID: 27835656 PMCID: PMC5106007 DOI: 10.1371/journal.pone.0165796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 10/18/2016] [Indexed: 01/28/2023] Open
Abstract
Objective To determine the predictors of periprocedural blood transfusion and the association of transfusion on outcomes in high risk patients undergoing endoluminal percutaneous vascular interventions (PVI) for peripheral arterial disease. Methods/Results Between 2010–2014 at 47 hospitals participating in a statewide quality registry, 4.2% (n = 985) of 23,273 patients received a periprocedural blood transfusion. Transfusion rates varied from 0 to 15% amongst the hospitals in the registry. Using multiple logistic regression, factors associated with increased transfusion included female gender (OR = 1.9; 95% CI: 1.6–2.1), low creatinine clearance (1.3; 1.1–1.6), pre-procedural anemia (4.7; 3.9–5.7), family history of CAD (1.2; 1.1–1.5), CHF (1.4; 1.2–1.6), COPD (1.2; 1.1–1.4), CVD or TIA (1.2; 1.1–1.4), renal failure CRD (1.5; 1.2–1.9), pre-procedural heparin use (1.8; 1.4–2.3), warfarin use (1.2; 1.0–1.5), critical limb ischemia (1.7; 1.5–2.1), aorta-iliac procedure (1.9; 1.5–2.5), below knee procedure (1.3; 1.1–1.5), urgent procedure (1.7; 1.3–2.2), and emergent procedure (8.3; 5.6–12.4). Using inverse weighted propensity matching to adjust for confounders, transfusion was a significant risk factor for death (15.4; 7.5–31), MI (67; 29–150), TIA/stroke (24; 8–73) and ARF (19; 6.2–57). A focused QI program was associated with a 28% decrease in administration of blood transfusion (p = 0.001) over 4 years. Conclusion In a large statewide PVI registry, post procedure transfusion was highly correlated with a specific set of clinical risk factors, and with in-hospital major morbidity and mortality. However, using a focused QI program, a significant reduction in transfusion is possible.
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Affiliation(s)
- Peter K. Henke
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
| | - Yeo Jung Park
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Sachinder Hans
- Henry Ford Malcomb Hospital, Wyndott, MI, United States of America
| | - Paul Bove
- Beaumont Health System, Royal Oak, MI, United States of America
| | - Robert Cuff
- Spectrum Health System, Grand Rapids, MI, United States of America
| | - Andris Kazmers
- McLaren Northern Michigan Health System, Traverse City, MI, United States of America
| | | | - Hitinder S. Gurm
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - P. Michael Grossman
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
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Muszynski JA, Spinella PC, Cholette JM, Acker JP, Hall MW, Juffermans NP, Kelly DP, Blumberg N, Nicol K, Liedel J, Doctor A, Remy KE, Tucci M, Lacroix J, Norris PJ. Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness. Transfusion 2016; 57:195-206. [PMID: 27696473 DOI: 10.1111/trf.13855] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/01/2016] [Accepted: 08/15/2016] [Indexed: 02/06/2023]
Abstract
Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care Medicine, Canadian Blood Services, Edmonton, Alberta, Canada.,The Research Institute, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Philip C Spinella
- Department of Pediatrics, Division Pediatric Critical Care, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Jill M Cholette
- Pediatric Critical Care and Cardiology, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Jason P Acker
- Centre for Innovation, Canadian Blood Services.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Mark W Hall
- Division of Critical Care Medicine, Canadian Blood Services, Edmonton, Alberta, Canada.,The Research Institute, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Daniel P Kelly
- Division of Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Neil Blumberg
- Transfusion Medicine/Blood Bank and Clinical Laboratories, Departments of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer Liedel
- Pediatric Critical Care Medicine, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Allan Doctor
- Departments of Pediatrics and Biochemistry, Washington University in St Louis, St Louis, Missouri
| | - Kenneth E Remy
