Elective Cardiopulmonary Bypass Research Articles

Comparison of the Quantra QPlus and ROTEM Goal-Directed Transfusion Protocols in Cardiothoracic Surgery Patients: A Prospective Observational Study

To compare the designed treatment protocols for the Quantra QPlus and rotational thromboelastometry (ROTEM) with regard to transfusion advice. Prospective observational study. Maastricht University Medical Center, The Netherlands. Adults with elective cardiopulmonary bypass surgery with a ROTEM test. ROTEM tests were performed postoperatively for standard monitoring of coagulation status and clinical decision making. Simultaneously, a concurrent sample was analyzed for the Quantra QPlus. A total of 100 samples were analyzed using both the ROTEM and Quantra QPlus. Agreement between the transfusion advice for the ROTEM and Quantra QPlus protocols were compared using Cohen κ values for i.a. fibrinogen, platelet concentrates, and fresh frozen plasma (FFP). The agreement between ROTEM and Quantra QPlus was poor for overall transfusion (0.174) and fibrinogen transfusion (0.300). The agreement of cutoff values for fibrinogen clot stiffness for the Quantra QPlus and EXTEM A10 for the ROTEM was poor (0.160). The fibrinogen clot stiffness and FIBTEM A10 had a moderate agreement (0.731). A Cohen κ could not be calculated for the agreement of protamine, thrombocytes, FFP or cutoff values for these transfusions since frequencies included zero in these cases. The Quantra QPlus transfusion protocol advises transfusion in many non-bleeders, adjustments appear to be necessary. In a small group of cases in which clinically relevant blood loss was observed, the Quantra QPlus advised administration of transfusion products, whereas the ROTEM tests did not. ROTEM-guided and Quantra-guided transfusion did not correspond in this patient group, and agreement was moderate at best. Specificity and sensitivity for transfusion within protocols were heterogeneous between the methods. More clinical research in high-bleeding risk populations is needed to determine the clinical impact of the different protocols.

Hemadsorption to Contain Postoperative Cell-Free Hemoglobin and Haptoglobin Preservation for Extended Cardiopulmonary Bypass Time in Cardiac Surgery for Acute Kidney Injuries Prevention.

Prevention of acute kidney injury during cardiopulmonary bypass (CPB) is still a challenge and has been the object of numerous studies. The incidence of acute kidney injury in the context of CPB is related to a multifactorial etiology. The role of hemadsorption in relation to cell-free hemoglobin and haptoglobin preservation is not well defined in the literature on CPB during cardiac surgery procedures. This is a single-center pilot randomized report including 20 patients undergoing elective CPB procedures with an expected time > 120 minutes for each extracorporeal procedure. Patients were randomly allocated to either standard of care (n=10) or Jafron HA380 (n=10) during CPB. The primary outcome measured was the incidence of postoperative acute kidney injuries. The Jafron study group vs. control group reported postoperative values for cell-free hemoglobin at 10 minutes after CPB (mg/L) (11.6 ± 0.6 vs. 29.9 ± 0.3) (P-value 0.021), haptoglobin 10 minutes after CPB (mg/dl) (129.16 ± 1.22 vs. 59.17 ± 1.49) (P-value 0.017), creatinine peak after CPB (mg/dL) (0.92 ± 0.17 vs. 1.32 ± 0.9) (P-value 0.030), and acute kidney injury after 48 hours (number of patients) (one vs. four) (P-value 0.027). This pilot study suggested that the use of Hemoperfusion Cartridge HA380 Jafron for extended CPB time for complex cardiac surgery procedures was safe and effective and is associated with a better postoperative preservation of haptoglobin with a reduction of cell-free hemoglobin values and less incidence of acute kidney injury, though larger studies are warranted to confirm our result.

Outcomes after lung transplantation performed using elective cardiopulmonary bypass: A single-center experience

PurposeThere remains significant variability in the use of intraoperative mechanical circulatory support in lung transplantation. This report details our outcomes using elective CPB in lung transplantation. MethodsWe performed a single institution analysis of consecutively enrolled patients who underwent isolated lung transplantation between August 2020 and April 2023. Primary outcomes included rates of grade 3 PGD and one-year survival. Results40 consecutive lung transplants were performed on CBP over the study period. The average PaO2/FiO2 at 72 hours was 369.7+121.4, with grade 3 PGD occurring in two patients (5%). The median intra-operative packed red blood cell transfusion requirement was 300 (93.75-727.5) mL. Freedom from non-elective re-operation was 82.5% (n=33). Mortality was 0% at 90-days, and one-year survival was 90.5%. ConclusionLung transplantation can be safely performed with elective CPB support.

