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Zero-Balance Ultrafiltration of Priming Blood Attenuates Procalcitonin and Improves the Respiratory Function in Infants After Cardiopulmonary Bypass: A Randomized Controlled Trial.
Gholampour Dehaki, M, Niknam, S, Azarfarin, R, Bakhshandeh, H, Mahdavi, M
Artificial organs. 2019;(2):167-172
Abstract
Blood priming is needed for cardiopulmonary bypass (CPB) in neonates and infants to avoid exceeding hemodilution; however, transfusion-related inflammation affects post-CPB outcomes in infant open-heart surgery. Procalcitonin, a newly detected inflammatory moderator and a sensitive parameter for predicting pulmonary dysfunction secondary to CPB, rises after CPB. We hypothesized that the hemofiltration of priming blood before CPB might decrease inflammatory mediators in the blood and post-CPB inflammatory replications, thereby improving the respiratory function after CPB in infants. Sixty infants with a weight below 10 kg were divided randomly into two equal groups of CPB with the zero-balance ultrafiltration (Z-BUF) of priming blood and CPB without it. The procalcitonin level was measured before anesthesia, after admission to the intensive care unit (ICU), and 24 h afterward. The respiratory index and pulmonary compliance were measured after anesthesia, at the end of CPB, and 2 h after admission to the ICU. Additionally, time to extubation was recorded. The Z-BUF of priming blood maintained electrolytes within a physiologic level, and procalcitonin had a slighter rise in the Z-BUF Group at 24 h after admission to the ICU (P = 0.05). The respiratory index was decreased in the Z-BUF Group, but the difference with the control group did not reach statistical significance (P > 0.05). The change in pulmonary compliance was significantly increased in the cyanotic patients in the intervention group, but there was no significant difference between the two groups. The time to extubation and the ICU stay were shorter in the Z-BUF Group (P < 0.05). A positive correlation was found between the peak procalcitonin concentration and the time to extubation directly and pulmonary compliance reversely. These results suggest that the Z-BUF of priming blood may have some beneficial clinical effects such as improved respiratory function and attenuated procalcitonin.
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Perioperative Vitamin C and E levels in Cardiac Surgery Patients and Their Clinical Significance.
Hill, A, Borgs, C, Fitzner, C, Stoppe, C
Nutrients. 2019;(9)
Abstract
BACKGROUND Oxidative stress contributes to organ dysfunction after cardiac surgery and still represents a major problem. Antioxidants, such as vitamins C and E might be organ protective. METHODS The primary objective of this prospective observational study was the description to evaluate the perioperative vitamin C and E levels in 56 patients undergoing cardiac surgery with the use of cardiopulmonary bypass. The association of vitamin C with inflammatory reaction, oxidative stress, organ dysfunctions, and clinical outcomes were evaluated in an explorative approach. RESULTS Vitamin C levels decreased significantly from 6.5 (3.5-11.5) mg/L before surgery to 2.8 (2.0-3.9) mg/L 48 h after surgery (p < 0.0001). Fifty-six percent of patients had a suboptimal vitamin C status even before surgery. In protein-denaturized probes, significantly higher vitamin C concentrations were detected (p = 0.0008). Vitamin E levels decreased significantly from preoperative level 11.6 (9.5-13.2) mg/L to 7.1 (5.5-7.4) mg/L, (p = 0.0002) at the end of cardiopulmonary bypass, remained low during the first day on ICU and recovered to 8.2 (7.1-9.3) mg/L 48 h after surgery. No patient was vitamin E deficient before surgery. Analysis showed no statistically significant association of vitamin C with inflammation, oxidative stress or organ dysfunction levels in patients with previously suboptimal vitamin C status or patients with a perioperative decrease of ≥50% vitamin C after surgery. Patients with higher vitamin C levels had a shorter ICU stay than those who were vitamin C depleted, which was not statistically significant (72 versus 135 h, p = 0.1990). CONCLUSION Vitamin C and E levels significantly declined intraoperatively and remained significantly reduced low for 2 days after cardiac surgery. The influence of reduced serum levels on the inflammatory reaction and clinical outcome of the patients remain unclear in this small observational study and need to be investigated further. Given vitamin C´s pleiotropic role in the human defense mechanisms, further trials are encouraged to evaluate the clinical significance of Vitamin C in cardiac surgery patients.