- Department of Pediatrics, Division Pediatric Critical Care, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Marisa Tucci
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Philip J Norris
- Blood Systems Research Institute.,Departments of Laboratory Medicine and Medicine, University of California, San Francisco, San Francisco, California
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Chasovskyi K, Zhovnir V, Vorobiova G, Yemets I. Relationship Between Antiinflammatory Cytokine Interleukin-10 and Lactate Concentrations in Neonates Undergoing the Arterial Switch Operation. Ann Thorac Surg 2016; 101:1020-4. [DOI: 10.1016/j.athoracsur.2015.09.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/19/2015] [Accepted: 09/28/2015] [Indexed: 11/30/2022]
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Pereira LA, Baiocchi OC, Silva JMK, Takata ET, Bordin JO. Regulatory CD4 + T lymphocytes after allogeneic transfusion in orthopaedic surgical patients. Br J Haematol 2016; 176:327-330. [PMID: 26913576 DOI: 10.1111/bjh.13956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/07/2015] [Accepted: 12/09/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Luciana A Pereira
- Departamento de Oncologia Clínica e Experimental, Universidade Federal de São Paulo, UNIFESP/EPM, São Paulo, Brazil
| | - Otavio C Baiocchi
- Departamento de Oncologia Clínica e Experimental, Universidade Federal de São Paulo, UNIFESP/EPM, São Paulo, Brazil
| | - Joyce M K Silva
- Departamento de Oncologia Clínica e Experimental, Universidade Federal de São Paulo, UNIFESP/EPM, São Paulo, Brazil
| | - Edmilson T Takata
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, UNIFESP/EPM, São Paulo, Brazil
| | - José O Bordin
- Departamento de Oncologia Clínica e Experimental, Universidade Federal de São Paulo, UNIFESP/EPM, São Paulo, Brazil
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Zheng YJ, Xu WP, Ding G, Gao YH, Wang HR, Pan SM. Expression of HMGB1 in septic serum induces vascular endothelial hyperpermeability. Mol Med Rep 2015; 13:513-21. [PMID: 26572550 DOI: 10.3892/mmr.2015.4536] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 09/09/2015] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to investigate the effects of high mobility group protein B1 (HMGB1), which is expressed in the serum of patients with sepsis, on vascular endothelial permeability. Sera from patients with sepsis were used to treat endothelial cells (ECs), and the effect on endothelial permeability was evaluated using immunofluorescence. The morphologies of endothelial cytoskeletal actin and vascular endothelial (VE)‑cadherin were assessed using laser scanning confocal microscopy. The protein expression levels of HMGB1, B‑cell lymphoma 2 (BCL‑2) and BCL‑2‑associated X protein (BAX) were detected using western blotting. EC apoptosis was measured using flow cytometry. The results demonstrated that HMGB1 was significantly expressed in the serum 24 h following the onset of sepsis, and the expression levels peaked at 48 h, which were sustained until 96 h post‑onset. Compared with the control group, treatment of the ECs with 20% septic serum in vitro significantly increased endothelial monolayer permeability (P<0.01), markedly induced transcellular filamentous (F)‑actin rearrangement with stress fiber formation, and resulted in the localization of VE‑cadherin fragmentations at the cell borders with increased gaps between ECs. Furthermore, flow cytometry showed that the apoptotic rate of ECs was significantly increased following treatment with septic serum. In addition, the expression levels of BAX were significantly increased, whereas the expression levels of BCL‑2 were significantly decreased. Pretreatment with an HMGBI inhibitor (ethyl pyruvate; 5 µM) 24 h prior to treatment with the septic serum attenuated the effects of septic serum treatment. Together, these findings suggested that treatment of ECs with sera from patients with sepsis may induce the loss of vascular endothelial monolayer integrity, elicit the formation of endothelial F‑actin stress fibers and initiate VE‑cadherin redistribution, which may be attributed to high levels of HMGB1 in the serum. This mechanism also appears to involve changes in the activation of BAX and BCL‑2, resulting in EC apoptosis.