Preoperative hypoalbuminemia and postoperative acute kidney injury in adult patients after elective on-pump cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background An earlier published prospective cohort study evaluating the impact of malnutrition on cardiac surgery outcomes showed serum albumin ≤42 g/dL to be associated with a poor prognosis [1]. However, the association with kidney outcomes was not studied. The adverse effect of preoperative hypoalbuminemia on postoperative kidney injury and its cut-off value in on-pump cardiac surgery patients is still controversial [2]. Methods A retrospective matched case-control study based on the secondary analysis of the open-access dataset [3] was conducted. The research hypothesis was that preoperative hypoalbuminemia is independently associated with a higher risk of acute kidney injury (AKI) requiring postoperative new-onset dialysis. We defined cases as patients treated with new-onset dialysis for AKI and controls as those who did not. Hypoalbuminemia was defined as serum albumin of ≤42 g/L based on findings from the original study. The dataset counted 1178 adults from multiple centers who underwent elective cardiopulmonary bypass (CPB) cardiac surgery in 2011. We excluded patients with missing data and compared key demographic and medical history characteristics. Following the hypothesis, subjects were matched on the type of surgery they received (coronary, valvular, or combined) in a multiple conditional logistic regression model that included the hypoalbuminemia status, diabetes history, CPB time, and logistic EuroScore. Additionally, univariate regression with and without conditional matching was performed. Results In total, 831 (39 cases and 792 controls) subjects were included. Subjects shared similar demographics and medical history. Expectedly, cases had prolonged CPB and aortic cross-clamp time. The median CPB time in cases and controls was 120 and 79 min, respectively (p=0.001). The median aortic cross-clamp time was 79 in cases and 54 in controls (p=0.001). Hypoalbuminemia was observed in 18 cases (46%) in cases compared to 241 (30%) in controls (p=0.038). Multiple conditional regression demonstrated that the risk of postoperative AKI requiring dialysis was not associated with preoperative hypoalbuminemia (OR 1.43, [0.70, 2.89]). Similarly, univariate conditional regression showed no association (OR 1.84 [0.95, 3.53]). Only univariate unmatched regression resulted in statistical significance(OR 1.96 [1.03, 3.74]). The higher logistic EuroScore (OR 1.11, [1.06, 1.15]) and the longer cardiopulmonary bypass time (OR 1.01, [1.01, 1.02]), but not the history of diabetes (OR 0.61, [0.19, 1.88]), increased the odds of renal replacement therapy requirement. Conclusion In our study, preoperative hypoalbuminemia was not independently associated with a higher risk of postoperative AKI requiring new-onset dialysis after elective on-pump cardiac surgery. Patients who required dialysis had lower preoperative albumin levels, but the association between hypoalbuminemia ≤ 42 g/L and kidney outcomes could be confounded.

(920) Elective Cardiopulmonary Bypass for Lung Transplantation: Is It Safer Than We Think

(920) Elective Cardiopulmonary Bypass for Lung Transplantation: Is It Safer Than We Think

Neuroprotective effect of remote ischemic preconditioning in patients undergoing cardiac surgery: A randomized controlled trial.

BackgroundThe neuroprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing elective cardiopulmonary bypass (CPB)-assisted coronary artery bypass graft (CABG) or valvular cardiac surgery remains unclear.MethodsA randomized, double-blind, placebo-controlled superior clinical trial was conducted in patients undergoing elective on-pump coronary artery bypass surgery or valve surgery. Before anesthesia induction, patients were randomly assigned to RIPC (three 5-min cycles of inflation and deflation of blood pressure cuff on the upper limb) or the control group. The primary endpoint was the changes in S-100 calcium-binding protein β (S100-β) levels at 6 h postoperatively. Secondary endpoints included changes in Neuron-specific enolase (NSE), Mini-mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) levels.ResultsA total of 120 patients [mean age, 48.7 years; 36 women (34.3%)] were randomized at three cardiac surgery centers in China. One hundred and five patients were included in the modified intent-to-treat analysis (52 in the RIPC group and 53 in the control group). The primary result demonstrated that at 6 h after surgery, S100-β levels were lower in the RIPC group than in the control group (50.75; 95% confidence interval, 67.08 to 64.40 pg/ml vs. 70.48; 95% CI, 56.84 to 84.10 pg/ml, P = 0.036). Compared to the control group, the concentrations of S100-β at 24 h and 72 h and the concentration of NSE at 6 h, 24 h, and 72 h postoperatively were significantly lower in the RIPC group. However, neither the MMSE nor the MoCA revealed significant between-group differences in postoperative cognitive performance at 7 days, 3 months, and 6 months after surgery.ConclusionIn patients undergoing CPB-assisted cardiac surgery, RIPC attenuated brain damage as indicated with the decreased release of brain damage biomarker S100-β and NSE.Clinical trial registration[ClinicalTrials.gov], identifier [NCT01231789].