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Pharmacological and non-surgical renal protective strategies for cardiac surgery patients undergoing cardiopulmonary bypass: a systematic review.
Tan, SI, Brewster, DJ, Horrigan, D, Sarode, V
ANZ journal of surgery. 2019;(4):296-302
Abstract
BACKGROUND Post-operative acute kidney injury after cardiopulmonary bypass (AKI-CPB) for cardiac surgery is a frequent complication. It may require renal replacement therapy (RRT), which is associated with an increased morbidity and mortality. This review explores the efficacy of proposed pharmacological and non-surgical renal protective strategies. METHODS A comprehensive literature search was done using Ovid MEDLINE, Embase and Scopus databases. Keywords included were cardiopulmonary bypass, cardiac surgery, coronary artery bypass, renal protection and renal preservation. Eligible articles consisted of all studies on patients who had undergone cardiac surgery via CPB with an outcome of AKI and/or RRT reported. All studies underwent a quality check via the risk of bias tool. The three most researched interventions (based on number of randomized controlled trials and total patients analysed) and their renal outcomes were then analysed with Review Manager Software. RESULTS Eighty-eight articles were extracted. A total of 26 management strategies for renal protection following CPB were identified. N-acetylcysteine (NAC), remote ischaemic preconditioning (RIPC) and the use of volatile anaesthetic agents (VAAs) were further analysed. NAC, RIPC and VAA had no statistically significant benefit in reducing either AKI-CPB or the need for RRT following CPB. CONCLUSION NAC, RIPC and VAA were found to have no statistical significant benefit in reducing either AKI-CPB or the need for RRT following CPB. There remains clinical uncertainty with all currently proposed pharmacological and non-surgical renal protective strategies for CPB. Future research in this area should analyse the effects of combined interventions or specifically focus on 'at-risk' patients.
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Early intraoperative iron-binding proteins are associated with acute kidney injury after cardiac surgery.
Choi, N, Whitlock, R, Klassen, J, Zappitelli, M, Arora, RC, Rigatto, C, Ho, J
The Journal of thoracic and cardiovascular surgery. 2019;(1):287-297.e2
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OBJECTIVES Iron regulation is an important modifier of renal ischemia-reperfusion injury, but the role of iron-binding proteins during cardiopulmonary bypass remains unclear. The goal was to characterize iron-binding proteins throughout ischemia-reperfusion injury to determine their association with acute kidney injury development. METHODS A prospective observational cohort of adult patients who underwent cardiac surgery (n = 301) was obtained, and acute kidney injury was defined by Kidney Disease Improving Global Outcomes. Serum ferritin, transferrin saturation, and urine hepcidin-25 were measured. RESULTS Intraoperative serum ferritin was lower at the start of cardiopulmonary bypass (P = .005) and 1-hour cardiopulmonary bypass (P = .001) in patients with acute kidney injury versus patients without acute kidney injury. Lower serum ferritin and higher transferrin saturation at 1-hour cardiopulmonary bypass were independent predictors of acute kidney injury (serum ferritin odds ratio, 0.66; 95% confidence interval [CI], 0.48-0.91; transferrin saturation odds ratio, 1.26; 95% CI, 1.02-1.55) and improved model discrimination (area under the curve [AUC], 0.76; 95% CI, 0.67-0.85) compared with clinical prediction alone (AUC, 0.72; 95% CI, 0.62-0.81; ΔAUC and net reclassification index, P = .01). Lower ferritin, higher transferrin saturation at 1-hour cardiopulmonary bypass, and lower urine hepcidin-25 at postoperative day 1 were also independent predictors for acute kidney injury development, and this model demonstrated an AUC of 0.80 (0.72-0.87), which was superior to clinical prediction (ΔAUC P = .002, integrated discrimination improvement and net reclassification index P = .003). CONCLUSIONS Our findings suggest that lower levels of intraoperative iron-binding proteins may reflect an impaired capacity to rapidly handle catalytic iron released during cardiopulmonary bypass, leading to kidney injury. These data highlight the importance of iron homeostasis in human ischemia-reperfusion injury and suggest it is a potentially modifiable risk during cardiac surgery. Intraoperative detection of incipient acute kidney injury may be feasible and could be used as an enrichment strategy for clinical trials.
