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Bouisset B, Pozzi M, Ruste M, Varin T, Vola M, Rodriguez T, Jolivet ML, Chiari P, Fellahi JL, Jacquet-Lagreze M. Cardiopulmonary Bypass Blood Flow Rates and Major Adverse Kidney Events in Cardiac Surgery: A Propensity Score-adjusted Before-After Study. J Cardiothorac Vasc Anesth 2024; 38:2213-2220. [PMID: 39095213 DOI: 10.1053/j.jvca.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/06/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES Cardiac surgery associated-acute kidney injury is a common and serious postoperative complication of cardiac surgery, which is associated with increased postoperative morbidity and mortality. This study aimed to explore the association between cardiopulmonary bypass (CPB) blood flow rate (BFR), and major adverse kidney events (MAKEs) at day 30. DESIGN Retrospective single-center before-after observational study. Patients were divided in 2 groups according to CPB flow rates: a first group with an institutional protocol targeting a CPB-BFR of >2.2 L/min/m² (low CPB-BFR group), and a second group with a modified institutional protocol targeting a CPB-BFR of >2.4 L/min/m² (high CPB-BFR group). The primary outcome was MAKE at 30 days, defined as the composite of death, renal replacement therapy or persistent renal dysfunction. SETTING The data were collected from clinical routines in university hospital. PARTICIPANTS Adult patients who underwent elective and urgent cardiac surgery without severe chronic renal failure, for whom CPB duration was ≥90 minutes. INTERVENTIONS We included 533 patients (low CPB-BFR group, n = 270; high CPB-BFR group, n = 263). MEASUREMENTS AND MAIN RESULTS A significant decrease in MAKE at 30 days was observed in the high CPB-BFR group (3% v 8%; odds ratio [OR], 0.779; 95% confidence interval [CI], 0.661-0.919; p < 0.001) mainly mediated by a lower 30-day mortality in the high CPB-BFR group (1% v 5%; OR, 0.697; 95% CI, 0.595-0.817; p = 0.001), as was renal replacement therapy (1% v 4%; OR, 0.739; 95% CI, 0.604-0.904; p = 0.016). CONCLUSIONS In patients undergoing cardiac surgery, increased CPB-BFR was associated with a decrease in MAKE at 30 days including mortality and renal replacement therapy.
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Affiliation(s)
- Benoit Bouisset
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France.
| | - Matteo Pozzi
- Service de Chirurgie Cardiovasculaire de l'Adulte, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Laboratoire RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon Cedex, France
| | - Martin Ruste
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
| | - Thomas Varin
- Service de Chirurgie Cardiovasculaire de l'Adulte, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France
| | - Marco Vola
- Service de Chirurgie Cardiovasculaire de l'Adulte, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Laboratoire RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon Cedex, France
| | - Thomas Rodriguez
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France
| | - Maxime Le Jolivet
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France
| | - Pascal Chiari
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
| | - Matthias Jacquet-Lagreze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
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Bagaria V, Badragiri L, Hiremath CS. Effect of blood conservation protocol on the utilisation of blood and outcome of patients undergoing open heart surgery. Perfusion 2024:2676591241239838. [PMID: 38491948 DOI: 10.1177/02676591241239838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Cardiac surgery is fraught with increased consumption of blood and blood products. Various strategies for blood conservation have been described. Our aim was to study the impact of a structured blood conservation protocol (BCP) on the utilization of blood and patient outcome. METHODS Retrospective analysis of prospectively collected data comparing adult patients undergoing open heart surgery with BCP with those undergoing surgery without BCP. The primary objective was to compare the amount of blood utilized and the hematocrit at discharge. The secondary objective was to compare the parameters of patient outcomes. The level of significance was set at 0.05. RESULTS The proportion of patients requiring transfusion (19.1% [9/47] vs 58.9% [33/56]; p < 0.001) and the quantity of blood transfused (12 units vs 45 units; p 0.003) in the BCP group was significantly lower. Interestingly, the hematocrit level at discharge was comparable between the groups (30.9 (4.8) versus 31.8 (2.4), p-0.671). The average cost incurred for transfusing blood in the BCP group was ₹ 370.2 as compared to ₹1165.1 in the other (p < 0.001). BCP reduced the odds of overall blood transfusion by 79.8% (OR 0.202 (0.084-0.485); p < 0.001) and intraoperative blood transfusion by 95.3% (OR 0.047 (0.010-0.213); p < 0.001). The morbidity and mortality were comparable between the groups. CONCLUSION Implementing a structured blood conservation protocol in patients undergoing open heart surgery significantly reduces the need for blood transfusion. It also has a promising impact on patient recovery after surgery and significant positive cost implications.
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Affiliation(s)
- Vivek Bagaria
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
- Department of Congenital Cardiac Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Lahari Badragiri
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - C S Hiremath
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
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Shiravi F, Shahzamani M, Hosseini SA, Shafie D. A Comparison of the Clinical Outcomes of Minimum and Maximum Hematocrit Levels During Cardiopulmonary Bypass (CPB) in Low-risk Patients Undergoing Coronary Artery Bypass Graft Surgery (CABG): A Cross-sectional Study. Adv Biomed Res 2024; 13:3. [PMID: 38525389 PMCID: PMC10958727 DOI: 10.4103/abr.abr_145_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/23/2023] [Accepted: 07/30/2023] [Indexed: 03/26/2024] Open
Abstract
Background This study investigated the clinical outcomes at the minimum and maximum levels of hematocrit (HCT) during cardiopulmonary bypass (CPB) in low-risk patients undergoing coronary artery bypass graft (CABG) surgery. Materials and Methods In this cross-sectional study, 85 patients who underwent CABG with an ejection fraction of greater than 35% were selected. Based on the HCT range during CPB, patients were divided into two groups: minimum HCT: HCT = 16-18% and maximum HCT: HCT = 25-27%. Then the operation outcomes, amount of drainage, and transfusion were recorded and compared between these groups. Results In the middle tube 8 h after surgery and left tube 24 h after surgery, the amount of drainage in the minimum HCT group with mean of 71.00 ± 130.9 and 60.65 ± 71.23, respectively, was significantly lower than the maximum HCT group with mean of 101.5 ± 246.50 and 123.76 ± 93.17, respectively (P value < 0.05). The incidence of cognitive disorders in the maximum HCT group was significantly higher than in the minimum HCT group (11.1% vs. 0%, P value = 0.041). Also, the mean transfusion of packed red blood cell (PRBC) and fresh frozen plasm (FFP) during CPB in the maximum HCT group, with mean of 346.7 ± 86.22 and 396.1 ± 21.05, respectively, were significantly higher than the minimum HCT group with mean of 178.8 ± 80.91 and 136.8 ± 46.77, respectively (P value < 0.05). After CPB, there was no significant difference in transfusion products (P value > 0.05). Conclusion According to the results of this study, patients undergoing CABG surgery with maximum HCT level versus minimum HCT level during CPB, need more packed cells and fresh frozen plasma products transfusion, which will be associated with the complication of cognitive impairment.