83 The predictive role of neutrophil-to-lymphocyte ratio in post-operative cardiopulmonary bypass surgery

Abstract Aims Postoperative arrhythmias (POA) are a common complication after cardiac surgical repairs for congenital heart disease (CHD), representing a substantial source of morbidity, mortality, and prolonged total in-hospital stay, with an incidence of 7.5–48% in postoperative pediatric cardiac patients. The etiology is multifactorial, and it has been related to the direct surgical manipulation of the cardiac conduction system, to the local tissue inflammation in the myocardium adjacent to the conduction system and to the arrhythmogenic effects of cardiopulmonary bypass (CPB), inotropes, and electrolyte disturbances. Recently, the prognostic role of neutrophil-to-lymphocyte ratio (NLR), a novel inflammation marker, has been evaluated in pediatric patients after CPB surgery. To evaluate the predictive role of NLR in POA in a population of pediatric CHD patients after CPB. Methods and results We retrospectively collected perioperative clinical and laboratory data of 146 patients (age 8.27 ± 10.79 years; male gender: 60.8%) consecutively admitted to the cardiac surgery intensive care unit (ICU) of our institute after elective cardiac surgery with CPB in 2018. We grouped and analyzed our population over NLR tertiles evaluated at 24 h from CPB and types of POA: supraventricular (SVT) and junctional (JET). The prognostic value of NLR and its association with POA was analyzed. Diagnoses of 146 patients included atrial septal defect (n = 36), ventricular septal defect (n = 20), pulmonary atresia/stenosis (n = 10), tetralogy of Fallot (n = 20), endocardial cushion defect (n = 8), left ventricular outflow tract obstruction (n = 14), anomalous origin of coronary artery (n = 6), complex CHD (n = 13), interrupted/hypoplastic aortic arch (n = 12), anomalous pulmonary venous return (n = 3). The mean CPB time was 121.6 ± 84.6 min. The median ICU hospitalization was 48 h [Q1, Q3: 24, 96]. Twelve patients experienced POA: 6 SVT and 6 JET. The frequency of POA incremented over NLR-tertiles (P-Trend 0.017), while SVT onset was associated with higher values of NLR and C-reactive protein (P = 0.034 and P = 0.011, respectively). Patients in the second and third tertiles of NLR had a prolonged hospitalization (log-rank, P = 0.029), especially when associated with POA (log-rank, P = 0.012). At the multivariable analysis, higher age and NLR values were independently associated with SVT [OR per year 1.22; 95% CI (1.02, 1.25), P = 0.043 and OR per point 1.91; 95% CI (1.29, 2.82), P = 0.012, respectively], but not with JET. Conclusions 24-h post-CPB NLR can predict postoperative SVT in a population of pediatric CHD patients. Our data suggest that the NLR could be a useful, easy-to-obtain marker for postoperative outcome in pediatric patients who had undergone elective CPB.

The association between end-tidal carbon dioxide and arterial partial pressure of carbon dioxide after cardiopulmonary bypass pumping in cyanotic children.

