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Bierer J, Horne D, Stanzel R, Henderson M, Boulos L, Hayden JA. Continuous Ultrafiltration Enhances Recovery After Adult Cardiac Surgery With Cardiopulmonary Bypass: A Systematic Review and Meta-analysis. CJC Open 2023; 5:494-507. [PMID: 37496782 PMCID: PMC10366635 DOI: 10.1016/j.cjco.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/17/2023] [Indexed: 07/28/2023] Open
Abstract
Background Cardiac surgery with cardiopulmonary bypass is associated with systemic inflammation. Ultrafiltration used throughout the cardiopulmonary bypass time, continuously, is hypothesized to be an immunomodulatory therapy. Methods A systematic review and meta-analysis of randomized trials investigating continuous forms of ultrafiltration during adult cardiac surgery (CRD42020219309) was conducted and is reported following PRISMA guidelines. MEDLINE, Embase, CENTRAL, and Scopus were searched on November 3, 2021. The primary endpoint was operative mortality, and secondary outcomes included intensive care unit length of stay (ICU LOS), ventilation time, acute kidney injury or renal failure, and pneumonia. Each study was assessed for risk of bias using the Cochrane Risk-of Bias-Tool for Randomized Trials (RoB2) instrument. Outcomes were analyzed with inverse variance random-effects models and assessed for GRADE quality of evidence. Results Twelve randomized trials consisting of 989 adult patients undergoing coronary, valvular, or concomitant cardiac procedures were included. Compared to controls, patients receiving continuous ultrafiltration had no statistical difference in operative mortality; risk ratio of 0.32 (95% confidence interval [CI]: 0.10-1.03; P = 0.06). Reductions occurred in ICU LOS, by 7.01 hours (95% CI: 1.86-12.15; P = 0.008); ventilation time, by 2.11 hours (95% CI: 0.71-3.51; P = 0.003); and incidence of pneumonia, with a risk ratio of 0.33 (95% CI: 0.15-0.75; P = 0.008). There wasno difference in renal injury. The GRADE quality of evidence for these outcomes ranged from very low to low. Conclusions Continuous forms of ultrafiltration enhance recovery after adult cardiac surgery by reducing ICU LOS, ventilation time, and incidence of pneumonia. A multicentre randomized trial could confirm and generalize these findings.
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Affiliation(s)
- Joel Bierer
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roger Stanzel
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Mark Henderson
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Leah Boulos
- Maritime SPOR SUPPORT Unit, Halifax, Nova Scotia, Canada
| | - Jill A. Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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Cowart C, Roberts SM. Pro: Modified Ultrafiltration Is Beneficial for Adults Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:1049-1052. [PMID: 36754730 DOI: 10.1053/j.jvca.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Affiliation(s)
- Christopher Cowart
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
| | - S Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA.
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Kandil OA, Motawea KR, Darling E, Riley JB, Shah J, Elashhat MAM, Searles B, Aiash H. Ultrafiltration and cardiopulmonary bypass associated acute kidney injury: A systematic review and meta-analysis. Clin Cardiol 2021; 44:1700-1708. [PMID: 34837387 PMCID: PMC8715396 DOI: 10.1002/clc.23750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Cardiopulmonary bypass is known to raise the risk of acute kidney injury (AKI). Previous studies have identified numerous risk factors of cardiopulmonary bypass including the possible impact of perioperative ultrafiltration. However, the association between ultrafiltration (UF) and AKI remains conflicting. Thus, we conducted a meta-analysis to further examine the relationship between UF and AKI. HYPOTHESIS Ultrafiltration during cardiac surgery increases the risk of developping Acute kidney Injury. METHODS We searched PubMed, Web of Science, EBSCO, and SCOPUS through July 2021. The RevMan (version 5.4) software was used to calculate the pooled risk ratios (RRs) and mean differences along with their associated confidence intervals (95% CI). RESULTS We identified 12 studies with a total of 8005 patients. There was no statistically significant difference in the incidence of AKI between the group who underwent UF and the control group who did not (RR = 0.90, 95% CI = 0.64-1). Subgroup analysis on patients with previous renal insufficiency also yielded nonsignificant difference (RR = 0.84, 95% CI = 0.53 -1.33, p = .47). Subgroup analysis based on volume of ultrafiltrate removed (> or <2900 ml) was not significant and did not increase the AKI risk as predicted (RR = 0.82, 95% CI = 0.63 -1.07, p = .15). We also did subgroup analysis according to the type of UF and again no significant difference in AKI incidence between UF groups and controls was observed in either the conventional ultrafiltration (CUF), modified ultrafiltration (MUF), zero-balanced ultrafiltration (ZBUF), or combined MUF and CUF subgroups. CONCLUSION UF in cardiac surgery is not associated with increased AKI incidence and may be safely used even in baseline chronic injury patients.