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Affiliation(s)
- Fatemeh Shiravi
- Department of Blood Circulation Technology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehran Shahzamani
- Department of Surgery, Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sayyed Alireza Hosseini
- Department of Surgery, Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Davood Shafie
- Department of Cardiology, Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Fang YH, Zhang YJ, Zhen YN, Liu XP, Sun G, Han YX. Hyperlactatemia in patients undergoing pulmonary endarterectomy with deep hypothermic circulatory arrest: Risk factors and its effects on the outcome. Perfusion 2023:2676591231208984. [PMID: 38124315 DOI: 10.1177/02676591231208984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
INTRODUCTION To determine the risk factors of hyperlactatemia in pulmonary endarterectomy (PEA) surgery and assess whether elevated blood lactate levels are associated with adverse outcomes. METHODS In this retrospective observational study, a total of 111 consecutive patients who underwent PEA for chronic thromboembolic pulmonary hypertension at the XXX Hospital between December 2016 and January 2022 were included. We retrospectively evaluated arterial blood samples analyzed intraoperatively. The pre- and intraoperative risk factors for hyperlactatemia and the postoperative outcomes were recorded. RESULTS Lactate levels gradually increased during surgery. The optimal cut-off lactate level for major postoperative complications, calculated using receiver operating characteristic analysis, was 7.0 mmol/L. Deep hypothermic circulatory arrest (DHCA) duration, nadir hematocrit, and preoperative pulmonary vascular resistance were risk factors for lactate levels >7 mmol/L. Moreover, the intraoperative peak lactate level during PEA under DHCA was found to be a statistically significant predictor of major complications being associated with longer mechanical ventilation time (r = 0.294; p = .003) and intensive care unit length of stay (r = 0.327; p = .001). CONCLUSIONS Deep hypothermic circulatory arrest duration, nadir hematocrit, and preoperative pulmonary vascular resistance were associated with hyperlactatemia. Increased lactate levels were independent predictors of longer mechanical ventilation time, intensive care unit length of stay, and major complications.
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Affiliation(s)
- Ying-Hui Fang
- Department of Anesthesia, China-Japan Friendship Hospital, Beijing, China
| | - Ya-Jun Zhang
- Department of Anesthesia, China-Japan Friendship Hospital, Beijing, China
| | - Ya-Nan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiao-Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Guang Sun
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yong-Xin Han
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
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The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology Clinical Practice Guidelines for the Prevention of Adult Cardiac Surgery-Associated Acute Kidney Injury. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2022; 54:267-290. [PMID: 36742026 PMCID: PMC9891467 DOI: 10.1182/ject-54301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Accepted: 06/25/2022] [Indexed: 02/07/2023]
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Carrasco-Serrano E, Jorge-Monjas P, Muñoz-Moreno MF, Gómez-Sánchez E, Priede-Vimbela JM, Bardají-Carrillo M, Cubero-Gallego H, Tamayo E, Ortega-Loubon C. Impact of Oxygen Delivery on the Development of Acute Kidney Injury in Patients Undergoing Valve Heart Surgery. J Clin Med 2022; 11:jcm11113046. [PMID: 35683434 PMCID: PMC9180985 DOI: 10.3390/jcm11113046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/02/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
One of the strongest risk factors for death in individuals undergoing cardiac surgery is Cardiac Surgery Associated-Acute Kidney Injury (CSA-AKI). Although the minimum kidney oxygen delivery index (DO2i) during cardiopulmonary bypass (CPB) has been reported, the optimal threshold value has not yet been established. A prospective study was conducted from June 2012 to January 2016 to asses how DO2i influences the pathogenesis of CSA-AKI, as well as its most favorable cut-off value. DO2 levels were recorded at the beginning, middle, and end of the CPB. The association between DO2i and CSA-AKI was investigated using multivariable logistic regression analysis. The optimal cut-off of DO2i as a predictor of CSA-AKI was determined using Classification and Regression Tree (CART) analysis. A total of 782 consecutive patients were enrolled. Of these, 231 (29.5%) patients developed AKI. Optimal DO2i thresholds of 303 mL/min/m2 during the CPB and 295 mL/min/m2 at the end of the intervention were identified, which increased the odds of CSA-AKI almost two-fold (Odds Ratio (OR), 1.90; 95% CI, 1.12–3.24) during the surgery and maintained that risk (OR 1.94; 95% CI, 1.15–3.29) until the end. Low DO2i during cardiopulmonary bypass is a risk factor for CSA-AKI that cannot be ruled out. Continuous renal oxygen supply monitoring for adult patients could be a promising method for predicting AKI during CPB.
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Affiliation(s)
- Elena Carrasco-Serrano
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
| | - Pablo Jorge-Monjas
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
- Department of Surgery, University of Valladolid, 47003 Valladolid, Spain
| | - María Fé Muñoz-Moreno
- Unit of Research, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain;
| | - Esther Gómez-Sánchez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
- Department of Surgery, University of Valladolid, 47003 Valladolid, Spain
- Correspondence:
| | - Juan Manuel Priede-Vimbela
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
| | - Miguel Bardají-Carrillo
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
| | - Héctor Cubero-Gallego
- Interventional Cardiology Unit, Cardiology Department, Hospital del Mar, 08003 Barcelona, Spain;
| | - Eduardo Tamayo
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
- Department of Surgery, University of Valladolid, 47003 Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Christian Ortega-Loubon
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Palazuelos J, Iborra C, Jauregui M. Commentary: Should RASi Toxicity Conducting AKI on Patients Undergoing Cardiac Surgery be Questioned? Semin Thorac Cardiovasc Surg 2021; 33:1023-1024. [PMID: 33609675 DOI: 10.1053/j.semtcvs.2021.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Jorge Palazuelos
- Interventional Unit, Cardiology Department, Hospital La Luz, Madrid, Spain.