Introduction: Evidence suggests the high capability of non-invasive assessment of the End-tidal carbondioxide (ETCO2) in predicting changes in arterial carbon dioxide pressure (PCO2) following major surgeries in children. We aimed to compare EtCO2 values measured by capnography with mainstream device and EtCO2 values assessed by arterial blood gas analysis before and after cardiopulmonary bypass pumping in cyanotic children. Methods: This cross-sectional study was performed on 32 children aged less than 12 years with ASA II suffering cyanotic heart diseases and undergoing elective cardiopulmonary bypass pumping. Arterial blood sample was prepared through arterial line before and after pumping and arterial blood gas (ABG)was analyzed. Simultaneously, the value of EtCO2 was measured by capnography with mainstream device. Results: A significant direct relationship was found between the changes in ETCO2 and arterialPCO2 (r = 0.529, P = 0.029) postoperatively. According to significant linear association between postoperative change in ETCO2 and arterial PCO2, we revealed a new linear formula between the two indices: ΔPCO2 = 0.89× ETCO2-0.54. The association between arterial PCO2 and ETCO2 remained significant adjusted for gender, age, and body weight. Conclusion: the value of ETCO2 can reliability estimate postoperative changes in arterial PCO2 in cyanotic children undergoing cardiopulmonary bypass pumping.

ATF3: a novel biomarker for the diagnosis of acute kidney injury after cardiac surgery.

BackgroundTo investigate the expression of ATF3 in the blood and urine of adult patients undergoing cardiopulmonary bypass (CPB) surgery and to identify the changes during the perioperative period of CPB, and to determine whether ATF3 can be used as a biological marker for the early diagnosis of acute kidney injury (AKI).MethodsWe prospectively studied 83 patients who underwent elective CPB (ECB). Relevant clinical information was collected. Blood and urine samples were collected preoperatively (T0) and at 2 h (T1), 6 h (T2), 12 h (T3), 24 h (T4), and 48 h (T5) after surgery, and grouped according to the occurrence of AKI. The changes in ATF3 levels were observed, and the accuracy of the diagnosis of AKI was compared through receiver operating characteristic (ROC) curve analysis. Factors influencing the expression of ATF3 at baseline were also analyzed.ResultsA total of 83 adult patients undergoing cardiac surgery with CPB were included, and 42 of them developed AKI. The levels of serum ATF3 (sATF3) in the AKI group were significantly higher than those in the non-AKI group 24 h after surgery, and the difference was statistically significant (662.62±204.72 vs. 586.93±175.87; P=0.0345). Urinary ATF3 (uATF3) increased significantly 6 h after surgery, and the area under the ROC curve (AUC) for diagnosing AKI 12 h after surgery was 0.691 (95% CI: 0.576–0.807). When uATF3 was higher than 1,216 pg/mL, the sensitivity and specificity for the diagnosis of AKI were 0.43 and 0.85, respectively. On the other hand, the preoperative expression of ATF3 was negatively correlated with the preoperative creatinine level, but not affected by the patient’s age, weight, gender, preoperative cardiac function, preoperative blood routine examination and liver function.ConclusionsATF3 can be expressed early in the blood and urine of patients after CPB and can be used as a diagnostic marker for AKI after CPB in adult patients.

The predictive role of neutrophil-to-lymphocyte ratio in post-operative arrhythmias in pediatric patients after cardiopulmonary bypass surgery

Abstract Background Postoperative arrhythmias (POA) are a common complication after cardiac surgical repairs for congenital heart disease (CHD), representing a substantial source of morbidity, mortality and prolonged total in-hospital stay, with an incidence of 7.5–48% in postoperative pediatric cardiac patients. The etiology is multifactorial, and it has been related to the direct surgical manipulation of the cardiac conduction system, to the local tissue inflammation in the myocardium adjacent to the conduction system and to the arrhythmogenic effects of cardiopulmonary bypass (CPB), inotropes and electrolyte disturbances. Recently, the prognostic role of neutrophil-to-lymphocyte ratio (NLR), a novel inflammation marker, has been evaluated in pediatric patients after CPB surgery. Purpose To evaluate the predictive role of NLR in POA in a population of pediatric CHD patients after CPB. Methods We retrospectively collected perioperative clinical and laboratory data of 146 patients (age 8.27±10.79 years; male gender: 60.8%) consecutively admitted to the cardiac surgery intensive care unit (ICU) of our institute after elective cardiac surgery with CPB in 2018. We grouped and analyzed our population over NLR tertiles evaluated at 24 hours from CPB and types of POA: supraventricular (SVT) and junctional (JET). The prognostic value of NLR and its association with POA was analyzed. Results Diagnoses of 146 patients included atrial septal defect (n=36), ventricular septal defect (n=20), pulmonary atresia/stenosis (n=10), tetralogy of Fallot (n=20), endocardial cushion defect (n=8), left ventricular outflow tract obstruction (n=14), anomalous origin of coronary artery (n=6), complex CHD (n=13), interrupted/hypoplastic aortic arch (n=12), anomalous pulmonary artery venous return (n=3). The mean CPB time was 121.6±84.6 minutes. The median ICU hospitalization was 48 hours [Q1, Q3: 24, 96]. Twelve patients experienced POA: 6 SVT and 6 JET. The frequency of POA incremented over NLR-tertiles (P-Trend 0.017), while SVT onset was associated with higher values of NLR and C-reactive protein (P=0.034 and P=0.011, respectively). Patients in the second and third tertiles of NLR had a prolonged hospitalization (Log-rank, P=0.029), especially when associated with POA (Log-rank, P=0.012). At the multivariable analysis, higher age and NLR values were independently associated with SVT [OR per year 1.22; 95% CI (1.02, 1.25), P=0.043 and OR per point 1.91; 95% CI (1.29, 2.82), P=0.012, respectively], but not with JET. Conclusions 24-h post-CPB NLR can predict postoperative SVT in a population of pediatric CHD patients. Our data suggest that the NLR could be a useful, easy-to-obtain marker for postoperative outcome in pediatric patients who had undergone elective CPB. Funding Acknowledgement Type of funding sources: None.

