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1.
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.
Kośka, A, Kowalik, MM, Lango-Maziarz, A, Karolak, W, Jagielak, D, Lango, R
Acta biochimica Polonica. 2021;(4):695-704
Abstract
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.
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2.
Comparison of enteral versus intravenous potassium supplementation in hypokalaemia in paediatric patients in intensive care post cardiac surgery: open-label randomised equivalence trial (EIPS).
Rehman Siddiqu, NU, Merchant, Q, Hasan, BS, Rizvi, A, Amanullah, M, Rehmat, A, Ul Haq, A
BMJ open. 2017;(5):e011179
Abstract
OBJECTIVES The primary objective was to compare the efficacy of enteral potassium replacement (EPR) and intravenous potassium replacement (IVPR) as first-line therapy. Secondary objectives included comparison of adverse effects and number of doses required to resolve the episode of hypokalaemia. TRIAL DESIGN The EIPS trial is designed as a randomised, equivalence trial between two treatment arms. STUDY SETTING The study was conducted at the paediatric cardiac intensive care unit (PCICU) at Aga Khan University Hospital, Karachi. PARTICIPANTS 41 patients (aged 1 month to 15 years) who were admitted to PCICU post cardiac surgery were recruited (23 IVPR arm and 18 EPR arm). INTERVENTION Intervention arms were block randomised on alternate weeks for IVPR and EPR. OUTCOME MEASURE Change in serum potassium levels in (mmol/L) and percentage change after each event of potassium replacement by the intravenous or enteral route. RESULTS Both groups (41 patients) had similar baseline characteristics. Mean age was 4.7 (SD±4) years while the most common surgical procedure was ventricular septal defect repair (12 patients, 29.3%). No mortality was observed in either arm. Four episodes of vomiting and one arrhythmia were seen in the EPR group. After adjusting for age, potassium level at the beginning of the episode, average urine output, inotropic score and diuretic dose, it was found that there was no statistically significant difference in change in potassium levels after EPR and IVPR 0.86 mmol/L (±0.8) and 0.82 mmol/L (±0.7) respectively (p=0.86, 95% CI -0.08 to 1.10), or percentage change in potassium level after enteral and intravenous replacement: 26% (±30) and 24% (±20) (95% CI -3.42 to 4.03, p=0.87). CONCLUSION EPR may be an equally efficacious alternative first-line therapy in treating hypokalaemia after surgery in selective patients with congenital heart disease. ETHICS AND DISSEMINATION This study has been approved by Ethics Review Committee at AKU. TRIAL REGISTRATION NUMBER NCT02015962.
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3.
Metabotyping Patients' Journeys Reveals Early Predisposition to Lung Injury after Cardiac Surgery.
Maltesen, RG, Rasmussen, BS, Pedersen, S, Hanifa, MA, Kucheryavskiy, S, Kristensen, SR, Wimmer, R
Scientific reports. 2017;:40275
Abstract
Cardiovascular disease is the leading cause of death worldwide and patients with severe symptoms undergo cardiac surgery. Even after uncomplicated surgeries, some patients experience postoperative complications such as lung injury. We hypothesized that the procedure elicits metabolic activity that can be related to the disease progression, which is commonly observed two-three days postoperatively. More than 700 blood samples were collected from 50 patients at nine time points pre-, intra-, and postoperatively. Dramatic metabolite shifts were observed during and immediately after the intervention. Prolonged surgical stress was linked to an augmented anaerobic environment. Time series analysis showed shifts in purine-, nicotinic acid-, tyrosine-, hyaluronic acid-, ketone-, fatty acid, and lipid metabolism. A characteristic 'metabolic biosignature' was identified correlating with the risk of developing postoperative complications two days before the first clinical signs of lung injury. Hence, this study demonstrates the link between intra- and postoperative time-dependent metabolite changes and later postoperative outcome. In addition, the results indicate that metabotyping patients' journeys early, during or just after the end of surgery, may have potential impact in hospitals for the early diagnosis of postoperative lung injury, and for the monitoring of therapeutics targeting disease progression.
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4.
The Feasibility of a Completely Automated Total IV Anesthesia Drug Delivery System for Cardiac Surgery.