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The effect of restrictive versus liberal transfusion strategies on longer-term outcomes after cardiac surgery: a systematic review and meta-analysis with trial sequential analysis. Can J Anaesth 2020; 67:577-587. [DOI: 10.1007/s12630-020-01592-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/25/2019] [Accepted: 11/03/2019] [Indexed: 02/03/2023] Open
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Andersen LW. Lactate Elevation During and After Major Cardiac Surgery in Adults: A Review of Etiology, Prognostic Value, and Management. Anesth Analg 2017; 125:743-752. [PMID: 28277327 DOI: 10.1213/ane.0000000000001928] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elevated lactate is a common occurrence after cardiac surgery. This review summarizes the literature on the complex etiology of lactate elevation during and after cardiac surgery, including considerations of oxygen delivery, oxygen utilization, increased metabolism, lactate clearance, medications and fluids, and postoperative complications. Second, the association between lactate and a variety of outcomes are described, and the prognostic role of lactate is critically assessed. Despite the fact that elevated lactate is strongly associated with many important outcomes, including postoperative complications, length of stay, and mortality, little is known about the optimal management of postoperative patients with lactate elevations. This review ends with an assessment of the limited literature on this subject.
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Affiliation(s)
- Lars W Andersen
- From the *Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; †Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; ‡Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; and §Department of Medicine, Regional Hospital Holstebro, Aarhus University, Holstebro, Denmark
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13
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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14
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Lighthall GK, Singh S. Perioperative Maintenance of Tissue Perfusion and Cardiac Output in Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth 2017; 18:117-36. [PMID: 24876228 DOI: 10.1177/1089253214534781] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Sumit Singh
- University of California Los Angeles, CA, USA
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15
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Ideal Hematocrit to Minimize Renal Injury on Cardiopulmonary Bypass. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 10:420-4. [PMID: 26650616 DOI: 10.1097/imi.0000000000000196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Renal dysfunction after cardiopulmonary bypass (CBP) ranges from subclinical injury to established renal failure requiring dialysis. The pathophysiology is multifactorial, and recently, hemodilution during CBP has been thought to be an important determinant of postoperative renal injury. In this study, we attempted to assess the independent effect of hemodilution on renal function. We also aimed to identify the optimal hematocrit where hemodilution-induced renal injury is minimal. METHODS A prospective observational study was conducted on 200 patients between February 2012 and July 2013. One hundred fifty patients were included in the study group, who were further subdivided on the basis of lowest hemodilution as mild hemodilution (>25%), moderate hemodilution (21%-25%), and severe hemodilution (<21%) categories. The primary outcome of the study was renal outcome measure, which was assessed by comparing the creatinine clearance across the groups. RESULTS The creatinine clearance decreased over a period in all three groups. When compared with mild or moderate hemodilution, the reduction in creatinine clearance was significantly higher in the group with severe hemodilution (P ≤ 0.0001). However, there was no significant difference in creatinine clearance reduction between the mild and moderate hemodilution groups (P = 0.813; 95% confidence interval, -8.41 to 10.68). CONCLUSIONS Based on our observations, we would like to propose that a hematocrit of 21% should be considered the critical threshold. Hematocrit below this value of 21% during CBP is associated with the most significant deterioration in renal function.
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16
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The effect of coronary angiography timing and use of cardiopulmonary bypass on acute kidney injury after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2016; 152:254-261.e3. [DOI: 10.1016/j.jtcvs.2016.02.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 02/04/2016] [Accepted: 02/19/2016] [Indexed: 12/12/2022]
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17
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Acute kidney injury after cardiac surgery is not always related to coronary angiography timing. J Thorac Cardiovasc Surg 2016; 152:262-3. [PMID: 27107465 DOI: 10.1016/j.jtcvs.2016.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 11/20/2022]
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18
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Palazuelos J, Rubio Alonso MÁ, Clares Montón P. Prognostic implications of baseline NT-proBNP before cardiac surgery. J Thorac Cardiovasc Surg 2016; 152:252-3. [PMID: 27056760 DOI: 10.1016/j.jtcvs.2016.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Jorge Palazuelos
- Interventional Cardiac Unit, Cardiology Department, "Gómez Ulla" Central Defense University Hospital, Madrid, Spain.
| | | | - Patricia Clares Montón
- Interventional Cardiac Unit, Cardiology Department, "Gómez Ulla" Central Defense University Hospital, Madrid, Spain
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19
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Ellis L, Murphy GJ, Culliford L, Dreyer L, Clayton G, Downes R, Nicholson E, Stoica S, Reeves BC, Rogers CA. The Effect of Patient-Specific Cerebral Oxygenation Monitoring on Postoperative Cognitive Function: A Multicenter Randomized Controlled Trial. JMIR Res Protoc 2015; 4:e137. [PMID: 26685289 PMCID: PMC4704972 DOI: 10.2196/resprot.4562] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/15/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Indices of global tissue oxygen delivery and utilization such as mixed venous oxygen saturation, serum lactate concentration, and arterial hematocrit are commonly used to determine the adequacy of tissue oxygenation during cardiopulmonary bypass (CPB). However, these global measures may not accurately reflect regional tissue oxygenation and ischemic organ injury remains a common and serious complication of CPB. Near-infrared spectroscopy (NIRS) is a noninvasive technology that measures regional tissue oxygenation. NIRS may be used alongside global measures to optimize regional perfusion and reduce organ injury. It may also be used as an indicator of the need for red blood cell transfusion in the presence of anemia and tissue hypoxia. However, the clinical benefits of using NIRS remain unclear and there is a lack of high-quality evidence demonstrating its efficacy and cost effectiveness. OBJECTIVE The aim of the patient-specific cerebral oxygenation monitoring as part of an algorithm to reduce transfusion during heart valve surgery (PASPORT) trial is to determine whether the addition of NIRS to CPB management algorithms can prevent cognitive decline, postoperative organ injury, unnecessary transfusion, and reduce health care costs. METHODS Adults aged 16 years or older undergoing valve or combined coronary artery bypass graft and valve surgery at one of three UK cardiac centers (Bristol, Hull, or Leicester) are randomly allocated in a 1:1 ratio to either a standard algorithm for optimizing tissue oxygenation during CPB that includes a fixed transfusion threshold, or a patient-specific algorithm that incorporates cerebral NIRS monitoring and a restrictive red blood cell transfusion threshold. Allocation concealment, Internet-based randomization stratified by operation type and recruiting center, and blinding of patients, ICU and ward care staff, and outcome assessors reduce the risk of bias. The primary outcomes are cognitive function 3 months after surgery and infectious complications during the first 3 months after surgery. Secondary outcomes include measures of inflammation, organ injury, and volumes of blood transfused. The cost effectiveness of the NIRS-based algorithm is described in terms of a cost-effectiveness acceptability curve. The trial tests the superiority of the patient-specific algorithm versus standard care. A sample size of 200 patients was chosen to detect a small to moderate target difference with 80% power and 5% significance (two tailed). RESULTS Over 4 years, 208 patients have been successfully randomized and have been followed up for a 3-month period. Results are to be reported in 2015. CONCLUSIONS This study provides high-quality evidence, both valid and widely applicable, to determine whether the use of NIRS monitoring as part of a patient-specific management algorithm improves clinical outcomes and is cost effective. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN): 23557269; http://www.isrctn.com/ISRCTN23557269 (Archived by Webcite at http://www.webcitation.org/6buyrbj64).