Iatrogenic Acute Type A Aortic Dissection following Elective Cardiopulmonary Bypass.

We report a 62-year-old woman who was scheduled for an elective Tirone David valve sparing aortic root replacement under cardiopulmonary bypass. Within the next few hours, the patient developed bilateral acute ischemia of both lower limbs. A thoracic and abdominopelvic computed tomography scan showed acute Type A aortic dissection with a perforation at the brachiocephalic arterial trunk and a complete malperfusion of the inferior mesenteric and iliac arteries.

Desflurane and sevoflurane concentrations in blood passing through the oxygenator during cardiopulmonary bypass: a randomized prospective pilot study.

PurposeVolatile anesthetics (VAs) protect myocardial cells in cardiovascular surgery. A recent clinical trial of cardiopulmonary bypass (CPB) surgery reported no significant difference in mortality rates between the use of VAs and total intravenous anesthetics at 1 year postoperatively. However, oxygenator function may affect the VA pharmacokinetics. Thus, we measured the VA blood concentrations during CPB in patients managed with four different microporous polypropylene hollow fiber membrane oxygenators.MethodsTwenty-four patients scheduled for elective CPB were randomly allocated to one of the two VA groups (desflurane and sevoflurane groups) and, then, randomly divided into one of four oxygenator groups: Terumo, LivaNova, Medtronic, and Senko (n = 3). Additionally, in each VA group, three patients were randomly selected and redundantly allocated to the human lung group (for control blood VA concentration without oxygenator). Blood samples collected 20 min after starting 6.0 vol% desflurane or 1.7 vol% sevoflurane were analyzed using gas chromatography. Oxygenator-related complications and structural changes in the membrane surface of each oxygenator after surgery were evaluated.ResultsThe mean (standard deviation) concentrations of desflurane and sevoflurane in the human lung were 182.4 (23.2) and 54.0 (9.6) μg/ml, respectively; not significantly different from those in the four oxygenator groups. No oxygenator-related complications occurred. Structural changes in membrane fibers did not occur after clinical use, except for difficulty in image acquisition with Senko products.ConclusionOur results demonstrated that the blood concentrations of desflurane and sevoflurane passing through oxygenators used during CPB were similar to those in the human lung control.Electronic supplementary materialThe online version of this article (10.1007/s00540-020-02844-1) contains supplementary material, which is available to authorized users.

The Role of an Ultrasound-Guided Block of the Deep Plane of the Serratus Muscle in a Modified ERAS Protocol for Cardiac Surgery

To date, the use of multimodal techniques can allow substantial opioid-sparing and can reduce pain by using the local and systemic effects of different types of analgesics. Aims: This case report describes a modified ERAS protocol specific for cardiac surgery with the ultrasound-guided block of the deep plane of the serratus muscle (SAP deep block) in a multimodal opioid-sparing approach. \ Two male patients, aged 62 and 67, undergoing elective mini-invasive off-pump Cardiopulmonary Bypass Grafting (CPB), were treated with an opioid-sparing multimodal anesthesiological approach based on the continuous ultrasound-guided SAP deep block. The continuous ultrasound-guided SAP deep block alone can be used in the case of mini-left thoracotomy off-pump cardiopulmonary bypass grafting implementing a multi-modal opioid-sparing strategy. It seems effective in obtaining good (2 hours) weaning from mechanical ventilation, quick (36 hours) discharge from post-operative intensive care, and good post-operative pain control (NRS < 5) even in elderly and frail patients.