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Affiliation(s)
- Yun-Jiang Zheng
- Emergency Department, Chongming Branch, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 202150, P.R. China
| | - Wei-Ping Xu
- Administration Division, Chongming Branch, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 202150, P.R. China
| | - Gang Ding
- Department of Oncology, Chongming Branch, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 202150, P.R. China
| | - Yu-Hua Gao
- Administration Division, Chongming Branch, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 202150, P.R. China
| | - Hai-Rong Wang
- Emergency Department, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
| | - Shu-Ming Pan
- Emergency Department, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, P.R. China
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McQuilten ZK, Andrianopoulos N, van de Watering L, Aubron C, Phillips L, Bellomo R, Pilcher D, Cameron P, Reid CM, Cole-Sinclair MF, Newcomb A, Smith J, McNeil JJ, Wood EM. Introduction of universal prestorage leukodepletion of blood components, and outcomes in transfused cardiac surgery patients. J Thorac Cardiovasc Surg 2015; 150:216-22. [DOI: 10.1016/j.jtcvs.2015.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/15/2015] [Accepted: 03/11/2015] [Indexed: 11/25/2022]
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The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery. J Vasc Surg 2015; 61:1000-9.e1. [DOI: 10.1016/j.jvs.2014.10.106] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/30/2014] [Indexed: 01/28/2023]
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Spinelli E, Bartlett RH. Anemia and Transfusion in Critical Care. J Intensive Care Med 2015; 31:295-306. [DOI: 10.1177/0885066615571901] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 12/03/2014] [Indexed: 01/28/2023]
Abstract
Objective: The objective of this report is to review the physiology and management of anemia in critical care. Selected publications on physiology and transfusion related to anemia and critical care, including the modern randomized trials of conservative versus liberal transfusion policy, were used. Anemia is compensated and tolerated in most critically ill patients as long as oxygen delivery is at least twice oxygen consumption. There are risks to blood transfusion which can be minimized by blood banking practice. The availability of cultured red cells may allow correction of anemia without significant risk. The benefit of transfusion in anemia must be weighted against the risk in any specific patient. Conclusion and Recommendation: In a criticially ill patient, anemia should be managed to avoid oxygen supply dependency (oxygen delivery less than twice comsumption) and to maintain moderate oxygen delivery reserve (DO2/VO2 > 3).
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Affiliation(s)
- Elena Spinelli
- University of Michigan ECLS Laboratory, Ann Arbor, MI, USA
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Jiwaji Z, Nunn KP, Conway-Morris A, Simpson AJ, Wyncoll D, Rossi AG, Walsh TS. Leukoreduced blood transfusion does not increase circulating soluble markers of inflammation: a randomized controlled trial. Transfusion 2014; 54:2404-11. [DOI: 10.1111/trf.12669] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 02/03/2014] [Accepted: 02/23/2014] [Indexed: 02/01/2023]
Affiliation(s)
- Zoeb Jiwaji
- Anaesthetics and Critical Care, Royal Infirmary of Edinburgh and the MRC Centre for Inflammation Research, The Queen's Medical Research Institute; University of Edinburgh; Edinburgh United Kingdom
| | - Kieran P. Nunn
- Anaesthetics and Critical Care, Royal Infirmary of Edinburgh and the MRC Centre for Inflammation Research, The Queen's Medical Research Institute; University of Edinburgh; Edinburgh United Kingdom
| | - Andrew Conway-Morris
- Anaesthetics and Critical Care, Royal Infirmary of Edinburgh and the MRC Centre for Inflammation Research, The Queen's Medical Research Institute; University of Edinburgh; Edinburgh United Kingdom
| | - A. John Simpson
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne United Kingdom
| | - Duncan Wyncoll
- Guy's and St Thomas' NHS Foundation Trust; King's Health Partners; London United Kingdom
| | - Adriano G. Rossi