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Affiliation(s)
- Lucy Ellis
- Clinical Trials & Evaluation Unit, University of Bristol, Bristol, United Kingdom
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20
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Hwang NC. Preventive Strategies for Minimizing Hemodilution in the Cardiac Surgery Patient During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 29:1663-71. [DOI: 10.1053/j.jvca.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Indexed: 11/11/2022]
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21
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Ghatanatti R, Teli A, Narayan P, Chowdhuri KR, Mondal A, Bhattacharya S, Sengupta G, Datta M. Ideal Hematocrit to Minimize Renal Injury on Cardiopulmonary Bypass. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ravi Ghatanatti
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R, Kolkata, India
| | - Anita Teli
- Department of Physiology, BLDE University, Shri B. M. Patil Medical College, Bijapur, Karnataka, India
| | - Pradeep Narayan
- Department of Cardiothoracic and Vascular Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Kuntal Roy Chowdhuri
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R, Kolkata, India
| | - Ansuman Mondal
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R, Kolkata, India
| | - Subhankar Bhattacharya
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R, Kolkata, India
| | - Gautam Sengupta
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R, Kolkata, India
| | - Monalisa Datta
- Department of Cardiothoracic and Vascular Anaesthesia, SSKM Hospital and IPGME&R, Kolkata, India
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22
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Goldberg J, Paugh TA, Dickinson TA, Fuller J, Paone G, Theurer PF, Shann KG, Sundt TM, Prager RL, Likosky DS. Greater Volume of Acute Normovolemic Hemodilution May Aid in Reducing Blood Transfusions After Cardiac Surgery. Ann Thorac Surg 2015. [PMID: 26206721 DOI: 10.1016/j.athoracsur.2015.04.135] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Perioperative red blood cell transfusions (RBC) are associated with increased morbidity and mortality after cardiac surgery. Acute normovolemic hemodilution (ANH) is recommended to reduce perioperative transfusions; however, supporting data are limited and conflicting. We describe the relationship between ANH and RBC transfusions after cardiac surgery using a multi-center registry. METHODS We analyzed 13,534 patients undergoing cardiac surgery between 2010 and 2014 at any of the 26 hospitals participating in a prospective cardiovascular perfusion database. The volume of ANH (no ANH, <400 mL, 400 to 799 mL, ≥ 800 mL) was recorded and linked to each center's surgical data. We report adjusted relative risks reflecting the association between the use and amount of ANH and the risk of perioperative RBC transfusion. Results were adjusted for preoperative risk factors, procedure, body surface area, preoperative hematocrit, and center. RESULTS The ANH was used in 17% of the patients. ANH was associated with a reduction in RBC transfusions (RRadj [adjusted risk ratio] 0.74, p < 0.001). Patients having 800 mL or greater of ANH had the most profound reduction in RBC transfusions (RRadj 0.57, p < 0.001). Platelet and plasma transfusions were also significantly lower with ANH. The ANH population had superior postoperative morbidity and mortality compared with the no ANH population. CONCLUSIONS There is a significant association between ANH and reduced perioperative RBC transfusion in cardiac surgery. Transfusion reduction is most profound with larger volumes of ANH. Our findings suggest the volume of ANH, rather than just its use, may be an important feature of a center's blood conservation strategy.
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Affiliation(s)
- Joshua Goldberg
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Theron A Paugh
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - John Fuller
- St. John Providence Health System Detroit Hospitals, Detroit, Michigan
| | - Gaetano Paone
- Division of Cardiac Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Patty F Theurer
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kenneth G Shann
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thoralf M Sundt
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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Habicher M, von Heymann C, Spies CD, Wernecke KD, Sander M. Central Venous-Arterial pCO2 Difference Identifies Microcirculatory Hypoperfusion in Cardiac Surgical Patients With Normal Central Venous Oxygen Saturation: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2015; 29:646-55. [DOI: 10.1053/j.jvca.2014.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Indexed: 11/11/2022]
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Transfusion triggers for guiding RBC transfusion for cardiovascular surgery: a systematic review and meta-analysis*. Crit Care Med 2015; 42:2611-24. [PMID: 25167086 DOI: 10.1097/ccm.0000000000000548] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Restrictive red cell transfusion is recommended to minimize risk associated with exposure to allogeneic blood. However, perioperative anemia is an independent risk factor for adverse outcomes after cardiovascular surgery. The purpose of this systematic review and meta-analysis is to determine whether perioperative restrictive transfusion thresholds are associated with inferior clinical outcomes in randomized trials of cardiovascular surgery patients. DATA SOURCES The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from inception to October 2013; reference lists of published guidelines, reviews, and associated articles, as well as conference proceedings. No language restrictions were applied. STUDY SELECTION We included controlled trials in which adult patients undergoing cardiac or vascular surgery were randomized to different transfusion thresholds, described as a hemoglobin or hematocrit level below which RBCs were transfused. DATA EXTRACTION Two authors independently extracted data from included trials. We pooled risk ratios of dichotomous outcomes and mean differences of continuous outcomes across trials using random-effects models. DATA SYNTHESIS Seven studies (enrolling 1,262 participants) met inclusion criteria with restrictive and liberal transfusion thresholds most commonly differing by a hemoglobin of 1 g/dL or hematocrit of 6-7%, resulting in decreased transfusions by 0.71 units of RBCs (95% CI, 0.31-1.09, p = 0.0002) without an associated change in adverse events: mortality (risk ratio, 1.12; 95% CI, 0.65-1.95; p = 0.60), myocardial infarction (risk ratio, 0.94; 95% CI, 0.30-2.99; p = 0.92), stroke (risk ratio, 1.15; 95% CI, 0.57-2.32; p = 0.70), acute renal failure (risk ratio, 0.98; 95% CI, 0.64-1.49; p = 0.91), infections (risk ratio, 1.23; 95% CI, 0.85-1.78; p = 0.27), or length of stay. There was no between-trial heterogeneity for any pooled analysis. Including four pediatric trials (456 participants) and 10 trials utilizing only intraoperative acute normovolemic hemodilution (872 participants) did not substantially change the results except that unlike the transfusion threshold trials, the hemodilution trials did not reduce the proportion of patients transfused (interaction p = 0.01). CONCLUSIONS Further randomized controlled trials are necessary to determine the optimal transfusion strategy for patients undergoing cardiovascular surgery.