Application of Dexmedetomidine in Cardiopulmonary Bypass Prefilling.

Objective:The purpose of this study was to explore the application of dexmedetomidine (Dex) in cardiopulmonary bypass.Methods:A total of 60 patients undergoing elective cardiopulmonary bypass were divided into control (C) group and Dex group. In the Dex group, appropriate amount of Dex was added into the membrane lung prefilling solution before anesthesia induction, while those in control group were given normal saline. The levels of mean arterial pressure (MAP) and heart rate (HR) at different times were measured. The levels of cardiac troponin I (CTNI), malondialdehyde (MDA), interleukin 6 (IL-6), and tumor necrosis factor α (TNF-α) at different points (T0/T1/T2/T3/T4) in both groups were measured by enzyme-linked immunosorbent assay kits.Results:The intraoperative and postoperative levels of MAP and HR in the 2 groups were significantly lower than those preoperatively (P < .05). The levels of MAP and HR in the Dex group were significantly lower than those of the C group (P < .05). The levels of CTNI/MDA/IL-6/TNF-α at different points in both groups were significantly higher than those at T0 (P < .05). The serum levels of CTNI, MDA, IL-6, and TNF-α in the Dex group at T1/T2/T3/T4 were significantly lower than those in the C group (P < .05). The rate of arrhythmia in the Dex group was significantly lower than that in the C group (P < .05).Conclusion:Dexmedetomidine has a stable effect in cardiopulmonary priming solution.

Influence of hemoadsorption during cardiopulmonary bypass on blood vesicle count and function

BackgroundExtracorporeal circulation during major cardiac surgery triggers a systemic inflammatory response affecting the clinical course and outcome. Recently, extracellular vesicle (EV) research has shed light onto a novel cellular communication network during inflammation. Hemoadsorption (HA) systems have shown divergent results in modulating the systemic inflammatory response during cardiopulmonary bypass (CPB) surgery. To date, the effect of HA on circulating microvesicles (MVs) in patients undergoing CPB surgery is unknown.MethodsCount and function of MVs, as part of the extracellular vesicle fraction, were assessed in a subcohort of a single-center, blinded, controlled study investigating the effect of the CytoSorb device during CPB. A total of 18 patients undergoing elective CPB surgery with (n = 9) and without (n = 9) HA device were included in the study. MV phenotyping and counting was conducted via flow cytometry and procoagulatory potential was measured by tissue factor-dependent MV assays.ResultsBoth study groups exhibited comparable counts and post-operative kinetics in MV subsets. Tissue factor-dependent procoagulatory potential was not detectable in plasma at any timepoint. Post-operative course and laboratory parameters showed no correlation with MV counts in patients undergoing CPB surgery.ConclusionAdditional artificial surfaces to the CPB-circuit introduced by the use of the HA device showed no effect on circulating MV count and function in these patients. Larger studies are needed to assess and clarify the effect of HA on circulating vesicle counts and function.Trial registration ClinicalTrials.Gov Identifier: NCT01879176; registration date: June 17, 2013; https://clinicaltrials.gov/ct2/show/NCT01879176

Hemoadsorption does not Have Influence on Hemolysis During Cardiopulmonary Bypass.

Cardiopulmonary bypass (CPB) induces hemolysis, which manifests as plasma free hemoglobin. We investigated in a post hoc analysis of a single-center, blinded, controlled study whether the use of a novel hemoadsorption device (CytoSorb, CytoSorbents Europe GmbH, Berlin, Germany) affects hemolysis during CPB. A total of 35 patients undergoing elective CPB surgery with an expected CPB duration of more than 120 min were included in the analysis. The hemoadsorption device was used in 17 patients (intervention group) and not used in 18 patients (control group). The primary outcome was differences of postoperative free hemoglobin and haptoglobin levels. As secondary outcomes, we investigated differences in postoperative lactate dehydrogenase and bilirubin levels. Postoperative free hemoglobin levels were not significantly different between the groups. However, there were statistically significant differences between the treatment and control groups in the median levels of haptoglobin (58.4 vs. 17.9 mg/dL, respectively; P < 0.01) and lactate dehydrogenase (353.0 vs. 432.0 U/L, respectively; P < 0.05) on postoperative day 1. Thus, in this study, we did not find an effect on hemolysis in patients treated with hemoadsorption, though lower haptoglobin level and higher secondary hemolysis markers on postoperative day 1 in patients not treated with the hemoadsorber may be an indication of some moderate effect of the device. Studies with larger samples are needed to clarify the significance of the small differences detected in this study.

