Is the use of hydroxyethyl starch as priming solution during cardiac surgery advisable? A randomized, single-center trial.

INTRODUCTION: The use of cardiopulmonary bypass (CPB) leads to increased fluid filtration and edema. The use of artificial colloids to counteract fluid extravasation during cardiac surgery is controversial. Beneficial effects on global fluid loading, leading to better cardiac performance and hemodynamics, have been claimed. However, renal function and coagulation may be adversely affected, with unfavorable impact on outcome following cardiac surgery. METHODS: Forty patients were randomly allocated to study groups receiving either acetated Ringer's solution (CT group) or hydroxyethyl starch (HES group, Tetraspan®) as CPB priming solution. Fluid balance, bleeding and hemodynamics, including cardiac output, were followed postoperatively. The occurrence of acute kidney injury was closely registered. RESULTS: Two patients were excluded from further analyzes due to surgical complications. Fluid accumulation was attenuated in the HES group (3374 (883) ml) compared with the CT group (4328 (1469) ml) (p=0.024). The reduced perioperative fluid accumulation was accompanied by an increased cardiac index immediately after surgery (2.7 (0.4) L/min/m2 in the HES group and 2.1 (0.3) L/min/m2 in the CT group (p<0.001)). No increase in bleeding could be demonstrated in the HES group. Three patients, all of them in the HES group, experienced acute kidney injury postoperatively. CONCLUSIONS: CPB priming with HES solution lowers fluid loading during bypass and improves cardiac function in the early postoperative period. The manifestation of acute kidney injury exclusively in the HES group of patients raises doubts about the use of HES products in conjunction with cardiac surgery. ( https://clinicaltrials.gov/ct2/show/NCT01511120 ).

Microvascular fluid exchange during CPB with deep hypothermia circulatory arrest or low flow.

OBJECTIVE: Use of deep hypothermic low-flow (DHLF) cardiopulmonary bypass (CPB) has been associated with higher fluid loading than the use of deep hypothermia circulatory arrest (DHCA). We evaluated whether these perfusion strategies influenced fluid extravasation rates and edema generation differently per-operatively. MATERIALS AND METHODS: Twelve anesthetized pigs, randomly allocated to DHLF (n = 6) or DHCA (n = 6), underwent 2.5 hours CPB with cooling to 20°C for 30 minutes (min), followed by 30 min arrested circulation (DHCA) or 30 min low-flow circulation (DHLF) before 90 min rewarming to normothermia. Perfusion of tissues, fluid requirements, plasma volumes, colloid osmotic pressures and total tissue water contents were recorded and fluid extravasation rates calculated. During the experiments, cerebral microdialysis was performed in both groups. RESULTS: Microvascular fluid homeostasis was similar in both groups, with no between-group differences, reflected by similar fluid extravasation rates, plasma colloid osmotic pressures and total tissue water contents. Although extravasation rates increased dramatically from 0.10 (0.11) ml/kg/min (mean with standard deviation in parentheses) and 0.16 (0.02) ml/kg/min to 1.28 (0.58) ml/kg/min and 1.06 (0.41) ml/kg/min (DHCA and DHLF, respectively) after the initiation of CPB, fluid filtrations during both cardiac arrest and low flow were modest and close to baseline values. Cerebral microdialysis indicated anaerobic metabolism and ischemic brain injury in the DHCA group. CONCLUSION: No differences in microvascular fluid exchange could be demonstrated as a direct effect of DHCA compared with DHLF. Thirty minutes of DHCA was associated with anaerobic cerebral metabolism and possible brain injury.

Detection of specific immunoglobulin E antibodies toward common airborne allergens, peanut, wheat, and latex in solvent/detergent-treated pooled plasma.

BACKGROUND: Allergic transfusion reactions (ATRs) present with a broad range of symptoms probably caused by mediators released from mast cells and basophil granulocytes upon activation. Passive immunoglobulin (Ig)E sensitization may yield clinical symptoms and positive allergy tests. Unexpected findings of IgE antibodies in pooled solvent/detergent (S/D)-treated plasma (Octaplas, Octapharma) during routine analysis initiated an investigation of serum proteins. STUDY DESIGN AND METHODS: Consecutive batches of S/D-plasma transfused during September 2014 through March 2015 were investigated for IgE, IgG, IgA IgM, C3, C4, haptoglobin, anti-nuclear antibodies (ANAs), and red blood cell (RBC) antibodies. RESULTS: During the study period, 4203 S/D-plasma units were transfused. Nineteen (14 Octaplas A and five Octaplas AB) of 20 batches of S/D-plasma were included, representing 99.9% of total number of plasma units. A total of 0.4% of units and five batches reported ATRs. Concentrations of total IgE higher than expected values in adults (<120 kU/L) were observed in 18 of the 19 (95%) batches investigated (median concentration [quartiles], 161 [133-183]). Specific IgE antibodies (expected < 0.35 kilounits antigen [kUA]/L) against house dust mite (2.52 [1.01-5.09]), timothy (2.83 [2.48-3.24]), cat (1.13 [0.58-1.52]), dog (0.83 [0.50-1.05]), mugwort (0.69 [0.53-0.97]), birch (0.62 [0.28-0.92]), peanut (0.52 [0.29-075]), wheat (0.46 [0.33-0.69]), and latex (0.32 [0.21-0.53]) were also detected. IgG, IgA, IgM, C3, C4, and haptoglobin were within or below normal ranges. No RBC antibodies were observed, but 18% of batches showed low levels of ANA (anti-RNP). CONCLUSION: Specific IgE antibodies against airborne allergens, food allergens, and latex were detected in S/D-treated pooled plasma.