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Shahbazi S, Panah A, Sahmeddini MA. Evaluation of factors influencing liver function test in on-pump coronary artery bypass graft surgery. IRANIAN JOURNAL OF MEDICAL SCIENCES 2013; 38:308-13. [PMID: 24293784 PMCID: PMC3838982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 11/11/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Liver dysfunction during on-pump coronary artery bypass graft surgery (CABG) is a rare complication but is associated with significant morbidity and mortality. The ability to identify high-risk patients may be helpful in planning appropriate management strategies. We aimed to evaluate the factors influencing liver function tests during on-pump CABG. METHODS In 146 patients scheduled for on-pump CABG, the liver function test was done preoperatively and on the first postoperative day. Some preoperative and intraoperative risk factors were checked and then the postoperative liver function tests were compared with the preoperative ones. Probable relationships between these changes and the preoperative and intraoperative risk factors were studied. RESULTS A medical history of diabetes had a significant relationship with the changes in direct bilirubin. Preoperative central venous pressure had a significant relationship with the changes in aspartate aminotransferase and alanine aminotransferase. Use of intra-aortic balloon pump and duration of aortic cross-clamp were significantly related to the changes in the liver function tests except for alanine aminotransferase and alkaline phosphatase. CONCLUSION It seems that the techniques for the reduction of cardiopulmonary bypass and aortic cross-clamp duration may be useful to protect liver function. We recommend that a larger population of patients be studied to confirm these findings.
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Loor G, Li L, Sabik JF, Rajeswaran J, Blackstone EH, Koch CG. Nadir hematocrit during cardiopulmonary bypass: End-organ dysfunction and mortality. J Thorac Cardiovasc Surg 2012; 144:654-662.e4. [DOI: 10.1016/j.jtcvs.2012.03.058] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/27/2012] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
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27
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Implications and management of anemia in cardiac surgery: Current state of knowledge. J Thorac Cardiovasc Surg 2012; 144:538-46. [DOI: 10.1016/j.jtcvs.2012.04.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 02/17/2012] [Accepted: 04/13/2012] [Indexed: 12/17/2022]
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Mariscalco G, Lorusso R, Dominici C, Renzulli A, Sala A. Acute Kidney Injury: A Relevant Complication After Cardiac Surgery. Ann Thorac Surg 2011; 92:1539-47. [DOI: 10.1016/j.athoracsur.2011.04.123] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 04/27/2011] [Accepted: 04/29/2011] [Indexed: 11/25/2022]
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Haase M, Bellomo R, Story D, Letis A, Klemz K, Matalanis G, Seevanayagam S, Dragun D, Seeliger E, Mertens PR, Haase-Fielitz A. Effect of mean arterial pressure, haemoglobin and blood transfusion during cardiopulmonary bypass on post-operative acute kidney injury. Nephrol Dial Transplant 2011; 27:153-60. [PMID: 21677302 DOI: 10.1093/ndt/gfr275] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) after cardiac surgery is a common and serious condition carrying significant costs. During cardiopulmonary bypass (CPB) surgery, modifiable factors may contribute to post-operative AKI. Their avoidance might be a potential target for nephroprotection. METHODS The objective of the present study was to identify and determine whether intraoperative hypotension, anaemia, or their combination, red blood cell transfusion or vasopressor use are independent risk factors for post-operative AKI defined by the RIFLE (renal Risk, Injury, Failure, Loss of renal function and End-stage renal disease) classification and other thresholds using a mixed logistic multivariate model. RESULTS We analysed 381 468 mean arterial pressure (MAP) measurements from 920 consecutive on-pump cardiac surgery patients. Overall, 19.5% developed AKI which was associated with an 8.2-fold increase in-hospital mortality. Haemoglobin concentration was an independent risk factor for AKI {odds ratio [OR] 1.16 per g/dL decrease [95% confidence interval (CI) 1.05-1.31]; P = 0.018} with systemic arterial oxygen saturation and pressure values not adding further strength to such an association. MAP alone or vasopressor administration was not independently associated with AKI but volume of red blood cell transfusion was, with its effect being apparent at a haemoglobin level of >8 g/dL (>5 mmol/L). In patients with severe anaemia (<25th percentile of lowest haemoglobin), the independent effect of hypotension (>75th percentile of area under the curve MAP <50 mmHg) on AKI was more pronounced [OR 3.36 (95% CI 1.34-8.41); P = 0.010]. CONCLUSION Intraoperative avoidance of the extremes of anaemia, especially during severe hypotension and avoidance of transfusion in patients with haemoglobin levels >8 g/dL (>5 mmol/L) may help decrease AKI in patients undergoing cardiac surgery and represent targets for future controlled interventions.