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Affiliation(s)
- Omneya A Kandil
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Karam R Motawea
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Edward Darling
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jeffrey B Riley
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jaffer Shah
- Medical Research Center, Kateb University, Kabul, Afghanistan
| | | | - Bruce Searles
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Hani Aiash
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA.,Department of Family Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.,Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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Zanaboni D, Min J, Seshadri R, Gaynor JW, Dreher M, Blinder JJ. Higher total ultrafiltration volume during cardiopulmonary bypass-assisted infant cardiac surgery is associated with acute kidney injury and fluid overload. Pediatr Nephrol 2021; 36:2875-2881. [PMID: 33651177 DOI: 10.1007/s00467-021-04976-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/20/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ultrafiltration (UF) is used for fluid removal during and after infant cardiopulmonary bypass (CPB) surgery to reduce fluid overload. Excessive UF may have the opposite of its intended effect, resulting in acute kidney injury (AKI), oliganuria, and fluid retention. METHODS This is a single-center, retrospective review of infants treated with conventional and/or modified UF during CPB surgery. UF volume was indexed to weight. AKI was defined using serum creatinine "Kidney Disease Improving Global Outcome (KDIGO)" criteria. Fluid balance was defined according to: [Formula: see text]. Peak fluid overload was determined on postoperative day 3. Multivariable logistic regression adjusted for multiple covariates was used to explore associations with UF, AKI, and fluid overload. RESULTS Five hundred thirty subjects < 1 year of age underwent CPB-assisted congenital heart surgery with UF. Sixty-four (12%) developed postoperative AKI. On multivariable regression, higher indexed total UF volume was associated with increased AKI risk (OR 1.11, 95% CI=1.04-1.19, p = 0.003). UF volume > 119.9 mL/kg did not reduce peak fluid overload. Subjects with AKI took longer to reach a negative fluid balance (2 vs. 3 days, p = 0.04). Those with more complex surgery were at highest AKI risk (STAT 3 [25-75 percentile: 3-4] in AKI group versus STAT 3 [25-75 percentile: 2-4] in non-AKI group, p = 0.05). AKI was reduced in subjects undergoing more complex surgery and treated with UF volume < 119.9 mL/kg. CONCLUSIONS Judicious use of UF in more complex congenital cardiac surgery reduces the risk of AKI.
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Affiliation(s)
- Dominic Zanaboni
- Division of Pediatric Cardiology, University of Michigan C.S. Mott Children's Hospital, 1540 E Hospital Drive, Ann Arbor, MI, 48109, USA. .,Division of Cardiac Critical Care, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Jungwon Min
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Roopa Seshadri
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - J William Gaynor
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Molly Dreher
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Joshua J Blinder
- Division of Pediatric Cardiology, University of Michigan C.S. Mott Children's Hospital, 1540 E Hospital Drive, Ann Arbor, MI, 48109, USA
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Tirilomis T, Friedrich M, Sîrbu H, Aleksic I, Busch T. Intraoperative Hemofiltration in Adults: Prevention of Hypercirculatory Syndrome? Asian Cardiovasc Thorac Ann 2016; 13:17-9. [PMID: 15793044 DOI: 10.1177/021849230501300104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypercirculatory syndrome (HCS) after cardiac surgery may be a sequela of extracorporeal circulation due to hemodilution and release of inflammatory mediators. The aim of this study was to investigate the influence of intraoperative hemofiltration (HF) on the incidence of HCS. A prospective cohort study of 80 patients scheduled for elective coronary bypass was performed. The patients were randomized to two groups: in the conventional (CONV) group 40 patients were treated conventionally and in the HF group 40 patients underwent intraoperative HF. There was no perioperative mortality. The incidence of HCS was comparable in both groups (32% in CONV group versus 40% in HF group; n.s.). Mean cardiac output was higher and systemic vascular resistance lower in CONV group patients than in HF group patients, however these differences did not reach statistical significance. According to this data intraoperative HF does not prevent postoperative HCS induced by cardiopulmonary bypass. Further studies are required to identify the etiology of HCS, and to prevent it occurring after open-heart surgery.