- Anaesthetics and Critical Care, Royal Infirmary of Edinburgh and the MRC Centre for Inflammation Research, The Queen's Medical Research Institute; University of Edinburgh; Edinburgh United Kingdom
| | - Timothy S. Walsh
- Anaesthetics and Critical Care, Royal Infirmary of Edinburgh and the MRC Centre for Inflammation Research, The Queen's Medical Research Institute; University of Edinburgh; Edinburgh United Kingdom
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Corsi R, McMichael MA, Smith SA, O'Brien M, Herring J, Ngwenyama TR, Galligan A, Beloshapka AN, Deng P, Swanson KS. Cytokine concentration in stored canine erythrocyte concentrates. J Vet Emerg Crit Care (San Antonio) 2014; 24:259-63. [PMID: 24697952 DOI: 10.1111/vec.12160] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 12/29/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the effect of leukoreduction (LR) as compared to standard nonleukoreduced (NLR) units on cytokine concentrations in canine erythrocyte concentrates during regular storage time. DESIGN Randomized, experimental study. SETTING University teaching hospital. ANIMALS Ten random-source research dogs. INTERVENTIONS One unit of whole blood was collected from each dog and randomized to standard processing (NLR, n = 5) or prestorage LR (n = 5). All units were stored at 4°C. Samples were aseptically collected from each unit weekly for 5 weeks. On day 35, 1 mL of blood was collected from each unit and submitted for aerobic culture. MEASUREMENT AND MAIN RESULTS An ELISA assay was used to analyze the concentrations of IL-1β, IL-8, TNF-α, and IL-10. There were no significant effects of either group or storage time for IL-1β, IL-10, or TNF-α. IL-8 concentration was significantly increased over the storage period in NLR units, and was significantly higher compared to LR units on days 28 and 35. Aerobic culture was negative on all units. CONCLUSIONS This study demonstrated a marked, storage time-dependent accumulation of IL-8 in canine erythrocyte concentrates. Prestorage LR attenuated the accumulation of IL-8. This chemokine may contribute to the proinflammatory effects of transfusion of stored erythrocyte concentrates.
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Affiliation(s)
- Raffaella Corsi
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Illinois at Urbana-Cham-paign, Urbana, IL, 61802
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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Lachmann N, Todorova K, Schulze H, Schönemann C. Luminex(®) and its applications for solid organ transplantation, hematopoietic stem cell transplantation, and transfusion. ACTA ACUST UNITED AC 2013; 40:182-9. [PMID: 23922543 DOI: 10.1159/000351459] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 03/19/2013] [Indexed: 01/29/2023]
Abstract
SUMMARY The detection of antibodies against the human leukocyte antigen (HLA) complex has become indispensable in every clinical practice. The development of solid-phase assays like the Luminex allows the standardized measurement of anti-HLA antibodies (HLAab) with high sensitivity, albeit the relevance for some clinical settings remains a matter of debate. In this review we aim to describe the principle of Luminex-based antibody detection, including two modifications that allow identifying solely complement-activating antibodies. We then describe three applications for Luminex: i) detection of HLAab preceding solid-organ transplantation and monitoring of donor-specific antibodies posttransplant as a risk factor for antibody-mediated rejection; ii) presence of HLAab in recipients as a risk for graft failure in hematopoietic stem cell transplantation, especially in haploidentical or mismatched transplantations; iii) role of HLAab in blood transfusion including refractory thrombocytopenia and selection of suitable platelet donors, transfusion-related lung injury after plasma transfusion, and immunization against HLA after red blood cell transfusion despite leukodepletion. Although the Luminex platform constitutes a potent technology for HLA antibody detection, some drawbacks require the well-educated analysis and interpretation of data in critical cases. In addition, Luminex has become an important tool to identify clinically relevant antibodies.