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Affiliation(s)
- Michael Haase
- Department of Nephrology and Intensive Care, Charité—University Medicine Berlin, Berlin, Germany
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Patel NN, Lin H, Toth T, Welsh GI, Jones C, Ray P, Satchell SC, Sleeman P, Angelini GD, Murphy GJ. Reversal of anemia with allogenic RBC transfusion prevents post-cardiopulmonary bypass acute kidney injury in swine. Am J Physiol Renal Physiol 2011; 301:F605-14. [PMID: 21653630 DOI: 10.1152/ajprenal.00145.2011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Anemia during cardiopulmonary bypass (CPB) is strongly associated with acute kidney injury in clinical studies; however, reversal of anemia with red blood cell (RBC) transfusions is associated with further renal injury. To understand this paradox, we evaluated the effects of reversal of anemia during CPB with allogenic RBC transfusion in a novel large-animal model of post-cardiac surgery acute kidney injury with significant homology to that observed in cardiac surgery patients. Adult pigs undergoing general anesthesia were allocated to a Sham procedure, CPB alone, Sham+RBC transfusion, or CPB+RBC transfusion, with recovery and reassessment at 24 h. CPB was associated with dilutional anemia and caused acute kidney injury in swine characterized by renal endothelial dysfunction, loss of nitric oxide (NO) bioavailability, vasoconstriction, medullary hypoxia, cortical ATP depletion, glomerular sequestration of activated platelets and inflammatory cells, and proximal tubule epithelial cell stress. RBC transfusion in the absence of CPB also resulted in renal injury. This was characterized by endothelial injury, microvascular endothelial dysfunction, platelet activation, and equivalent cortical tubular epithelial phenotypic changes to those observed in CPB pigs, but occurred in the absence of severe intrarenal vasoconstriction, ATP depletion, or reductions in creatinine clearance. In contrast, reversal of anemia during CPB with RBC transfusion prevented the reductions in creatinine clearance, loss of NO bioavailability, platelet activation, inflammation, and epithelial cell injury attributable to CPB although it did not prevent the development of significant intrarenal vasoconstriction and endothelial dysfunction. In conclusion, contrary to the findings of observational studies in cardiac surgery, RBC transfusion during CPB protects pigs against acute kidney injury. Our study underlines the need for translational research into indications for transfusion and prevention strategies for acute kidney injury.
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Affiliation(s)
- Nishith N Patel
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, UK
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Bahrainwala ZS, Grega MA, Hogue CW, Baumgartner WA, Selnes OA, McKhann GM, Gottesman RF. Intraoperative hemoglobin levels and transfusion independently predict stroke after cardiac operations. Ann Thorac Surg 2011; 91:1113-8. [PMID: 21440132 DOI: 10.1016/j.athoracsur.2010.12.049] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 12/23/2010] [Accepted: 12/29/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Anemia has been associated with adverse cerebrovascular outcomes, particularly after cardiac operations. This study was conducted to determine if hemoglobin levels during and after cardiopulmonary bypass (CPB) predict postoperative stroke in cardiac surgical patients, independent of transfusion requirements. METHODS Individuals who had sustained a clinical postoperative stroke (cases) were matched 1:2 with controls by age, sex, surgical procedure, and year of operation. In 617 patients, conditional logistic regression was performed to analyze associations between hemoglobin levels before and after CPB, and stroke. RESULTS After adjustment for potentially confounding vascular risk factors, lower hemoglobin after CPB was associated with a higher risk of stroke, even after adjustment for the amount of packed red blood cells transfused (adjusted odds ratio, 1.28; 95% confidence interval, 1.00 to 1.64, per point of lower hemoglobin level; adjusted odds ratio for stroke per higher quartile of packed red blood cells transfused in this model, 1.37; 95% confidence interval, 1.02 to 1.83). Similar associations were not found for hemoglobin concentrations preoperatively nor change in hemoglobin from before to after CPB. A post-CPB hemoglobin level below the median was associated with 37% increased odds of a postoperative stroke occurring (p = 0.02). CONCLUSIONS Lower postoperative hemoglobin levels and higher intraoperative transfusion requirements are each independently associated with a higher risk of stroke. Reduced cerebral oxygen delivery due to anemia may contribute to cerebral injury after coronary artery bypass grafting.
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Affiliation(s)
- Zainab S Bahrainwala
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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McMillan D, Potger K, Southwell J. Blood management issues: getting clots together when you want them. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2011; 43:P52-P57. [PMID: 21449241 PMCID: PMC4680098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Coagulation is a complex process that allows whole blood to form clots at tissue and vessel sites where damage has occurred. Activation of the hemostasis system causes platelets and fibrin-containing clot to stop the bleeding. Perfusionists must find ways to preserve the coagulation system if we are to avoid bleeding in the cardiopulmonary bypass patient. It is still unclear what techniques are best to continue maintaining hemostasis and avoiding transfusion in patients requiring cardiopulmonary bypass (CPB). There are numerous factors that come into play with the use of CPB including deactivating the coagulation system with anticoagulants, hemodilution of the circulating blood volume, inflammatory response, and a possible pro-coagulant response from protamine with heparin reversal once the surgical procedure has been completed and CPB terminated. All these factors make achieving hemostasis post CPB extremely difficult. This review attempts to assess what is currently being discussed in the literature, which may improve hemostasis with cardiopulmonary bypass. There is still no one technique that will improve hemostasis post CPB. Perhaps the answer may lie in a combination of reported techniques that may in some way lead to the preserving of coagulation factors during CPB.
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Affiliation(s)
- Darryl McMillan
- Cardiopulmonary Perfusion and Autotransfusion Unit, Department of Anaesthesia and Pain Management, Royal North Shore Hospital of Sydney, Sydney, Australia.
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Senay S, Toraman F, Karabulut H, Alhan C. Is it the patient or the physician who cannot tolerate anemia? A prospective analysis in 1854 non-transfused coronary artery surgery patients. Perfusion 2010; 24:373-80. [DOI: 10.1177/0267659109358118] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and objective: Low hematocrit level and transfusion may coexist during cardiopulmonary bypass and the actual impact of one on the outcome parameters may be counfounded or masked by the other. This study aims to determine the impact of the lowest hematocrit level during cardiopulmonary bypass on outcome parameters in non-transfused patients. Methods: Two thousand six hundred and thirty-two consecutive patients who underwent isolated coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass were evaluated prospectively:1854 (70.4%) patients who did not receive any red blood cells during hospital stay were included in the study. Perioperative data and outcome parameters were recorded. Outcomes were evaluated in 2 groups according to the lowest level of hematocrit (>21%: high hematocrit group, n= 1680, (91.6%) and ≤21%: low hematocrit group, n=174, (9.4%)) during cardiopulmonary bypass. Results: Overall mean lowest hematocrit level of patients was 27.7±4.4% (19.7±1.9% in the low hematocrit group, 28.5±4.1% in the high hematocrit group). The comparison of outcome parameters regarding the time on ventilator, duration of intensive care unit stay, intensive care unit re-admission, hospital re-admission, reoperation for bleeding or tamponade, low cardiac output, postoperative atrial fibrillation, stroke, creatinine level at hospital discharge, new onset renal failure, mediastinitis, pulmonary complication and mortality rates were similar in both groups. Conclusions: Our findings suggest that a lowest hematocrit level of ≤21% during cardiopulmonary bypass has no adverse impact on outcome after isolated coronary surgery in non-transfused patients.