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Nitric oxide provides myocardial protection when added to the cardiopulmonary bypass circuit during cardiac surgery: Randomized trial.
Kamenshchikov, NO, Mandel, IA, Podoksenov, YK, Svirko, YS, Lomivorotov, VV, Mikheev, SL, Kozlov, BN, Shipulin, VM, Nenakhova, AA, Anfinogenova, YJ
The Journal of thoracic and cardiovascular surgery. 2019;(6):2328-2336.e1
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OBJECTIVES The aim of this pilot study was to elucidate the effects of exogenous nitric oxide (NO) supply to the extracorporeal circulation circuit for cardioprotection against ischemia-reperfusion injury during coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). METHODS A total of 60 patients with coronary artery disease scheduled for CABG with CPB were enrolled in a prospective randomized study. Patients were allocated randomly to receive treatment according to standard or modified CPB protocol where 40-ppm NO was added to the CPB circuit during cardiac surgery. The primary endpoint was the measurement of cardiac troponin I (cTnI). The secondary end points consisted in the measurements of creatine kinase-muscle/brain fraction (CK-MB) and vasoactive inotropic score (VIS). RESULTS NO delivered into the CPB circuit had a cardioprotective effect. The level of cTnI was significantly lower in NO-treated group compared with the control group 6 hours after surgery: 1.79 ± 0.39 ng/mL versus 2.41 ± 0.55 ng/mL, respectively (P = .001). The CK-MB value was significantly lower in NO-treated group compared with the control group 24 hours after surgery: 47.69 ± 8.08 U/L versus 62.25 ± 9.78 U/L, respectively (P = .001); and the VIS was significantly lower in the NO-treated group 6 hours after the intervention. CONCLUSIONS NO supply to the CPB circuit during CABG exerted a cardioprotective effect and was associated with lower levels of VIS and cardiospecific blood markers cTnI and CK-MB.
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Impact of Cardiopulmonary Bypass Flow on Renal Oxygenation in Patients Undergoing Cardiac Operations.
Lannemyr, L, Bragadottir, G, Hjärpe, A, Redfors, B, Ricksten, SE
The Annals of thoracic surgery. 2019;(2):505-511
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with acute kidney injury, and the risk increases with low oxygen delivery during CPB. We hypothesized that renal oxygenation could be improved at higher than normal CPB flow rates. METHODS After ethical approval and informed consent, 17 patients with normal serum creatinine undergoing normothermic CPB were included and received pulmonary artery and renal vein catheters after anesthesia induction for measurements of systemic and renal variables. Renal oxygen extraction, a direct measure of the renal oxygen delivery/renal oxygen consumption ratio, and renal filtration fraction were measured, the latter by renal extraction of 51chromium-ethylenediaminetetraacetic acid. After start of CPB and aortic cross-clamp, the pump flow rate was randomly varied between 2.4, 2.7, and 3.0 L · min-1 · m-2, and measurements were made after 10 minutes at each flow rate. RESULTS Renal oxygen extraction increased by 30% at a flow rate of 2.4 L · min-1 · m-2 versus pre-CPB (p < 0.05). At a flow rate of 2.7 and 3.0 L · min-1 · m-2, Renal oxygen extraction was 12% (p < 0.05) and 23% (p < 0.01) lower, respectively, compared with 2.4 L · min-1 · m-2. This corresponds to a 14% and 30% improvement, respectively, of the renal oxygen supply/demand relationship. Filtration fraction was not affected by changes in flow rate, indicating that the glomerular filtration rate increased in proportion to the increase in renal perfusion. CONCLUSIONS The impaired renal oxygenation seen during CPB is ameliorated by an increase in CPB flow rate. Thus, one way to protect the kidneys during CPB could be to use a higher flow rate than the one traditionally used.
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The use of mannitol in cardiopulmonary bypass prime solution-Prospective randomized double-blind clinical trial.