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Affiliation(s)
- Theodor Tirilomis
- Department of Thoracic, Cardiac and Vascular Surgery, University of Göttingen. Robert-Koch-Str. 40, Göttingen D-37075, Germany.
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Soliman R, Fouad E, Belghith M, Abdelmageed T. Conventional hemofiltration during cardiopulmonary bypass increases the serum lactate level in adult cardiac surgery. Ann Card Anaesth 2016; 19:45-51. [PMID: 26750673 PMCID: PMC4900403 DOI: 10.4103/0971-9784.173019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/22/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To evaluate the effect of hemofiltration during cardiopulmonary bypass on lactate level in adult patients who underwent cardiac surgery. DESIGN An observational study. SETTING Prince Sultan cardiac center, Riyadh, Saudi Arabia. PARTICIPANTS The study included 283 patients classified into two groups: Hemofiltration group (n=138), hemofiltration was done during CPB. Control group (n = 145), patients without hemofiltration. INTERVENTIONS Hemofiltration during cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Monitors included hematocrit, lactate levels, mixed venous oxygen saturation, amount of fluid removal during hemofiltration and urine output. The lactate elevated in group H than group C (P < 0.05), and the PH showed metabolic acidosis in group H (P < 0.05). The mixed venous oxygen saturation decreased in group H than group C (P < 0.05). The number of transfused packed red blood cells was lower in group H than group C (P < 0.05). The hematocrit was higher in group H than group C (P < 0.05). The urine output was lower in group H than group C (P < 0.05). CONCLUSIONS Hemofiltration during cardiopulmonary bypass leads to hemoconcentration, elevated lactate level and increased inotropic support. There are some recommendations for hemofiltration: First; Hemofiltration should be limited for patients with impaired renal function, positive fluid balance, reduced response to diuretics or prolonged bypass time more than 2 hours. Second; Minimal amount of fluids should be administered to maintain adequate cardiac output and reduction of priming volumes is preferable to maintain controlled hemodilution. Third; it should be done before weaning of or after cardiopulmonary bypass and not during the whole time of cardiopulmonary bypass.
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Affiliation(s)
- Rabie Soliman
- Department of Cardiac anesthesia, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Department of Anesthesia, Cairo University, Giza, Egypt
| | - Eman Fouad
- Department of Anesthesia, Cairo University, Giza, Egypt
| | - Makhlouf Belghith
- Department of Cardiac anesthesia, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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Abstract
BACKGROUND This study examines the relationship between the use and volume of conventional ultrafiltration (CUF) and the risk of acute kidney injury (AKI) after isolated on-pump coronary artery bypass graft surgery. METHODS A total of 6,407 consecutive patients underwent isolated on-pump coronary artery bypass graft surgery between 2010 and 2013 at 21 medical centers participating in the PERFusion Measures and Outcomes (PERForm) registry. We assessed the effect of CUF use on AKI and other postoperative sequelae using a generalized linear mixed-effect model with a logit link. We also modeled the effect of increasing volume of CUF per weight on AKI, and tested for any modification by a patient's preoperative kidney function. RESULTS Patients having CUF were more likely to have diabetes, vascular disease, chronic obstructive pulmonary disease, congestive heart failure, history of a myocardial infarction, or an intraaortic balloon pump (p < 0.05). They had lower preoperative and nadir hematocrits, creatinine clearance, and ejection fraction (p < 0.05). Patients exposed to CUF had higher adjusted risk of AKI (adjusted odds ratio, 1.36; p = 0.002), although similar rates of death, stroke, and reoperation for bleeding (p > 0.05). The risk of AKI was modified by a patient's preoperative kidney function (p < 0.0004). Among patients with a creatinine clearance of less than 99.6 mL/min (95% confidence interval, 67.6 to 137.5), increasing volume of CUF was associated with a higher risk of AKI. CONCLUSIONS Patients exposed to CUF had a higher adjusted risk of AKI. Clinical teams should consider lower volumes of CUF among patients with low creatinine clearance to minimize the risk of AKI.