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Affiliation(s)
- Sahin Senay
- Acibadem University School of Medicine, Department of Cardiovascular Surgery, Istanbul, Turkey,
| | - Fevzi Toraman
- Acibadem University School of Medicine, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Hasan Karabulut
- Acibadem University School of Medicine, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Cem Alhan
- Acibadem University School of Medicine, Department of Cardiovascular Surgery, Istanbul, Turkey
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McMillan D, Potger K, Southwell J, Ambrose M, Connolly T, Louis M. Getting it right: optimizing transfusion management during the procedure. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2009; 41:P65-P70. [PMID: 20092090 PMCID: PMC4813542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
There is little doubt that blood transfusions have saved many lives in cases of acute hypovolemia and anemia, but both the literature and practitioners still do not agree as to what the appropriate indicators for transfusion are in a cardiac surgical patient. Furthermore, there are those who claim that the benefit of blood transfusions has never been conclusively demonstrated, and evidence of transfusion related harm continues to accumulate. Cardiac surgical patients may be transfused not only because of bleeding but also due to hemodilution from preoperative and intraoperative intravenous fluids and pump primes in conjunction with a possible preoperative anemia. Getting transfusion right to improve our practice has to be approached multifactorially. The use of prophylactic dosing of blood products has been suggested to be ineffective in reducing blood loss. There are many factors that impact transfusion rates including determining the optimal hematocrit where it is highly unlikely that one figure will be applicable to all patients. The formulation of transfusion guidelines and algorithms that have been agreed upon by all practitioners involved in the care of cardiac surgical patients may have a positive effect-if everyone agrees to transfuse patients via the formulated guidelines or algorithms. Importantly, no one individual should be able make the decision on whether a patient requires a blood transfusion-it must at all times be a team decision, whether in the operating room or intensive care unit.
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Affiliation(s)
- Darryl McMillan
- Cardiopulmonary Perfusion and Autotransfusion Unit, Department of Anaesthesia and Pain Management, Royal North Shore Hospital, Sydney, Australia
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Berger K, Sander M, Spies C, Weymann L, Bühner S, Lochs H, Wernecke KD, von Heymann C. Profound haemodilution during normothermic cardiopulmonary bypass influences neither gastrointestinal permeability nor cytokine release in coronary artery bypass graft surgery. Br J Anaesth 2009; 103:511-7. [DOI: 10.1093/bja/aep201] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Sander M, Spies CD, Berger K, Schröder T, Grubitzsch H, Wernecke KD, von Heymann C. Perioperative indocyanine green clearance is predictive for prolonged intensive care unit stay after coronary artery bypass grafting--an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R149. [PMID: 19747406 PMCID: PMC2784368 DOI: 10.1186/cc8045] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 08/12/2009] [Accepted: 09/14/2009] [Indexed: 12/21/2022]
Abstract
Introduction During cardiac surgery with cardiopulmonary bypass (CPB) haemodilution occurs. Hepatic dysfunction after CPB is a rare, but serious, complication. Clinical data have validated the plasma-disappearance rate of indocyanine green (PDR ICG) as a marker of hepatic function and perfusion. Primary objective of this analysis was to investigate the impact of haemodilutional anaemia on hepatic function and perfusion by the time course of PDR ICG and liver enzymes in elective CABG surgery. Secondary objective was to define predictors of prolonged ICU treatment like decreased PDR ICG after surgery. Methods 60 Patients were subjected to normothermic CPB with predefined levels of haemodilution anaemia (haemotacrit (Hct) of 25% versus 20% during CPB). Hepatic function and perfusion was assessed by PDR ICG, plasma levels of aspartate aminotransferase (ASAT) and α-GST. Prolonged ICU treatment was defined as treatment ≥ 48 hours. Results Logistic regression analysis showed that all postoperative measurements of PDR ICG (P < 0.01), and the late postoperative ASAT (P < 0.01) measurement were independent risk factors for prolonged ICU treatment. The predictive capacity for prolonged ICU treatment was best of the PDR ICG one hour after admission to the ICU. Furthermore, the time course of PDR ICG as well as ASAT and α-GST did not differ between groups of haemodilutional anaemia. Conclusions Our study provides evidence that impaired PDR ICG as a marker of hepatic dysfunction and hypoperfusion may be a valid marker of prolonged ICU treatment. Additionally this study provides evidence that haemodilutional anaemia to a Hct of 20% does not impair hepatic function and perfusion. Trial registration [ISRCTN35655335]
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Affiliation(s)
- Michael Sander
- Department of Anaesthesiology and Intensive Care Medicine, Charité Universitätsmedizin - Berlin, Campus Virchow Klinikum and Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany.
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De Somer F. Optimal Versus Suboptimal Perfusion During Cardiopulmonary Bypass and the Inflammatory Response. Semin Cardiothorac Vasc Anesth 2009; 13:113-7. [DOI: 10.1177/1089253209337746] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite major improvements in perfusion techniques over the past 50 years, it is still not possible to formulate a clear definition of what is meant by optimal perfusion. In part this is due to the lack of sufficient evidence-based data and in part because of the complex pathophysiology that takes place during cardiac surgery with cardiopulmonary bypass. To find an answer we need to understand the exact mechanism of the inflammatory reaction triggered by the cardiopulmonary bypass. However, it is clear that further improvement of the cardiopulmonary bypass components alone will be sufficient. Only a combined strategy can further improve cardiopulmonary bypass—related morbidity and mortality. Such a combined strategy will embrace perfusion techniques as well as a pharmacological approach. It will also require a continuous monitoring of the microcirculation. The latter will not only allow to rapidly sense changes in the quality of perfusion but, even more important, also make it possible to intervene at the moment of deterioration. Recent research shows that such an approach has positive an impact on cardiopulmonary bypass—related morbidity postoperatively.
