Ionic homeostasis, acid-base balance and the risk of citrate accumulation in patients after cardiovascular surgery treated with continuous veno-venous haemofiltration with post-dilution regional citrate anticoagulation - An observational case-control study

BACKGROUND

Patients after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation.

METHODS

This prospective observational case-control study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients treated with post-dilution CVVH with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients were evaluated. Base excess, pH, bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations, the total to ionized calcium ratio (tCa/iCa), and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors.

RESULTS

Thirty-three (66%) patients died. The therapies were very well balanced in sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions lasting longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 4.5% and was significantly higher in non-survivors (p=0.037). Initial lactate concentration did not correlate with tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors.

CONCLUSIONS

The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors. Supplementation with magnesium and phosphate ions is needed in CVVH with RCA.

Clinical, biochemical and genetic risk factors for 30-day and 5-year mortality in 518 adult patients subjected to cardiopulmonary bypass during cardiac surgery - the INFLACOR study

There is increasing evidence that genetic variability influences patients' early morbidity after cardiac surgery performed using cardiopulmonary bypass (CPB). The use of mortality as an outcome measure in cardiac surgical genetic association studies is rare. We publish the 30-day and 5-year survival analyses with focus on pre-, intra-, postoperative variables, biochemical parameters, and genetic variants in the INFLACOR (INFLAmmation in Cardiac OpeRations) cohort. In a prospectively recruited cohort of 518 adult Polish Caucasians, who underwent cardiac surgery in which CPB was used, the clinical data, biochemical parameters, IL-6, soluble ICAM-1, TNFα, soluble E-selectin, and 10 single nucleotide polymorphisms were evaluated for their association with 30-day and 5-year mortality. The 30-day mortality was associated with: pre-operative prothrombin international normalized ratio, intra-operative blood lactate, postoperative serum creatine phosphokinase, and acute kidney injury requiring renal replacement therapy (AKI-RRT) in logistic regression. Factors that determined the 5-year survival included: pre-operative NYHA class, history of peripheral artery disease and severe chronic obstructive pulmonary disease, intra-operative blood transfusion; and postoperative peripheral hypothermia, myocardial infarction, infection, and AKI-RRT in Cox regression. Serum levels of IL-6 and ICAM-1 measured three hours after the operation were associated with 30-day and 5-year mortality, respectively. The ICAM1 rs5498 was associated with 30-day and 5-year survival with borderline significance. Different risk factors determined the early (30-day) and late (5-year) survival after adult cardiac surgery in which cardiopulmonary bypass was used. Future genetic association studies in cardiac surgical patients should account for the identified chronic and perioperative risk factors.

Comparison of haemodynamics and myocardial injury markers under desflurane vs. propofol anaesthesia for off-pump coronary surgery. A prospective randomised trial

BACKGROUND

Several studies have highlighted that volatile anaesthetics improve myocardial protection in cardiopulmonary bypass coronary surgery. However, the haemodynamic effect of desflurane in off-pump coronary surgery has not been clarified yet. Our study hypothesis was that desflurane-fentanyl anaesthesia could decrease myocardial injury markers and improve haemodynamics compared to propofol-fentanyl in patients undergoing off-pump coronary surgery.

METHODS

DESIGN

Prospective, randomised open-lable study. Sixty elective patients with left ventricular ejection fraction above 30% received either desflurane (group D, n = 32) or propofol (group P, n = 28), in addition to fentanyl and vecuronium bromide anaesthesia for off-pump coronary surgery. Assessment of haemodynamic function included thermodilution continuous cardiac output and right ventricular end diastolic volume.

RESULTS

No significant differences in cardiac output, stroke volume and mean arterial pressure were noted between groups. The only observed difference in haemodynamic profile was that group D demonstrated improved stability, expressed as left ventricular stroke work index (LVSWI). Decrease in LVSWI after performing distal anastomoses was smaller in D compared to P (median value: -14.3 and -19.8 [g m m⁻² beat⁻¹]), respectively (P = 0.029). Oxygen uptake index (VO₂I) and oxygen extraction ratio (OER) after skin incision were lower in D, while blood lactate concentration was slightly higher after surgery in D compared to P. The groups did not differ with respect to CK-MB and troponin I concentration.

CONCLUSIONS

This study demonstrated no difference between desflurane and propofol anaesthesia for off-pump coronary surgery in major haemodynamic parameters, as well as in myocardial injury markers and the long-term outcome. However, the study indicated that desflurane might accelerate recovery of myocardial contractility, as assessed by LVSWI. Lower oxygen uptake and elevated lactate under desflurane anaesthesia indicated a discrete shift towards anaerobic metabolism.

CLINICAL TRIAL REGISTRATION INFORMATION

NCT00528515 (http://www.clinicaltrials.gov/ ct2/show/NCT00528515?term = NCT00528515&rank = 1).

Microscopic examination of bone marrow aspirate in healthy adults - comparison of two techniques of slide preparation

INTRODUCTION

According to the International Council for Standardization in Hematology (ICSH) guidelines for the standardization of bone marrow specimens and reports, smears from bone marrow aspirates for microscopic examination should be prepared using two techniques simultaneously: the wedge-spread and the crush technique. However, the outcomes of these techniques have never been compared.