Lund exhaust on hemodynamic parameters and inflammatory mediators in patients undergoing cardiac valve replacement under cardiopulmonary bypass.

The effect of Lund exhaust technique on hemodynamics and inflammatory mediators in patients undergoing cardiac valve replacement under cardiopulmonary bypass was evaluated. A total of 60 patients with heart disease undergoing elective heart valve replacement under elective cardiopulmonary bypass were randomly divided into Lund exhaust group (group A) and control group (group B), with 30 patients in each group. Group A underwent Lund exhaust during cardiopulmonary bypass, while group B was identical to group A except for not using the Lund exhaust technique during cardiopulmonary bypass. The hemodynamic parameters at different time-points showed that the indexes of MAP, PASP, CO, CI, PCWP, CVP and SVR in T1, T2, T3 and T4 moments between group A and group B were statistically significant (p<0.05). There was no statistical significance in IL-6, IL-8, IL-10, TNF-α and TIMP-1 between group A and group B patients at the T0 moment (p>0.05). The levels of IL-6, IL-8, IL-10, TNF-α and TIMP-1 in group B patients at T1, T2, T3 and T4 moments were statistically significant compared with those in group A (p<0.05). The IL-6, IL-8, TNF-α indexes of group B patients were statistically significant at the T5 moment compared with those in group A (p<0.05). The IL-10 and TIMP-1 of two groups were not statistically significant at the T5 moment. The operating time, CPB time, aortic clamp time, intraoperative blood loss, postoperative tube time, ICU stay time, hospital stay time and pulmonary infection of patients in group A were significantly less than those in group B. In conclusion, Lund exhaust technology can significantly reduce the fluctuation of hemodynamics, decrease the expression of inflammatory factors, improve lung function, and is conducive to the rehabilitation of patients.

Relationship between intraoperative serum lactate and hemoglobin levels on postoperative renal function in patients undergoing elective cardiac surgery.

We examined the relationship between serum lactate and hemoglobin levels on renal function and postoperative outcome in low-risk elective coronary artery bypass graft (CABG) patients. Intraoperative hemoglobin and lactate levels were measured in elective isolated CABG patients. Patients with renal dysfunction (baseline creatinine>2 mg/dL) were excluded. Multivariate logistic regression was used to determine associations between lactate, hemoglobin, and acute kidney injury (AKI). A total of 375 patients met study requirements, and 56/375 (15%) developed AKI. Of the patients who developed AKI, 43/278 (15.5%) were males, 13/97 (13.4%) females, and 11/44 (25%) African-Americans. Bivariate analysis between AKI and non-AKI subgroups found significant differences in age, race, baseline estimated glomerular filtration rate, preoperative hemoglobin, peak serum lactate, initial hemoglobin, and nadir hemoglobin. A high peak Lactate level (odds ratio [OR] 1.44[1.15-1.82]), low hemoglobin (OR 0.69[0.49-0.96]), and African American race (OR 2.26[0.96-5.05]) were independently associated with acute kidney injury. A significant relationship between decreasing intraoperative hemoglobin and increasing intraoperative serum lactate levels was observed exclusively in patients who developed postoperative AKI. Serum creatinine levels peaked, on average, 48 h postoperatively in the AKI subset of patients. In this series, 15% of patients who underwent elective cardiopulmonary bypass developed transient acute renal dysfunction. High lactate levels and low hemoglobin levels during cardiopulmonary bypass were associated with an increased risk of kidney injury.