Ljunggren, M, Sköld, A, Dardashti, A, Hyllén, S
Acta anaesthesiologica Scandinavica. 2019;(10):1298-1305
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BACKGROUND The optimal prime solution for the cardiopulmonary bypass (CPB) circuit in adult cardiac surgery has not yet been defined. Mannitol is widely used in the priming solution for CPB despite the fact that there is no clear consensus on the role of mannitol in cardiac surgery. The aim of this study was to investigate the effect of mannitol in the CPB prime solution. METHODS This prospective, randomized, double-blind study included 40 patients with normal cardiac and renal functions, who underwent coronary artery bypass grafting. One group received a prime based on Ringer's acetate (n = 20), and the other a prime consisting of Ringer's acetate with 200 mL mannitol (n = 20). Changes in osmolality, acid-base status, electrolytes, and renal-related parameters were monitored. RESULTS No significant differences were found in osmolality between the Ringer's acetate group and the mannitol group at any time. The mannitol group showed a pronounced decrease in sodium, from 138.7 ± 2.8 mmol/L at anaesthesia onset, to 133.9 ± 2.6 mmol/L after the start of CPB (P < .001). No differences were seen in the renal parameters between the groups, apart from a short-term effect of mannitol on peroperative urine production (P = .003). CONCLUSION We observed no effects on osmolality of a prime solution containing mannitol compared to Ringer's acetate-based prime in patients with normal cardiac and renal function. The use of mannitol in the prime resulted in a short-term, significant decrease in sodium level.
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Zero balance ultrafiltration using dialysate during nationwide bicarbonate shortage: a retrospective analysis.
Mullane, R, Fristoe, L, Markin, NW, Brakke, TR, Merritt-Genore, HM, Siddique, A, Miles, CD, Plumb, TJ
Journal of cardiothoracic surgery. 2019;(1):163
Abstract
BACKGROUND Zero balance ultrafiltration (Z-BUF) utilizing injectable 8.4% sodium bicarbonate is utilized to treat hyperkalemia and metabolic acidosis associated with cardiopulmonary bypass (CPB). The nationwide shortage of injectable 8.4% sodium bicarbonate in 2017 created a predicament for the care of cardiac surgery patients. Given the uncertainty of availability of sodium bicarbonate solutions, our center pro-actively sought a solution to the sodium bicarbonate shortage by performing Z-BUF with dialysate (Z-BUF-D) replacement fluid for patients undergoing cardiopulmonary bypass. METHODS Single-center, retrospective observational evaluation of the first 46 patients at an academic medical center who underwent Z-BUF using dialysate over a period of 150 days with comparison of these findings to a historical group of 39 patients who underwent Z-BUF with sodium chloride (Z-BUF-S) over the preceding 150 days. The primary outcome was the change in whole blood potassium levels pre- and post-Z-BUF-D. Secondary outcomes included changes in pre- and post-Z-BUF-D serum bicarbonate levels and the amount of serum bicarbonate used in each Z-BUF cohort (Z-BUF-D and Z-BUF-S). RESULTS Z-BUF-D and Z-BUF-S both significantly reduced potassium levels during CPB. However, Z-BUF-D resulted in a significantly decreased need for supplemental 8.4% sodium bicarbonate administration during CPB (52 mEq ± 48 vs. 159 mEq ± 85, P < 0.01). There were no complications directly attributed to the Z-BUF procedure. CONCLUSION Z-BUF with dialysate appears to be analternative to Z-BUF with sodium chloride with marked lower utilization of intravenous sodium bicarbonate.
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Factors associated with postoperative atrial fibrillation and other adverse events after cardiac surgery.
