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Choudhury M, Narula J, Saini K, Kapoor PM, Kiran U. Does Intraoperative Diuretic Therapy Affect the Thoracic Fluid Content and Clinical Outcome in Patients Undergoing Mitral Valve Surgery? JOURNAL OF CARDIAC CRITICAL CARE TSS 2020. [DOI: 10.1055/s-0040-1721186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
AbstractPulmonary congestion is inevitable in valvular heart disease. The condition worsens when a patient undergoes cardiopulmonary bypass (CPB). Thoracic fluid content (TFC) is an indicator of total volume status of lung in health and disease. We hypothesize that intraoperative diuretic therapy can improve the hemodynamic and clinical outcome in patients undergoing mitral valve surgery by decreasing TFC as measured by impedance cardiography (ICG).Sixty adult patients with critical mitral stenosis scheduled for mitral valve surgery divided into diuretic (Gr D, n = 30) and control (Gr C, n = 30) group. One mg/kg of furosemide was administered before CPB to Gr D and similar volume of normal saline to Gr C. Hemodynamic and TFC measurements were done by index of contractility (ICON), NICOM monitor at baseline, before anesthesia induction (T1), post skin closure (T2), postoperatively at 6th hour (T3), 24th hour (T4), and 48th hour (T5). The duration of mechanical ventilation (hour), intensive care unit stay (day) and inotropic score was significantly higher in Gr C (5.29 ± 1.4 vs. 2.15 ± 1.1; p = 0.001; 2.11 ± 0.64 vs. 1.67 ± 0.57, p = 0.002; 9 ± 5.4 vs. 5.8 ± 3.2, p = 0.05), respectively. Three patients in Gr C developed respiratory complication during their course of hospital stay. The baseline TFC value was comparable (p = 0.08). In Gr C. it gradually increased over time and never reached the baseline value, whereas in Gr D, there was slight increase in TFC till 6th postoperative hour and it came below the baseline value at 48th hour. A significantly higher TFC value in Gr C in comparison with Gr D from 6th to 48th postoperative hour (p = 0.005, 0.000, and 0.005, respectively) was observed.The ICON had a gradual improvement from 12th over 48th postoperative hour in Gr D in comparison to Gr C. The systemic vascular resistance index was decreased over time in Gr C, whereas in Gr D there was a mild fall at the end of surgery and it came back to near the baseline value at 48th postoperative hour. A continuous decrease in DO2 I except at 6th postoperative hour was seen in Gr C, whereas it remained near the baseline value in Gr D.Linear regression analysis showed significant direct correlation of TFC with intraoperative fluid balance (r = 0.524, p = 0.001), cumulative fluid balance (r = 0.680, p = 0.000) and both peak and mean airway pressure (r = 0.436, p = 0.001 and r = 0.548, p = 0.001, respectively).We concluded that TFC is clearly influenced by intraoperative diuretic therapy. A decrease in TFC has an association with better hemodynamic parameters that could find interesting clinical applications in the decision, whether or not to include a diuretic as a routine therapy during intraoperative management in valve surgery patients.
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Affiliation(s)
- Minati Choudhury
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Jitin Narula
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kulbhushan Saini
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Usha Kiran
- Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
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Meng F, Ma J, Wang W, Lin B. Meta-analysis of interleukin 6, 8, and 10 between off-pump and on-pump coronary artery bypass groups. Bosn J Basic Med Sci 2017; 17:85-94. [PMID: 28284177 DOI: 10.17305/bjbms.2017.1505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 10/06/2016] [Accepted: 10/07/2016] [Indexed: 12/24/2022] Open
Abstract
This study aimed to evaluate the role of off-pump coronary artery bypass (CAB) surgery on the decrease of postoperative inflammatory responses in patients. We systematically searched databases of PubMed and Embase to select the related studies. Interleukin (IL) 6, 8, and 10 were used as outcomes and pooled analysis was performed using R 3.12 software. Standardized mean differences (SMDs) and their 95% confidence intervals (95% CIs) were considered as effect estimates. A total of 27 studies, including 1340 participants, were recruited in this meta-analysis. The pooled analyses showed that postoperative concentration of IL-10 at 12 hours was significantly lower in off-pump CAB group compared to on-pump CAB group (SMD = -1.3640, 95% CI = -2.0086--0.7193). However, no significant differences were found in pre and postoperative concentrations of IL-6 and 8 between off-pump and on-pump CAB groups. These results suggest that there is no advantage of off-pump CAB surgery in the reduction of inflammation compared to on-pump CAB surgery.
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Affiliation(s)
- Fanbo Meng
- Department of Cardiology, China Japan Union Hospital of Jilin University, Changchun, China.