Zaouter, C, Hemmerling, TM, Lanchon, R, Valoti, E, Remy, A, Leuillet, S, Ouattara, A
Anesthesia and analgesia. 2016;(4):885-93
Abstract
BACKGROUND In this pilot study, we tested a novel automatic anesthesia system for closed-loop administration of IV anesthesia drugs for cardiac surgical procedures with cardiopulmonary bypass. This anesthesia drug delivery robot integrates all 3 components of general anesthesia: hypnosis, analgesia, and muscle relaxation. METHODS Twenty patients scheduled for elective cardiac surgery with cardiopulmonary bypass were enrolled. Propofol, remifentanil, and rocuronium were administered using closed-loop feedback control. The main objective was the feasibility of closed-loop anesthesia defined as successful automated cardiac anesthesia without manual override by the attending anesthesiologist. Secondary qualitative observations were clinical and controller performances. The clinical performance of hypnosis control was the efficacy to maintain a bispectral index (BIS) of 45. To evaluate the hypnosis performance, BIS values were stratified into 4 categories: "excellent," "good," "poor," and "inadequate" hypnosis control defined as BIS values within 10%, ranging from 11% to 20%, ranging from 21% to 30%, or >30% of the target value, respectively. The clinical performance of analgesia was the efficacy to maintain NociMap values close to 0. The analgesia performance was assessed classifying the NociMap values in 3 pain control groups: -33 to +33 representing excellent pain control, -34 to -66 and +34 to +66 representing good pain control, and -67 to -100 and +67 to +100 representing insufficient pain control. The controller performance was calculated using the Varvel parameters. RESULTS Robotic anesthesia was successful in 16 patients, which is equivalent to 80% (97.5% confidence interval [CI], 53%-95%) of the patients undergoing cardiac surgery. Four patients were excluded from the final analysis because of technical problems with the automated anesthesia delivery system. The secondary qualitative observations revealed that the clinical performance of hypnosis allowed an excellent and good control during 70% (97.5% CI, 63%-76%) of maintenance time and an insufficient clinical performance of analgesia for only 3% (97.5% CI, 1%-6%) of maintenance time. CONCLUSIONS The completely automated closed-loop system tested in this investigation could be used successfully and safely for cardiac surgery necessitating cardiopulmonary bypass. The results of the present trial showed satisfactory clinical performance of anesthesia control.
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5.
Adjunctive surgical atrial fibrillation ablation during cardiac surgery: real life experiences.
Tischer, TS, Schneider, R, Lauschke, J, Nesselmann, C, Steinhoff, G, Bänsch, D
Herzschrittmachertherapie & Elektrophysiologie. 2015;(3):291-6
Abstract
AIM: Several tools have been invented for surgical atrial fibrillation (AF) ablation. In this study, we investigated the real world efficacy of intraoperative AF ablation (AFA) with radiofrequency-energy or cryo-ablation and performed an electro-anatomical remap in some patients with recurrences. METHODS Seventy-three consecutive patients (53 male, median age of 69 ± 7 years) with history of AF underwent cardiac surgery for valve repair (74 % mitral defects, 60 % aortic defects) and/or coronary artery bypass graft procedures (56 %). During a follow-up of 23 ± 11 months after AFA we performed intensified holter-monitoring (4-7 days). Patients with symptomatic relapse of atrial arrhythmias (AA) were offered the opportunity for additional electrophysiological examination (EPE). RESULTS During 23 ± 11 months after AFA, 45 patients (62 %) had recurrent AA. In eight patients we performed EPE. In all 8 cases, septal circumferential lesions could be demonstrated during mapping with discrete gaps. All lateral veins were isolated however, posteriorly deep inside the vein leaving the antral region completely untreated. Neither roof lines nor mitral isthmus lines were complete. Performing catheter ablation, all veins could be isolated and seven patients were free of any arrhythmias during follow up (9 ± 5 months) without taking antiarrhythmic drugs. CONCLUSION Surgical AF ablation may often be incomplete rendering sobering results in unselected patients. Completion of the ablation is feasible with catheter ablation with good clinical outcome.
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6.
Predictors associated with an efficient health information management in patients with cardiac surgery.
Lee, SR
Technology and health care : official journal of the European Society for Engineering and Medicine. 2014;(3):317-23
Abstract
Because of the increasing number of cardiac patients all over the world, the importance of cardiac disease prevention is increasing. This study was attempted to identify the predictors associated with an efficient health information patients in two general hospitals located in Seoul from May 13 to June 13, 2012. The results were as follows: First, analysis of the percentage of nutrient intake in terms of meal pattern showed that the response rate of 47.9% in the case group at vegetable intake of 2 or 3 times per week was significantly higher than the response rate of 47.1% in the control group (X^{2}=9.08, p< 0.05), Second, the multiple logistic regression analysis revealed that efficiency of a health information management was significantly associated with female (OR=3.24, 95% Cl: 1.93-6.84), the subjects having abdominal obesity (OR=2.29, 95% Cl: 1.15-3.60). Therefore, the proposed framework will be helpful for health information system developers.