Contemporary Oxygenator Design: Shear Stress‐Related Oxygen and Carbon Dioxide Transfer

Design of contemporary oxygenators requires better understanding of the influence of hydrodynamic patterns on gas exchange. A decrease in blood path width or an increase in intraoxygenator turbulence for instance, might increase gas transfer efficiency but it will increase shear stress as well. The aim of this clinical study was to examine the association between shear stress and oxygen and carbon dioxide transfer in different contemporary oxygenators during cardiopulmonary bypass (CPB). The effect of additional parameters related to gas transfer efficiency, that is, blood flow, gas flow, sweep gas oxygen fraction (FiO2 ), hemoglobin concentration, the amount of hemoglobin pumped through the oxygenator per minute-Qhb, and shunt fraction were contemplated as well. Data from 50 adult patients who underwent elective CPB for coronary artery bypass grafting or aortic valve replacement were retrospectively analyzed. Data included five different oxygenator types with an integrated arterial filter. Relationships were determined using Pearson bivariate correlation analysis and scatterplots with LOESS curves. In the Capiox FX25, Fusion, Inspire 8F, Paragon, and Quadrox-i groups, mean blood flows were 4.8 ± 0.9, 5.3 ± 0.7, 4.9 ± 0.7, 5.0 ± 0.6, and 5.7 ± 0.6 L/min, respectively. The mean O2 transfer/m2 membrane surface area was 44 ± 14, 51 ± 9, 60 ± 10, 63 ± 14, and 77 ± 18, respectively, whereas the mean CO2 transfer/m2 was 26 ± 14, 60 ± 22, 73 ± 29, 74 ± 19, and 96 ± 20, respectively. Associations between oxygen transfer/m2 and shear stress differed per oxygenator, depending on oxygenator design and the level of shear stress (r = 0.249, r = 0.562, r = 0.402, r = 0.465, and r = 0.275 for Capiox FX25, Fusion, Inspire 8F, Paragon, and Quadrox-i, respectively, P < 0.001 for all). Similar associations were noted between CO2 transfer/m2 and shear stress (r = 0.303, r = 0.439, r = 0.540, r = 0.392, and r = 0.538 for Capiox FX25, Fusion, Inspire 8F, Paragon, and Quadrox-i, respectively, P < 0.001 for all). In addition, O2 transfer/m2 was strongly correlated with FiO2 (r = 0.633, P < 0.001), blood flow (r = 0.529, P < 0.001), and Qhb (r = 0.589, P < 0.001). CO2 transfer/m2 in contrast was predominately correlated to sweep gas flow (r = 0.567, P < 0.001). The design-dependent relationship between shear stress and gas transfer revealed that every oxygenator has an optimal range of blood flow and thus shear stress at which gas transfer is most efficient. Gas transfer is further affected by factors influencing the O2 or CO2 concentration gradient between the blood and the gas compartment.

Effect of Remote Ischemic Preconditioning on Intestinal Ischemia-Reperfusion Injury in Adults Undergoing On-Pump CABG Surgery: A Randomized Controlled Pilot Trial

Cardiopulmonary bypass (CPB) surgery commonly threatens the heart and remote organs with ischemia-reperfusion injury. Transient episodes of ischemia to nonvital tissue, known as remote ischemic preconditioning (RIPC), is thought to help local and remote vital organs to withstand subsequent ischemic insults. Prospective, randomized, double-blinded control trial. Tertiary referral academic teaching hospital. Thirty patients undergoing elective CPB surgery INTERVENTION: RIPC was achieved via three 5-minute cycles of upper limb ischemia using a blood pressure cuff or control (sham cuff). Primary outcome was the occurrence of intestinal injury, as measured by an increase in intestinal fatty acid binding protein (I-FABP). Secondary outcomes included incidence of gastrointestinal complications and duration of intensive care unit (ICU) stay. RIPC did not affect serum IFABP levels at the end of surgery and on the first postoperative day (p = 0.697 and p = 0.461, respectively). For all patients, mean I-FABP levels significantly increased at the end of surgery and decreased to under baseline levels on the first postoperative day (from a mean [± standard deviation] baseline value of 764 ± 492 pg/mL to 2,002 ± 974 pg/mL and decreased to 568 ± 319 pg/mL, p < 0.001). All patients remained clinically absent of gastrointestinal complications until hospital discharge. Duration of ICU stay was not correlated with I-FABP levels at the end of surgery. Neither duration of CPB nor duration of aortic clamping significantly correlated with postoperative I-FABP levels. These findings suggest that RIPC does not affect intestinal injury in patients undergoing CPB surgery. In patients undergoing cardiac surgery, intestinal injury appears to be moderate and transient without any clinical relevant complication.