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Parissis H, Mbarushimana S, Ramesh BC, Parissis M, Lampridis S, Mhandu P, Al-Alao B. The impact of off-pump surgery in end-organ function: practical end-points. J Cardiothorac Surg 2015; 10:159. [PMID: 26555853 PMCID: PMC4640374 DOI: 10.1186/s13019-015-0362-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/28/2015] [Indexed: 01/16/2023] Open
Abstract
Most surgeons perform coronary bypass surgery with the aid of cardiopulmonary bypass, which inflicts a massive systemic inflammatory response to the body leading to adverse clinical outcome. In an attempt to make CABG less invasive, interest have been diverted to the off pump technique. The current review attempts to bring an insight onto the last ten years knowledge on the off-pump impact in end organ function, with an aim to draw some clear conclusions in order to allow practitioners to reflect on the subject.
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Affiliation(s)
- Haralabos Parissis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Simon Mbarushimana
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | | | - Mondrian Parissis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Savvas Lampridis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Peter Mhandu
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Bassel Al-Alao
- Thoracic Department, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Vermeulen Windsant IC, de Wit NCJ, Sertorio JTC, van Bijnen AA, Ganushchak YM, Heijmans JH, Tanus-Santos JE, Jacobs MJ, Maessen JG, Buurman WA. Hemolysis during cardiac surgery is associated with increased intravascular nitric oxide consumption and perioperative kidney and intestinal tissue damage. Front Physiol 2014; 5:340. [PMID: 25249983 PMCID: PMC4157603 DOI: 10.3389/fphys.2014.00340] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/20/2014] [Indexed: 12/13/2022] Open
Abstract
Introduction: Acute kidney injury (AKI) and intestinal injury negatively impact patient outcome after cardiac surgery. Enhanced nitric oxide (NO) consumption due to intraoperative intravascular hemolysis, may play an important role in this setting. This study investigated the impact of hemolysis on plasma NO consumption, AKI, and intestinal tissue damage, after cardiac surgery. Methods: Hemolysis (by plasma extracellular (free) hemoglobin; fHb), plasma NO-consumption, plasma fHb-binding capacity by haptoglobin (Hp), renal tubular injury (using urinary N-Acetyl-β-D-glucosaminidase; NAG), intestinal mucosal injury (through plasma intestinal fatty acid binding protein; IFABP), and AKI were studied in patients undergoing off-pump cardiac surgery (OPCAB, N = 7), on-pump coronary artery bypass grafting (CABG, N = 30), or combined CABG and valve surgery (CABG+Valve, N = 30). Results: FHb plasma levels and NO-consumption significantly increased, while plasma Hp concentrations significantly decreased in CABG and CABG+Valve patients (p < 0.0001) during surgery. The extent of hemolysis and NO-consumption correlated significantly (r2 = 0.75, p < 0.0001). Also, NAG and IFABP increased in both groups (p < 0.0001, and p < 0.001, respectively), and both were significantly associated with hemolysis (Rs = 0.70, p < 0.0001, and Rs = 0.26, p = 0.04, respectively) and NO-consumption (Rs = 0.55, p = 0.002, and Rs = 0.41, p = 0.03, respectively), also after multivariable logistic regression analysis. OPCAB patients did not show increased fHb, NO-consumption, NAG, or IFABP levels. Patients suffering from AKI (N = 9, 13.4%) displayed significantly higher fHb and NAG levels already during surgery compared to non-AKI patients. Conclusions: Hemolysis appears to be an important contributor to postoperative kidney injury and intestinal mucosal damage, potentially by limiting NO-bioavailability. This observation offers a novel diagnostic and therapeutic target to improve patient outcome after cardiothoracic surgery.
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Affiliation(s)
- Iris C Vermeulen Windsant
- Department of Surgery, Maastricht University Medical Center Maastricht, Netherlands ; NUTRIM School for Nutrition, Toxicology & Metabolism, Maastricht University Medical Center Maastricht, Netherlands
| | - Norbert C J de Wit
- Central Diagnostic Laboratory, Maastricht University Medical Center Maastricht, Netherlands
| | - Jonas T C Sertorio
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paolo Ribeirao Preto, Brazil
| | - Annemarie A van Bijnen
- Department of Surgery, Maastricht University Medical Center Maastricht, Netherlands ; NUTRIM School for Nutrition, Toxicology & Metabolism, Maastricht University Medical Center Maastricht, Netherlands
| | - Yuri M Ganushchak
- Department of Extracorporeal Circulation, Maastricht University Medical Center Maastricht, Netherlands
| | - John H Heijmans
- Department of Anesthesiology, Maastricht University Medical Center Maastricht, Netherlands
| | - Jose E Tanus-Santos
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paolo Ribeirao Preto, Brazil
| | - Michael J Jacobs
- Department of Surgery, Maastricht University Medical Center Maastricht, Netherlands ; Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht, Netherlands ; Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital Aachen Aachen, Germany
| | - Jos G Maessen
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht, Netherlands ; Department of Cardiothoracic Surgery, Maastricht University Medical Center Maastricht, Netherlands
| | - Wim A Buurman
- Department of Surgery, Maastricht University Medical Center Maastricht, Netherlands ; Central Diagnostic Laboratory, Maastricht University Medical Center Maastricht, Netherlands