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7.
Sodium bicarbonate infusion to reduce cardiac surgery-associated acute kidney injury: a phase II multicenter double-blind randomized controlled trial.
McGuinness, SP, Parke, RL, Bellomo, R, Van Haren, FM, Bailey, M
Critical care medicine. 2013;(7):1599-607
Abstract
OBJECTIVES Cardiac surgery-associated acute kidney injury occurs in up to 50% of patients and is associated with increased mortality and morbidity. This study aimed to discover if perioperative urinary alkalinization with sodium bicarbonate infusion reduces the prevalence of cardiac surgery-associated acute kidney injury. DESIGN This study was a phase IIb multicenter double-blind randomized controlled trial. SETTING This study was conducted in three tertiary hospitals in New Zealand and Australia. PATIENTS A total of 427 patients scheduled to undergo elective cardiac surgery, who were at increased risk of development of cardiac surgery-associated acute kidney injury using recognized risk factors. MEASUREMENTS AND MAIN RESULTS Patients were randomly allocated to receive either sodium bicarbonate (n = 215) or sodium chloride (n = 212) infusion, commencing at the start of anesthesia, in a dose of 0.5 mEq/kg/hr for the first hour and then 0.2 mmol/kg/hr for 23 hours. The primary outcome measure was the number of patients with development of cardiac surgery-associated acute kidney injury, defined as an increase in creatinine greater than 25% or 0.5 mg/dL (44 µmol/L) from baseline to peak value within the first five postoperative days. Significant differences among the groups in both plasma and urinary biochemistry were achieved 6 hours after commencement of the infusion, and these changes persisted for more than 24 hours. A total of 100 out of 215 patients (47% [95% CI, 40%-53%]) in the sodium bicarbonate group and 93 of 212 patients (44% [95% CI, 37%-51%]) in the sodium chloride group with development of acute kidney injury within the first five postoperative days (p = 0.58). There were also no significant differences in ventilation hours, ICU or hospital length of stay, or mortality. CONCLUSIONS Perioperative alkalinization of blood and urine using an infusion of sodium bicarbonate did not result in a decrease in the prevalence of acute kidney injury in patients following cardiac surgery.
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8.
Preoperative statin treatment reduces systemic inflammatory response and myocardial damage in cardiac surgery.
Martínez-Comendador, JM, Alvarez, JR, Mosquera, I, Sierra, J, Adrio, B, Carro, JG, Fernández, A, Bengochea, J
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2009;(6):998-1005
Abstract
OBJECTIVE To determine if preoperative statin treatment is associated with a reduction in systemic inflammatory response (SIR) and myocardial damage markers following cardiac surgery with cardiopulmonary bypass (CPB). METHODS We study a prospective cohort of 138 patients who underwent coronary and valvular surgery with CPB. We differentiate two study groups: patients with (group A, n=72) or without (group B, n=66) statins. Plasma levels of pro-inflammatory interleukins (tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8 and IL-2R), creatine phosphokinase (CPK), CPK-MB and troponin I were measured before and 1, 6, 24 and >72 h after surgery. RESULTS The baseline, operative and postoperative morbidity and mortality characteristics were similar for both the groups. Group A had significantly lower postoperative levels of IL-6 than group B at 6h (68.8+/-5 pg ml(-1) vs 108.9+/-108 pg ml(-1), p=0.01), 24h (71.7+/-7 pg ml(-1) vs 110.4+/-106 pg ml(-1), p=0.01) and before hospital discharge (21.6+/-12 pg ml(-1) vs 32.8+/-27 pg ml(-1), p=0.005), as well as significantly lower average IL-6 levels in the first 24h following surgery (71.8+/-5 pgml(-1) vs 112.8+/-82 pg ml(-1), p=0.002). The postoperative CPK-MB at 24h (19.7+/-23 ng ml(-1) vs 33.1+/-32 ng ml(-1), p=0.02) and troponin I levels at the end of the intervention (2.2+/-2.2 ng ml(-1) vs 3.3+/-3.1 ng ml(-1), p=0.03) and at 24h (4.1+/-3.5 ng ml(-1) vs 6.6+/-8 ng ml(-1), p=0.04) were also significantly lower in the group treated with statins prior to surgery. CONCLUSIONS Preoperative treatment with statins is associated with a lower biochemical parameters of SIR and myocardial damage following cardiac surgery with CPB, regardless of it being coronary bypass grafting (CABG) or valvular surgery.