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Matata BM, Scawn N, Morgan M, Shirley S, Kemp I, Richards S, Lane S, Wilson K, Stables R, Jackson M, Haycox A, Mediratta N. A Single-Center Randomized Trial of Intraoperative Zero-Balanced Ultrafiltration During Cardiopulmonary Bypass for Patients With Impaired Kidney Function Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1236-47. [PMID: 26119403 DOI: 10.1053/j.jvca.2015.02.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The authors investigated whether zero-balance ultrafiltration (Z-BUF) during bypass significantly improves clinical and cost outcomes or biomarkers of kidney injury for patients with preoperative kidney impairment (estimated glomerular filtration rate [eGFR]<60 mL/minute) undergoing cardiac surgery. DESIGN A single-center randomized controlled trial recruited, patients between 2010 and 2013, with a 12-months follow-up. SETTING Hospital. PARTICIPANTS One hundred ninety-nine patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). INTERVENTIONS Patients were assigned randomly to receive zero-balance ultrafiltration (Z-BUF) or not, with stratification for degree of kidney dysfunction and diabetes. MEASUREMENTS AND MAIN RESULTS The authors assessed clinical efficacy and kidney function biomarkers. Cumulative probability of discharge from the intensive care unit (ICU) was assessed by Kaplan-Meier plots and was found not to be significantly different between the two trial arms (p = 0.61). After adjusting for EuroSCORE, diabetes, eGFR, cardioplegia types and type of surgery in a Cox proportional hazard model, hazard ratios (HR) for ICU length of stay between the Z-BUF and no-Z-BUF groups was not significantly different: HR (95% CI): 0.89 (0.66, 1.20; p = 0.44). In contrast, significant reductions in postoperative chest infections and the composite of clinical endpoints (death, strokes, and myocardial infarctions) in the Z-BUF group were observed. In addition, Z-BUF significantly abrogated the rise in the kidney damage markers urinary NGAL/creatinine ratio, urea, creatinine and eGFR during CPB and adverse events risks. CONCLUSIONS Z-BUF during bypass surgery is associated with significant reductions in morbidity and biomarkers of CPB-induced acute kidney injury soon after CPB, which are indicative of clearance of inflammatory/immune mediators from the circulation.
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Affiliation(s)
| | - Nigel Scawn
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | | | - Sarah Shirley
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | - Ian Kemp
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | | | - Steven Lane
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Keith Wilson
- Liverpool Heart and Chest Hospital NHS Foundation Trust
| | | | - Mark Jackson
- Liverpool Heart and Chest Hospital NHS Foundation Trust
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Vretzakis G, Kleitsaki A, Aretha D, Karanikolas M. Management of intraoperative fluid balance and blood conservation techniques in adult cardiac surgery. Heart Surg Forum 2011; 14:E28-39. [PMID: 21345774 DOI: 10.1532/hsf98.2010111] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Blood transfusions are associated with adverse physiologic effects and increased cost, and therefore reduction of blood product use during surgery is a desirable goal for all patients. Cardiac surgery is a major consumer of donor blood products, especially when cardiopulmonary bypass (CPB) is used, because hematocrit drops precipitously during CPB due to blood loss and blood cell dilution. Advanced age, low preoperative red blood cell volume (preoperative anemia or small body size), preoperative antiplatelet or antithrombotic drugs, complex or re-operative procedures or emergency operations, and patient comorbidities were identified as important transfusion risk indicators in a report recently published by the Society of Cardiovascular Anesthesiologists. This report also identified several pre- and intraoperative interventions that may help reduce blood transfusions, including off-pump procedures, preoperative autologous blood donation, normovolemic hemodilution, and routine cell saver use.A multimodal approach to blood conservation, with high-risk patients receiving all available interventions, may help preserve vital organ perfusion and reduce blood product utilization. In addition, because positive intravenous fluid balance is a significant factor affecting hemodilution during cardiac surgery, especially when CPB is used, strategies aimed at limiting intraoperative fluid balance positiveness may also lead to reduced blood product utilization.This review discusses currently available techniques that can be used intraoperatively in an attempt to avoid or minimize fluid balance positiveness, to preserve the patient's own red blood cells, and to decrease blood product utilization during cardiac surgery.