METHODS

We investigated the bone marrow of 105 adult, haematologically healthy subjects, using bone marrow smears prepared via both techniques simultaneously.

RESULTS

Comparison of the two techniques revealed significant differences in terms of the composition of bone marrow cells. Only the percentages of lymphocytes, mature eosinophils and basophils did not differ significantly. The reference ranges for each technique were established.

CONCLUSIONS

The crush technique seems to be more valuable than the wedge-spread technique because of the lack of a blood dilution effect and better assessment of megakaryopoiesis. We recommend the crush technique for the evaluation of the percentage composition of bone marrow cells. In a very small number of patients with irregular cell localization in the bone marrow particles, the wedge-spread technique may be more beneficial for the assessment of total cellularity. The recommendation to routinely prepare slides using both of these techniques is fully justified.

Coagulation, coma, and outcome in bacterial meningitis--an observational study of 38 adult cases

OBJECTIVES

The purpose of this study was to evaluate the epidemiology of intravascular coagulation in bacterial meningitis and to recognise the associations with disease severity and outcome.

METHODS

Thirty-eight consecutively admitted adult patients with microbiologically proven bacterial meningitis were observed prospectively for platelets count (PLT), platelets-decline (dPLT), prothrombin ratio (PTr), INR, and D-dimer levels during the first three days in relation to disease severity (Glasgow Coma Scale--GCS, APACHE-III) and outcome (Glasgow Outcome Scale--GOS).

RESULTS

The prevalence of activated coagulation measured by abnormal laboratory results varied respectively: PTr--30%, INR--36%, PLT--38%, dPLT--50%, and D-dimer--88%. Patients with GCS <9 at admission presented with laboratory results suggesting triggered coagulation: dPLT 48 vs. 15%/day (p=0.0246), INR 1.6 vs. 1.12 (p=0.0014), PTr 76 vs. 93% (p=0.0020). An unfavourable outcome (GOS 1-4) was observed in 42% of patients and was associated with: PLT <170 or >265 G/L (OR--24.4; p=0.0006), PTr <82% (OR--5.00; p=0.0388), INR >1.1 (OR--5.04; 0.0336), and D-dimer >850 ng/ml (OR--24.0; p=0.0033).

CONCLUSIONS

Coagulation was activated in a majority of patients with bacterial meningitis and related to coma and unfavourable outcome.

[Occurrence of disseminated intravascular coagulation in purulent meningitis and influence on mortality in 118 patients]

Disseminated intravascular coagulation (DIC) is an important, but not satisfactory explained risk factor of death in purulent meningitis (PM).

OBJECTIVE

Evaluation of: 1) acute thrombocytopenia (ATP) in patients with PM, 2) dynamics in changes of peripheral blood platelet (PLT) count and serum coagulation factors, 3) correlation between acute DIC and mortality in PM.

METHODS

Analysis ofATP (platelets < or = 150 K/microL and/or decrease in PLT > or = 100 K/microL/24 hours) and prothrombin ratio, fibrinogen, d-dimmer and antithrombin III in survivors and nonsurvivors in 118 adult patients with PM. 37 further patients have been disclosed because of non-bacterial PM or chronic conditions predisposing to ATP or DIC.

MAIN OBSERVATIONS

DIC defined as ATP occurred in 56 %, defined as elevated d-dimmer level in 72%. 16 (14%) patients died.

RESULTS

Mortality correlated significantly with the lowest PLT count on first 3. days (p=0,049) and with PLT decline (p=0,015). Differences in survivors/nonsurvivors were observed in: ATP on 1. day 48% vs. 75% (p<0,05), daily PLT decline 9%/day vs. 32%/day (p<0,05), prothrombin ratio 89% vs. 74% (p<0,05) and INR 1,2 vs. 1,7 (p<0,005).

CONCLUSION

DIC is an important risk factor in PM. Aggravated DIC do correlate significantly with higher risk of death.

[Influence of intravascular coagulation on brain injury and clinical course in purulent meningitis]

Purulent meningitis (PM), depending on etiology, is associated by up to 30-40 % risk of severe neurological complications and death. Neuronal death occurs frequently as a result of toxin-induced apoptosis and hypoxia. Hypoxia is the result of cerebral edema and hypoperfusion. The former being the reason for, the later the result of elevation of intracranial pressure. Hypoperfusion additionally results from loss of autoregulation of cerebral perfusion and disseminated intravascular coagulation (DIC), causing thrombosis. Spare works in human-beings announce a frequency of DIC of ca 40% in PM. The influence of DIC on prognosis remains unsatisfactory explained. Uncommon are also reports on use of anticoagulants, most often heparins, in PM, but they indicate a possible benefit. It is necessary to conduct epidemiological studies evaluating and staging DIC in patients with PM as well as multivariate analysis to determine its influence on outcome. Drugs of anticoagulant action should be considered for improvement the efficacy of supportive therapy, because this could be of benefit for outcome in PM.