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9.
Phase II, randomized, controlled trial of high-dose N-acetylcysteine in high-risk cardiac surgery patients.
Haase, M, Haase-Fielitz, A, Bagshaw, SM, Reade, MC, Morgera, S, Seevenayagam, S, Matalanis, G, Buxton, B, Doolan, L, Bellomo, R
Critical care medicine. 2007;(5):1324-31
Abstract
OBJECTIVE To assess the effect of high-dose N-acetylcysteine on renal function in cardiac surgery patients at higher risk of postoperative renal failure. DESIGN Multiblind, placebo-controlled, randomized, phase II clinical trial. SETTING Operating rooms and intensive care units of two tertiary referral hospitals. PATIENTS A total of 60 cardiac surgery patients at higher risk of postoperative renal failure. INTERVENTIONS Patients were allocated to either 24 hrs of high-dose N-acetylcysteine infusion (300 mg/kg body weight in 5% glucose, 1.7 L) or placebo (5% glucose, 1.7 L). MEASUREMENTS AND MAIN RESULTS The primary outcome measure was the absolute change in serum creatinine from baseline to peak value within the first five postoperative days. Secondary outcomes included the relative change in serum creatinine, peak serum creatinine level, serum cystatin C, and in urinary output. Further outcomes were needed for renal replacement therapy, length of ventilation, and length of stay in the intensive care unit and hospital. Randomization was successful and patients were well balanced for preoperative and intraoperative characteristics. There was no significant attenuation in the increase in serum creatinine from baseline to peak when comparing N-acetylcysteine with placebo (64.5 +/- 91.2 and 38.0 +/- 42.4 mumol/L, respectively; p = .15). Also, there was no attenuation in the increase in serum cystatin C from baseline to peak for N-acetylcysteine compared with placebo (0.45 +/- 0.43 and 0.30 +/- 0.33 mg/L, respectively; p = .40). Likewise, there was no evidence for differences in any other clinical outcome. CONCLUSIONS In this phase II, randomized, controlled trial, high-dose N-acetylcysteine was no more effective than placebo in attenuating cardiopulmonary bypass-related acute renal failure in high-risk cardiac surgery patients.
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10.
The efficacy of preoperative administration of a single dose of recombinant human erythropoietin in pediatric cardiac surgery.
Ootaki, Y, Yamaguchi, M, Yoshimura, N, Oka, S, Yoshida, M, Hasegawa, T
The heart surgery forum. 2007;(2):E115-9
Abstract
BACKGROUND Preoperative autologous blood donation with recombinant human erythropoietin (rHuEPO) is effective in adults. However, there are problems concerning the blood access, cost, and blood storage in children. The purpose of this study was to evaluate the efficacy of administering a single dose of rHuEPO without blood donation in children undergoing pediatric cardiac surgery. METHODS Eighty-two children (72 with noncyanotic heart disease, and 10 with cyanotic heart disease) whose hematocrit values were less than 45% were included in this prospective, nonrandomized study. The children were divided into 3 groups: group E0 (n = 20) was not treated with rHuEPO and iron sulfate; group E2 (n = 27) was treated with 200 IU/kg of rHuEPO and 2 mg/kg of iron sulfate; and group E4 (n = 35) was treated with 400 IU/kg of rHuEPO and 4 mg/kg of iron sulfate. Administration of rHuEPO was performed subcutaneously 7 days before the operation. The hematological and iron parameters were measured perioperatively. RESULTS A lower proportion of children treated with rHuEPO (group E2, 14.8%; group E4, 22.9%) than children without rHuEPO (group E0, 40.0%) were exposed to RBC transfusions; however, there was no significance. The elevations of the hematocrit levels were 0.7% in group E0, 1.3% in group E2, and 1.9% in group E4. The elevation of the hematocrit was greater in patients with anemia (hematocrit < or =37%). CONCLUSIONS Although the effectiveness for avoiding transfusion was not clear, the administration of a single dose of rHuEPO without autologous blood donations had an effect by increasing hematocrit levels.