The influence of socio-demographic and clinical factors on sick leave and return to work after open-heart surgery: a nationwide registry-based cohort study.

AIMS: To estimate sick leave (SL) duration after first-time elective open-heart surgery and identify factors contributing to increased SL. METHODS AND RESULTS: A retrospective nationwide cohort study combined data from the Norwegian Register for Cardiac Surgery and SL data from the Norwegian Labour and Welfare Administrations. All able-bodied adults who underwent first-time elective open-heart surgery in Norway between 2012 and 2021 were followed until one year after surgery. The impact of socio-demographic and clinical factors on SL after surgery was analysed using logistic regression and odds ratios. Of 5456 patients, 1643 (30.1%), 1798 (33.0%), 971 (17.8%), 1035 (18.9%), and 9 (0.2%) had SL of <3, 3-6, 6-9, and 9-12 months, and one year, respectively. SL > 6 months was associated with female gender, primary education only, and average annual income. Postoperative stroke, postoperative renal failure, New York Heart Association Functional Classification system (NYHA) score > 3, earlier myocardial infarction, and diabetes mellitus increased the odds of SL > 6 months. CONCLUSION: This study demonstrates that socio-demographic and clinical factors impact SL after first-time elective open-heart surgery. Patients who experience a stroke or develop renal failure after surgery have the highest odds of SL > 6 months. Females and patients with low education levels, earlier myocardial infarction, or NYHA scores III-IV have a twofold chance of SL > 6 months. The findings allow for future investigations of pre- and post-surgery interventions that can most effectively reduce SL and aid return to work.

Does Roller Pump-Induced Pulsatile CPB Perfusion Affect Microvascular Fluid Shifts and Tissue Perfusion?

BACKGROUND: Pulsatile versus nonpulsatile cardiopulmonary bypass (CPB) perfusion remains debated. Beneficial effects on tissue perfusion, inflammation, and microvascular fluid exchange have been linked to pulsatile perfusion by some investigators and denied by others. This study evaluated fluid extravasation and tissue perfusion during nonpulsatile or pulsatile roller pump-induced CPB perfusion. METHODS: Fourteen pigs underwent roller pump-induced pulsatile (n = 7) or nonpulsatile CPB perfusion (n = 7) for 90 minutes. Fluid input/losses, colloid osmotic pressures (plasma/interstitium), hematocrit, serum electrolytes, serum proteins, tissue perfusion, and total tissue water content were measured, and plasma volume and fluid extravasation were calculated. RESULTS: Fluid additions/losses, plasma volume, and fluid extravasation changed similarly in both groups during CPB with no between-group differences. Neither was between-group differences observed for tissue perfusion and total tissue water content, with one exception. Total tissue water content of the right (3.92 ± 0.26 versus 4.32 ± 0.28 g/g dry weight) and left ventricle (4.02 ± 0.25 versus 4.33 ± 0.24 g/g dry weight) was lowered in the pulsatile group. CONCLUSIONS: No important differences were found between pulsatile and nonpulsatile CPB perfusion for microvascular fluid balance and tissue perfusion.

Fluid overload during cardiopulmonary bypass is effectively reduced by a continuous infusion of hypertonic saline/dextran (HSD).

OBJECTIVE: Cardiopulmonary bypass (CPB) is associated with fluid overload. We examined how a continuous infusion of hypertonic saline/dextran (HSD) influenced fluid shifts during CPB. MATERIALS AND METHODS: Fourteen animals were randomized to a control-group (CT-group) or a hypertonic saline/dextran-group (HSD-group). Ringer's solution was used as CPB-prime and as maintenance fluid at a rate of 5 ml/kg/h. In the HSD group, 1 ml/kg/h of the maintenance fluid was substituted with HSD. After 60 min of normothermic CPB, hypothermic CPB was initiated and continued for 90 min. Fluid was added to the CPB-circuit as needed to maintain a constant level in the venous reservoir. Fluid balance, plasma volume, total tissue water (TTW), intracranial pressure (ICP) and fluid extravasation rates (FER) were measured/calculated. RESULTS: In the HSD-group the fluid need was reduced with 60% during CPB compared with the CT-group. FER was 0.38(0.06) ml/kg/min in the HSD-group and 0.74 (0.16) ml/kg/min in the CT-group. TTW was significantly lower in the heart and some of the visceral organs in the HSD-group. In this group ICP remained stable during CPB, whereas an increase was observed in the CT-group (p<0.01). CONCLUSIONS: A continuous infusion of HSD reduced the fluid extravasation rate and total fluid gain during CPB. TTW was reduced in the heart and some visceral organs. During CPB ICP remained normal in the HSD-group, whereas an increase was present in the CT-group. No adverse effects were observed.