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Affiliation(s)
- Nils Lachmann
- Center for Tumor Medicine, Charité-Universitätsmedizin Berlin - Campus Virchow-Klinikum, Berlin, Germany ; ZTB Zentrum für Transfusionsmedizin und Zelltherapie Berlin, HLA Tissue Typing Laboratory, Berlin, Germany
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Behrends M, DePalma G, Sands L, Leung J. Association between intraoperative blood transfusions and early postoperative delirium in older adults. J Am Geriatr Soc 2013; 61:365-70. [PMID: 23496244 DOI: 10.1111/jgs.12143] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine whether intraoperative blood transfusion, a known trigger and amplifier of inflammation, is an independent risk factor for early postoperative delirium (POD), an acute state of confusion with fluctuating consciousness and inattention after surgery, in older adults undergoing surgery. DESIGN Secondary analysis using a database created for a prospective cognitive outcomes study. SETTING University hospital. PARTICIPANTS Four hundred seventy-two individuals aged 65 and older undergoing major noncardiac surgery. MEASUREMENTS Perioperative data were examined for association with POD on the first postoperative day. Multivariable logistic regression analysis was conducted to determine whether intraoperative blood transfusion independently predicts POD after adjusting for covariates known to be associated with onset of delirium and blood transfusions. RESULTS One hundred thirty-seven individuals (29%) developed delirium on the first postoperative day. The multivariable logistic regression model identified age, sex, history of central nervous system disorder, preoperative cognitive dysfunction, and pain, as well as blood transfusions, as independent risk factors for POD. Intraoperative administration of more than 1,000 mL of red blood cells (RBCs) was the strongest predictor of POD on the first postoperative day (odds ratio = 3.68; 95% confidence interval = 1.32–10.94; P < .001). CONCLUSION Intraoperative blood transfusion of more than 1,000 mL of RBCs increases the risk of delirium on the first postoperative day in older adults undergoing noncardiac surgery.
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Affiliation(s)
- Matthias Behrends
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA 94143, USA.
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Kumar MA, Boland TA, Baiou M, Moussouttas M, Herman JH, Bell RD, Rosenwasser RH, Kasner SE, Dechant VE. Red Blood Cell Transfusion Increases the Risk of Thrombotic Events in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2013; 20:84-90. [DOI: 10.1007/s12028-013-9819-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sloniewsky D. Anemia and transfusion in critically ill pediatric patients: a review of etiology, management, and outcomes. Crit Care Clin 2013; 29:301-17. [PMID: 23537677 DOI: 10.1016/j.ccc.2012.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This article describes the incidence and etiology of anemia in critically ill children. In addition, the article details the pathophysiology and clinical ramifications of anemia in this population. The use of transfused packed red blood cells as a therapy for anemia in critically ill patients is also discussed, including the indications for and complications associated with this practice as well as potential reasons for these complications. Finally, the article lists some therapeutic practices that may lessen the risks associated with transfusion, and briefly discusses the use of blood substitutes.
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Affiliation(s)
- Daniel Sloniewsky
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stony Brook Long Island Children's Hospital, 100 Nicolls Road Stony Brook, NY 11794, USA.
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Keir AK, McPhee AJ, Andersen CC, Stark MJ. Plasma cytokines and markers of endothelial activation increase after packed red blood cell transfusion in the preterm infant. Pediatr Res 2013; 73:75-9. [PMID: 23095979 DOI: 10.1038/pr.2012.144] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transfusion of packed red blood cells (PRBCs) saves lives in the neonatal critical care setting and is one of the most common interventions in the preterm infant. The number and volume of PRBC transfusions are associated with several major neonatal morbidities, although a direct causal link between transfusion and major neonatal morbidity is still to be proven. Transfusion-related immunomodulation (TRIM) may underlie these adverse outcomes, yet it has received little attention in the high-risk preterm infant. METHODS One transfusion event was studied in infants ≤28 wk gestation between 2 and 6 wk postnatal age (n = 28). Plasma inflammatory cytokines and markers of endothelial activation were measured in the infants before and 2-4 h after transfusion, as well as in the donor pack. RESULTS Median (range) age at transfusion was 18 (14-39) days with the pretransfusion hemoglobin level at 9.8 (7.4-10.2) g/dl. Interleukin (IL)-1β (P = 0.01), IL-8 (P = <0.001), tumor necrosis factor-α (P = 0.008), and monocyte chemoattractant protein (P = 0.01) were increased after transfusion. A similar elevation in markers of endothelial activation was seen after transfusion with increased plasma macrophage inhibitory factor (P = 0.005) and soluble intracellular adhesion molecule-1 (P = <0.001). CONCLUSION Production of inflammatory cytokines and immunoactivation of the endothelium observed after the transfusion of PRBCs in the preterm infant may be a manifestation of TRIM. The implications of this emerging phenomenon within the preterm neonatal population warrant further investigation.