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Affiliation(s)
- F. De Somer
- Heart Centre, University Hospital Gent, Gent, Belgium,
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Vermeer H, Teerenstra S, de Sévaux RGL, van Swieten HA, Weerwind PW. The effect of hemodilution during normothermic cardiac surgery on renal physiology and function: a review. Perfusion 2009; 23:329-38. [DOI: 10.1177/0267659109105398] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the definitions of renal dysfunction vary, loss of renal function is a common complication following cardiac surgery using cardiopulmonary bypass (CPB). When postoperative dialysis is required, mortality is approximately 50%. CPB-accompanied hemodilution is a major contributing factor to renal damage as it notably reduces oxygen delivery by reducing the oxygen transport capacity of the blood as well as disturbing the microcirculation. To minimize hypoxemic damage during CPB, lowering of body temperature is applied to reduce the patient’s metabolic rate. At present, however, temperature management during elective adult cardiac surgery is shifting from moderate hypothermia to normothermia. To determine whether the currently accepted levels of hemodilution during CPB can suffice the normothermic patient’s high oxygen demand, we focused this study on renal physiology and postoperative renal function. Hemodilution reduces the capillary density through a diminished capillary viscosity, thereby, redistributing blood from the renal medulla to the renal cortex. As the physiology of the renal medulla makes it a hypoxic environment, this part of the kidney appears to be especially at risk for hypoxic damage caused by a hemodilution-induced lowered oxygen transport and oxygen delivery. In addition, hemodilution is also likely to disturb the hormonal systems regulating renal blood distribution. Clinical studies, mostly of retrospective or observational nature, show that perioperative nadir hematocrit levels lower than approximately 24% are associated with an increased risk to develop postoperative renal failure. A better comprehension of the cause-and-effect relation between low perioperative hematocrits and loss of postoperative renal function may enable more effective renal protective strategies.
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Affiliation(s)
- H Vermeer
- Department of Extra-Corporeal Circulation, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - S Teerenstra
- Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - RGL de Sévaux
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - HA van Swieten
- Department of Cardiothoracic Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - PW Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Murphy GS, Hessel EA, Groom RC. Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach. Anesth Analg 2009; 108:1394-417. [DOI: 10.1213/ane.0b013e3181875e2e] [Citation(s) in RCA: 233] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Haas V, Büning C, Buhner S, von Heymann C, Valentini L, Lochs H. Clinical relevance of measuring colonic permeability. Eur J Clin Invest 2009; 39:139-44. [PMID: 19200167 DOI: 10.1111/j.1365-2362.2008.02075.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Gastroduodenal and small intestinal permeability are increased in patients with Crohn's disease (CD) and intensive care patients. The relevance of colonic permeability has not yet been adequately investigated. The aim of this study was to investigate the clinical value of sucralose excretion as indicator for colonic permeability in these patient groups. DESIGN After oral administration of four sugars and subsequent analysis of urinary excretion, gastroduodenal and intestinal permeability were calculated from saccharose excretion and lactulose/mannitol (L/M) ratio over 5 h, and sucralose excretion from 5 to 26 h in 100 healthy controls, 29 CD and 35 patients after coronary surgery (CABG). RESULTS In controls, sucralose excretion was highly variable (0.67+/-0.92%) and not related to small intestinal permeability. In CD and CABG, L/M ratio was increased (0.054+/-0.060; 0.323+/-0.253 vs. 0.018+/-0.001 in controls). Sucralose excretion was increased in 77% of CABG but only in 7% of CD. There was an association between gastroduodenal and intestinal permeability in CD and CABG (r=0.72, and r=0.51), but sucralose excretion was not related to either one of these two parameters. Other than a weak association between sucralose and length of stay in intensive care in CABG patients (P=0.099), sucralose excretion was not related to clinical outcome. CONCLUSIONS The proposed cut-off for normal sucralose excretion is 2.11%, but its high variability and lack of association to gastrointestinal permeability or clinical outcome leave it open, if it can provide information beyond established permeability tests.
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Affiliation(s)
- V Haas
- Charité University Clinic, Berlin, Germany.
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Ranucci M. Perioperative renal failure: hypoperfusion during cardiopulmonary bypass? Semin Cardiothorac Vasc Anesth 2008; 11:265-8. [PMID: 18270190 DOI: 10.1177/1089253207311141] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute renal failure is one of the most frequent and life-threatening complications after cardiac surgery. There is a recent growing deal of information suggesting that during the time of cardiopulmonary bypass kidneys may suffer from an imbalance between oxygen supply and oxygen needs. A low hematocrit during cardiopulmonary bypass is associated with an increase risk of acute renal failure, mainly due to a low oxygen delivery. An inadequate oxygen delivery during cardiopulmonary bypass is associated with lactate production, and under normothermic conditions, hyperlactatemia appears for an oxygen delivery below 260 mL min(-1) m(-2). The risk of acute renal failure significantly increases for an oxygen delivery approximately at the same value (272 mL min(-1) m(- 2)). During cardiopulmonary bypass, the pump flow should be coupled with the hematocrit to avoid falling below this critical oxygen delivery.
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Affiliation(s)
- Marco Ranucci
- Department of Anestesia and Intensive Care, IRCCS Policlinico S. Donato, San Donato Milanese, Milan, Italy.
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Abstract
PURPOSE OF REVIEW Anemia is associated with increased morbidity and mortality, in community-dwelling persons, in critically ill patients and perioperatively. The exact reasons and extent of the risks induced by anemia are not known, however, nor the optimal therapeutic approach. Based on the assumption that transfusion invariably counteracts the risks associated with perioperative anemia, most studies do not exclude the confounding effects of transfusion, and anemia is inconsistently defined. Cardiovascular disease was identified as a major additional risk for anemic patients, but the combined effects of decreasing hemoglobin and comorbidities in patients with coronary stenoses have not been determined exactly. This review integrates recent data to present a more differentiated understanding of mechanisms and risks of anemia in coronary artery bypass grafting surgery. RECENT FINDINGS Patients with many comorbidities are more susceptible to the effects of anemia. Some outcomes may primarily be caused by concomitant risk factors associated with anemia rather than by low hemoglobin per se. The precise interactions of anemia and comorbidities to produce worse outcomes are still unclear, as is the optimal therapeutic approach. SUMMARY The review highlights recent developments on anemia in heart surgery, and advocates new studies to institute individually adapted therapies.
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Affiliation(s)
- Alexander Kulier
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Austria.
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