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Affiliation(s)
- George Vretzakis
- Cardiac Anaesthesia Unit, University Hospital of Larissa, Greece
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 859] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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Reges RV, Vicente WVDA, Rodrigues AJ, Basseto S, Alves Junior L, Scorzoni Filho A, Ferreira CA, Évora PRB. Perfusato autólogo retrógrado no circuito de circulação extracorpórea em pacientes adultos. Braz J Cardiovasc Surg 2011; 26:609-16. [DOI: 10.5935/1678-9741.20110052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Accepted: 10/25/2011] [Indexed: 11/20/2022] Open
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Ferraris VA, Ferraris SP, Saha SP, Hessel EA, Haan CK, Royston BD, Bridges CR, Higgins RSD, Despotis G, Brown JR, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27-86. [PMID: 17462454 DOI: 10.1016/j.athoracsur.2007.02.099] [Citation(s) in RCA: 543] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 01/21/2007] [Accepted: 02/08/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes. METHODS We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme. RESULTS Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions. CONCLUSIONS Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.
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Boodhwani M, Williams K, Babaev A, Gill G, Saleem N, Rubens FD. Ultrafiltration reduces blood transfusions following cardiac surgery: a meta-analysis. Eur J Cardiothorac Surg 2006; 30:892-7. [PMID: 17046273 DOI: 10.1016/j.ejcts.2006.09.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 08/18/2006] [Accepted: 09/15/2006] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although used routinely in pediatric patients, ultrafiltration techniques that reverse hemodilution are infrequently used in adults. Data from small, unblinded clinical trials suggest that the use of ultrafiltration can reduce inflammatory mediators, improve cardiac function, and reduce hemodilution. We conducted a meta-analysis of randomized trials to evaluate the effects of ultrafiltration on blood transfusions and blood loss following adult cardiac surgery. METHODS Medline, EMBASE, and Cochrane databases were searched and randomized controlled trials evaluating modified and/or conventional ultrafiltration, meeting pre-determined selection criteria, were obtained. Quality evaluation and data extraction were performed by two independent observers blinded to study source. Random effects models were used to determine pooled effect estimates and sources of heterogeneity were explored using meta-regression. RESULTS One hundred and thirty two studies were screened and 10 randomized trials evaluating 1004 patients (control, n = 495; ultrafiltration, n = 509) were identified of which only two were double-blinded. The use of ultrafiltration was associated with a reduction in postoperative blood transfusions (weighted mean difference [95% CI] of -0.73 units [-1.16, -0.31]; p = 0.001). This reduction was greater in studies evaluating modified ultrafiltration. Use of ultrafiltration was also associated with reduced postoperative bleeding (-70 ml, [-118, -21]; p = 0.005), which was driven primarily by trials evaluating modified rather than conventional ultrafiltration. CONCLUSIONS Use of ultrafiltration is associated with a significant reduction in postoperative blood transfusions as well as reduced bleeding in adults undergoing cardiac surgery. The efficacy and cost-effectiveness of ultrafiltration as a blood conservations strategy should be evaluated in a large, randomized, double-blinded study.
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Affiliation(s)
- Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Canada
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Raja SG, Dreyfus GD. Modulation of systemic inflammatory response after cardiac surgery. Asian Cardiovasc Thorac Ann 2006; 13:382-95. [PMID: 16304234 DOI: 10.1177/021849230501300422] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cardiac surgery and cardiopulmonary bypass initiate a systemic inflammatory response largely determined by blood contact with foreign surfaces and the activation of complement. It is generally accepted that cardiopulmonary bypass initiates a whole-body inflammatory reaction. The magnitude of this inflammatory reaction varies, but the persistence of any degree of inflammation may be considered potentially harmful to the cardiac patient. The development of strategies to control the inflammatory response following cardiac surgery is currently the focus of considerable research efforts. Diverse techniques including maintenance of hemodynamic stability, minimization of exposure to cardiopulmonary bypass circuitry, and pharmacologic and immunomodulatory agents have been examined in clinical studies. This article briefly reviews the current concepts of the systemic inflammatory response following cardiac surgery, and the various therapeutic strategies being used to modulate this response.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair Street, Glasgow G3 8SJ, Scotland, United Kingdom.
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Cromer MJ, Wolk DR. A minimal priming technique that allows for a higher circulating hemoglobin on cardiopulmonary bypass. Perfusion 1998; 13:311-3. [PMID: 9778714 DOI: 10.1177/026765919801300505] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Reduction in circuit prime during cardiopulmonary bypass has benefits for the patient with a low body surface area, anemia, patient refusal to receive blood products, and aids the practitioner's goal to minimize exposure to blood products. Described here is a simple, low-cost technique that has been shown to decrease priming volume in any bypass circuit and allow a significant increase in 'on bypass hemoglobin'.
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Affiliation(s)
- M J Cromer
- St Joseph's Hospital of Atlanta, Georgia 30342, USA
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