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Affiliation(s)
- Amy K Keir
- Department of Neonatal Medicine, Women's and Children's Hospital, South Australia, Australia
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Later AFL, Bruggemans EF, Romijn FPHTM, van Pelt J, Klautz RJM. A comparative study of the immune modulating properties of antifibrinolytics in cardiac surgery. Cytokine 2012. [PMID: 23186831 DOI: 10.1016/j.cyto.2012.10.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Antifibrinolytics, used in cardiac surgery to abate postoperative blood loss, share anti-inflammatory properties by suppression of pro-inflammatory D-dimer and plasmin levels. Additional drug specific immune modulating qualities are often mentioned in the discussion on which antifibrinolytic can best be used. To determine the extent and relevance of these effects, we investigated cytokine and growth factor plasma levels in cardiac surgery patients randomized to receive either tranexamic acid, aprotinin, or placebo. Corticosteroid-treated patients served to put the effects in perspective. METHODS Using a biochip immunoassay, plasma of 36 cardiac surgery patients was quantified for 12 cytokines and growth factors, assessed preoperatively and 6, 12, 24, and 48 h after the start of cardiopulmonary bypass. Eight patients were treated with tranexamic acid, nine with aprotinin, and nine received placebo. Ten placebo-treated patients received corticosteroids. RESULTS IL-1ß, IL-6, IL-8, IL-10, IFN-γ, TNF-α, VEGF, MCP-1, and EGF plasma concentrations significantly changed over time across all patients. Aprotinin-treated patients showed decreased pro-inflammatory TNF-α and peak MCP-1 plasma levels when compared with placebo. However, corticosteroids attenuated the inflammatory response to a much larger extent, lowering postoperative IL-6, IL-10, IFN-γ, and VEGF concentrations also. CONCLUSIONS Aprotinin attenuates postoperative pro-inflammatory levels TNF-α and MCP-1 whereas tranexamic acid does not. The majority of plasma proteins studied, however, were not affected by the use of antifibrinolytics when compared with placebo. A clinically relevant common anti-inflammatory effect through inhibition of fibrinolysis seems therefore unlikely.
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Affiliation(s)
- A F L Later
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Albinusdreef 2, Postbus 9600, 2300 RC Leiden, The Netherlands.
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Washing red blood cells and platelets transfused in cardiac surgery reduces postoperative inflammation and number of transfusions: results of a prospective, randomized, controlled clinical trial. Pediatr Crit Care Med 2012; 13:290-9. [PMID: 21926663 PMCID: PMC3839819 DOI: 10.1097/pcc.0b013e31822f173c] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Children undergoing cardiac surgery with cardiopulmonary bypass are susceptible to additional inflammatory and immunogenic insults from blood transfusions. We hypothesize that washing red blood cells and platelets transfused to these patients will reduce postoperative transfusion-related immune modulation and inflammation. DESIGN Prospective, randomized, controlled clinical trial. SETTING University hospital pediatric cardiac intensive care unit. PATIENTS Children from birth to 17 yrs undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Children were randomized to an unwashed or washed red blood cells and platelet transfusion protocol for their surgery and postoperative care. All blood was leuko-reduced, irradiated, and ABO identical. Plasma was obtained for laboratory analysis