Akintoye, E, Sellke, F, Marchioli, R, Tavazzi, L, Mozaffarian, D
The Journal of thoracic and cardiovascular surgery. 2018;(1):242-251.e10
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OBJECTIVE The study objective was to evaluate the impact of various surgical characteristics and practices on the risk of postoperative atrial fibrillation and other adverse outcomes after cardiac surgery. METHODS By using the prospectively collected data of patients who underwent cardiac surgery in 28 centers across the United States, Italy, and Argentina, the details of surgery characteristics were collected for each patient and the outcomes, including postoperative atrial fibrillation, major adverse cardiovascular events, and mortality. These were evaluated via multivariable-adjusted models. RESULTS In 1462 patients, a total of 460 cases of postoperative atrial fibrillation, 33 major adverse cardiovascular events, 23 cases of 30-day mortality, and 46 cases of 1-year mortality occurred. We found that type of surgery and cardiopulmonary bypass use predicted the occurrence of postoperative atrial fibrillation. Compared with coronary artery bypass grafting alone, there was a higher risk of postoperative atrial fibrillation with valvular surgery alone (odds ratio, 1.4; 95% confidence interval, 1.1-1.9), and the risk was even higher with concomitant valvular and coronary artery bypass grafting surgery (odds ratio, 1.8; 95% confidence interval, 1.2-2.7). Compared with no bypass, use of cardiopulmonary bypass was associated with higher risk of postoperative atrial fibrillation (odds ratio, 2.4; 95% confidence interval, 1.7-3.5), but there were significant age and sex differences of the impact of bypass use among patients undergoing coronary artery bypass grafting (P for interaction = .04). In addition, compared with spontaneous return of rhythm, ventricular pacing was associated with a higher risk of major adverse cardiovascular events (odds ratio, 5.0; 95% confidence interval, 1.4-18), whereas concomitant coronary artery bypass grafting and valvular surgery was associated with a higher risk of 30-day mortality (hazard ratio, 4.3; 95% confidence interval, 1.2-14) compared with coronary artery bypass grafting alone. Occurrence of postoperative atrial fibrillation was associated with greater length of stay and 1-year mortality (hazard ratio, 2.2; 95% confidence interval, 1.2-3.9). CONCLUSIONS In this multicenter trial, we identified specific adverse outcomes that are associated with concomitant valvular and coronary artery bypass graft surgery, cardiopulmonary bypass, ventricular pacing, and occurrence of postoperative atrial fibrillation.
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Cerebral Small Vessel, But Not Large Vessel Disease, Is Associated With Impaired Cerebral Autoregulation During Cardiopulmonary Bypass: A Retrospective Cohort Study.
Nomura, Y, Faegle, R, Hori, D, Al-Qamari, A, Nemeth, AJ, Gottesman, R, Yenokyan, G, Brown, C, Hogue, CW
Anesthesia and analgesia. 2018;(6):1314-1322
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BACKGROUND Impaired cerebral blood flow (CBF) autoregulation during cardiopulmonary bypass (CPB) is associated with stroke and other adverse outcomes. Large and small arterial stenosis is prevalent in patients undergoing cardiac surgery. We hypothesize that large and/or small vessel cerebral arterial disease is associated with impaired cerebral autoregulation during CPB. METHODS A retrospective cohort analysis of data from 346 patients undergoing cardiac surgery with CPB enrolled in an ongoing prospectively randomized clinical trial of autoregulation monitoring were evaluated. The study protocol included preoperative transcranial Doppler (TCD) evaluation of major cerebral artery flow velocity by a trained vascular technician and brain magnetic resonance imaging (MRI) between postoperative days 3 and 5. Brain MRI images were evaluated for chronic white matter hyperintensities (WMHI) by a vascular neurologist blinded to autoregulation data. "Large vessel" cerebral vascular disease was defined by the presence of characteristic TCD changes associated with stenosis of the major cerebral arteries. "Small vessel" cerebral vascular disease was defined based on accepted scoring methods of WMHI. All patients had continuous TCD-based autoregulation monitoring during surgery. RESULTS Impaired autoregulation occurred in 32.4% (112/346) of patients. Preoperative TCD demonstrated moderate-severe large vessel stenosis in 67 (25.2%) of 266 patients with complete data. In adjusted analysis, female sex (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25-0.86; P = .014) and higher average temperature during CPB (OR, 1.23; 95% CI, 1.02-1.475; P = .029), but not moderate-severe large cerebral arterial stenosis (P = .406), were associated with impaired autoregulation during CPB. Of the 119 patients with available brain MRI data, 42 (35.3%) demonstrated WMHI. The presence of small vessel cerebral vascular disease was associated with impaired CBF autoregulation (OR, 3.25; 95% CI, 1.21-8.71; P = .019) after adjustment for age, history of peripheral vascular disease, preoperative hemoglobin level, and preoperative treatment with calcium channel blocking drugs. CONCLUSIONS These data confirm that impaired CBF autoregulation is prevalent during CPB predisposing affected patients to brain hypoperfusion or hyperperfusion with low or high blood pressure, respectively. Small vessel, but not large vessel, cerebral vascular disease, male sex, and higher average body temperature during CPB appear to be associated with impaired autoregulation.