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Li W, Wu X, Yan F, Liu J, Tang Y, Ma K, Li S. Effects of pulmonary artery perfusion with urinary trypsin inhibitor as a lung protective strategy under hypothermic low-flow cardiopulmonary bypass in an infant piglet model. Perfusion 2013; 29:434-42. [PMID: 24335190 DOI: 10.1177/0267659113517286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effects of pulmonary artery perfusion with a urinary trypsin inhibitor (UTI) as a lung protective strategy in order to provide an experimental basis for immature lung clinical protective strategies on deep hypothermia with low-flow (DHLF) cardiopulmonary bypass (CPB)-induced pulmonary injury in an infant piglet model. METHODS The piglets (n=15), aged 18.7±0.3 days, weight 4.48±0.21kg, were randomly divided into 3 groups, with 5 piglets in each group: the control group, the pulmonary artery perfusion without UTI group (Group P) and the pulmonary artery perfusion with UTI group (Group U). The levels of the cytokines tumour necrosis factor-α, myeloperoxidase, malondialdehyde and interleukin-10 (TNF-α, MPO, MDA and IL-10) in pulmonary venous serum and lung tissue and the activity of NF-kappa B in lung tissue were measured by enzyme-linked immunosorbent assay (ELISA) and electrophoresis mobility shift assay (EMSA), respectively. RESULTS After DHLF-CPB, all of the piglets demonstrated a state of lung injury as a deterioration of lung function indices, lung injury scores, pulmonary ultrastructure changes, expression of TNF-α, MPO, MDA and IL-10 and the activities of nuclear factor-kappa B (NF-κB), while pulmonary artery perfusion with UTI significantly ameliorated lung function and histopathological changes, with greatly decreased serum levels of TNF-α and MPO compared to the other two groups. Also, we found an increase in the level of IL-10 in Group U lungs compared with that in Group P lungs, which correlated with a strong inhibition in the activity of NF-κB. CONCLUSION Pulmonary artery perfusion with UTI ameliorated the DHLF-induced immature pulmonary injury in the lungs via a reduction of pro-inflammatory cytokine expression and up-regulated levels of IL-10 by inhibiting the activity of NF-κB.
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Affiliation(s)
- W Li
- Center of Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - X Wu
- Center of Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - F Yan
- Center of Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - J Liu
- Center of Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - Y Tang
- Center of Animals for Experiment, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - K Ma
- Center of Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - S Li
- Center of Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
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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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Tagami T, Kushimoto S, Tosa R, Omura M, Hagiwara J, Hirama H, Yokota H. The precision of PiCCO®measurements in hypothermic post-cardiac arrest patients. Anaesthesia 2012; 67:236-43. [DOI: 10.1111/j.1365-2044.2011.06981.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pulmonary injury after cardiopulmonary bypass: beneficial effects of low-frequency mechanical ventilation. J Thorac Cardiovasc Surg 2009; 137:1530-7. [PMID: 19464476 DOI: 10.1016/j.jtcvs.2008.11.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 10/22/2008] [Accepted: 11/07/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Pulmonary dysfunction is a frequent postoperative complication after cardiac surgery with cardiopulmonary bypass, and atelectasis is thought to be one of the main causes. The aim of this study was to evaluate whether low-frequency ventilation and continuous positive airway pressure during cardiopulmonary bypass reduce postcardiopulmonary bypass lung injury. METHODS Eighteen Yorkshire pigs were subjected to 120 minutes of cardiopulmonary bypass (1 hour of cardioplegic arrest) followed by 90 minutes of recovery before being sacrificed. Six animals served as control with the endotracheal tube open to atmosphere during cardiopulmonary bypass. The remaining animals were divided into 2 groups of 6: One group received continuous positive airway pressure of 5 cm H(2)O, and one group received low-frequency ventilation (5/minutes) during cardiopulmonary bypass. Lung tissue biopsy and bronchoalveolar lavage samples were obtained before and 90 minutes after discontinuation of cardiopulmonary bypass for measurement of adenine nucleotide (adenosine-5'-triphosphate, adenosine diphosphate, adenosine monophosphate), lactate dehydrogenase, DNA levels, and histology. Hemodynamic data and arterial blood gases were also collected through the study. RESULTS The hemodynamic parameters were similar in the 3 groups. After cardiopulmonary bypass, the low-frequency ventilation group showed significantly better oxygen tension and alveolar arterial oxygen gradient, higher adenine nucleotide, lower lactate dehydrogenase levels, and reduced histologic damage in lung biopsy, as well as lower DNA levels in bronchoalveolar lavage compared with the control group. The continuous positive airway pressure group showed only significantly reduced lactate dehydrogenase levels compared with control. CONCLUSION Low-frequency ventilation during cardiopulmonary bypass in a pig experimental model reduces tissue metabolic and histologic damage in the lungs and is associated with improved postoperative gas exchange.
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