preoperatively, immediately, and 6 and 12 hrs after cardiopulmonary bypass. Primary outcome was the 12-hr postcardiopulmonary bypass interleukin-6-to-interleukin-10 ratio. Secondary measures were interleukin levels, C-reactive protein, and clinical outcomes. MEASUREMENTS AND MAIN RESULTS One hundred sixty-two subjects were studied, 81 per group. Thirty-four subjects (17 per group) did not receive any blood transfusions. Storage duration of blood products was similar between groups. Among transfused subjects, the 12-hr interleukin ratio was significantly lower in the washed group (3.8 vs. 4.8; p = .04) secondary to lower interleukin-6 levels (after cardiopulmonary bypass: 65 vs.100 pg/mL, p = .06; 6 hrs: 89 vs.152 pg/mL, p = .02; 12 hrs: 84 vs.122 pg/mL, p = .09). Postoperative C-reactive protein was lower in subjects receiving washed blood (38 vs. 43 mg/L; p = .03). There was a numerical, but not statistically significant, decrease in total blood product transfusions (203 vs. 260) and mortality (2 vs. 6 deaths) in the washed group compared to the unwashed group. CONCLUSIONS Washed blood transfusions in cardiac surgery reduced inflammatory biomarkers, number of transfusions, donor exposures, and were associated with a nonsignificant trend toward reduced mortality. A larger study powered to test for clinical outcomes is needed to determine whether these laboratory findings are clinically significant.
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The impact of plasma preparations and their storage time on short-term posttransfusion mortality. J Trauma Acute Care Surg 2012; 72:954-60. [DOI: 10.1097/ta.0b013e31824657c4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 576] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Bilgin YM, van de Watering LMG, Versteegh MIM, van Oers MHJ, Vamvakas EC, Brand A. Postoperative complications associated with transfusion of platelets and plasma in cardiac surgery. Transfusion 2011; 51:2603-10. [PMID: 21645007 DOI: 10.1111/j.1537-2995.2011.03200.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Studies in cardiac surgery have reported increased postoperative morbidity and mortality after allogeneic red blood cell (RBC) transfusions. Whether platelet (PLT) and/or plasma transfusions are a marker for more concomitant RBC transfusions or are independently associated with complications after cardiac surgery is unknown. STUDY DESIGN AND METHODS Data from two randomized controlled studies were combined to analyze the effects of PLT and/or plasma transfusions on postoperative infections, length of stay in the intensive care unit (ICU), all-cause mortality, and mortality in the presence or absence of infections in the postoperative period. RESULTS After adjusting for confounding factors, plasma units and not RBC transfusions were associated with all-cause mortality. White blood cell (WBC)-containing RBC transfusions and PLT transfusions were associated with mortality occurring in the presence of or after infections. The number of (WBC-containing) RBC transfusions was also significantly associated with postoperative infections and with ICU stay for 4 or more days. CONCLUSION Although it is difficult to separate the effects of blood components, we found that in cardiac surgery, perioperative plasma transfusions are independently associated with all-cause mortality. WBC-containing RBC transfusions and PLT transfusions are independently associated with mortality in the presence of infections in the postoperative period. Future transfusion studies in cardiac surgery should concomitantly consider the possible adverse effects of all the various transfused blood components.
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Affiliation(s)
- Yavuz M Bilgin
- Department of Immunohematology and Blood Transfusion and Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Machado LB, Negri EM, Bonafé WW, Santos LM, Sá Malbouisson LM, Carmona MJC. [Evaluation of cytokine levels and pulmonary function in patients undergoing coronary artery bypass graft]. Rev Bras Anestesiol 2011; 61:275-85. [PMID: 21596187 DOI: 10.1016/s0034-7094(11)70033-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 12/07/2010] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Systemic inflammatory response syndrome is commonly observed in coronary artery bypass grafts (CABG) with cardiopulmonary bypass (CB). The objective of this study was to evaluate the systemic and pulmonary levels of cytokines and their correlation with lung function in patients undergoing myocardial revascularization (MR) with CB. METHODS This study was approved by the Institutional Ethics Committee, and 13 patients undergoing MR with CB were evaluated. After anesthetic induction and at the end of CB, plasma and bronchoalveolar lavage levels of IL-1β, IL-6, IL-8, IL-10, and TNF-α were determined. The duration of CB and surgery, PaO(2)/FiO(2) ratio, alveolar-arterial oxygen gradient (A-a gradient), shunt, and lung compliance were evaluated. Results were submitted to analysis of variance for repeated measurements (*p < 0.05) and Spearman's correlation coefficient. RESULTS We observed increased levels of cytokines in plasma and bronchoalveolar lavage after CB and a direct relationship between the increase in IL-1β and decrease in lung compliance (p = 0.0439), as well as the inverse relationship between the increase in IL-10 and a decrease in compliance (p = 0.0325). The increase in IL-6 was directly related to the duration of CB (p = 0.012), while the increase in IL-8 was directly related to the duration of surgery (p < 0.0001). Levels of interleukin-1β, IL-8, and TNF-α in bronchoalveolar lavage were higher than in plasma. CONCLUSIONS There is an increase in cytokine levels in plasma and bronchoalveolar lavage after CB, as well as a correlation between increased cytokine levels and CB duration and surgery and changes in lung compliance.
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Sitniakowsky LS, Later AFL, van de Watering LMG, Bogaerts M, Brand A, Klautz RJM, Smit NPM, van Hilten JA. The effect of RBC transfusions on cytokine gene expression after cardiac surgery in patients developing post-operative multiple organ failure. Transfus Med 2011; 21:236-46. [PMID: 21518046 DOI: 10.1111/j.1365-3148.2011.01075.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM To determine the effect of red blood cell (RBC) transfusions during cardiac surgery on cytokine gene expression (GE) in relation to multiple organ failure (MOF) development after systemic inflammatory response syndrome (SIRS). BACKGROUND RBC transfusion in cardiac surgery patients is dose-dependently associated with post-operative MOF, possibly acting as a second hit after cardiopulmonary bypass. METHODS For this observational study, 29 patients divided into four groups of cardiac surgery patients were selected from a randomised controlled trial (RCT). Group 1: no-RBC, no-MOF (N = 8); group 2: MOF, no-RBC (N = 7); group 3: RBC, no-MOF (N = 6); group 4: RBC and MOF (N = 8). Selection was based on age, gender, number of (leukocyte-depleted) RBC transfusions, type and duration of surgery. A 114 cytokine GE array was applied to blood samples withdrawn before and 24 h after surgery. Expression of selected genes was confirmed with reverse transcriptase real time-polymerase chain reaction (RT-PCR). RESULTS Nineteen of the 39 detectable genes showed a significant change in GE after surgery. Confirmed by RT-PCR, transfused MOF patients exhibit significantly less downregulation of CD40 ligand than control patients. Patients who would develop MOF show significantly larger increases in GE of transforming growth factor-α (TGF-α), tumour necrosis factor (TNF)-superfamily members 10 and 13B (TNFsf10/13B). CONCLUSIONS When tested at 24 h after surgery, cytokine GE in peripheral blood leucocytes showed no significant differences between those transfused and those not transfused. Some alterations were seen in those developing MOF compared to those who did not, but the findings offer no role of leukocyte depleted (LD) RBC transfusion in the development of MOF.
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Affiliation(s)
- L S Sitniakowsky
- Department of Transfusion Medicine, Sanquin Blood Supply, Research Division Department of Cardiothoracic Surgery, LUMC, Leiden, The Netherlands.
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Möhnle P, Snyder-Ramos SA, Miao Y, Kulier A, Böttiger BW, Levin J, Mangano DT. Postoperative red blood cell transfusion and morbid outcome in uncomplicated cardiac surgery patients. Intensive Care Med 2010; 37:97-109. [DOI: 10.1007/s00134-010-2017-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 07/15/2010] [Indexed: 11/24/2022]
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Leukoreduction of blood transfusions--there is such a thing as a free lunch. Crit Care Med 2010; 38:720-1. [PMID: 20083944 DOI: 10.1097/ccm.0b013e3181c5867f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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