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1.
Khirurgiia (Mosk) ; (11): 83-87, 2021.
Artigo em Russo | MEDLINE | ID: mdl-34786920

RESUMO

Bleeding is a significant cause of complications and mortality in surgery for ascending aorta and aortic root disease. This is especially true after complex reconstructions associated with hypothermic circulatory arrest and long-standing cardiopulmonary bypass. The review is devoted to modern methods of hemostasis in reconstructive aortic root surgery.


Assuntos
Doenças da Aorta , Hemostáticos , Aorta/cirurgia , Ponte Cardiopulmonar/efeitos adversos , Parada Cardíaca Induzida , Hemostasia , Humanos
2.
Ann Card Anaesth ; 24(4): 434-440, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34747750

RESUMO

Background: Cardiopulmonary bypass (CPB) may lead to tissue hypoxia, inflammatory response, and risk for acute kidney injury (AKI). We evaluated the prevalence of AKI and inflammatory response in neonates undergoing heart surgery requiring CPB with or without antegrade cerebral perfusion (ACP). Methods: Forty neonates were enrolled. The patients were divided into two groups depending on the use of ACP. AKI was classified based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Inflammatory response was measured using plasma concentrations of interleukins 6 (IL-6) and 10 (IL-10), white blood cell count (WBC), and C-reactive protein (CRP). Results: Eight patients (20%) experienced AKI: five (29%) in the ACP group and three (13%) in the non-ACP group (P = 0.25). Postoperative peak plasma creatinine and urine neutrophil gelatinase-associated lipocalin were significantly higher in the ACP group than in the non-ACP group [46.0 (35.0-60.5) vs 37.5 (33.0-42.5), P = 0.044 and 118.0 (55.4-223.7) vs 29.8 (8.1-109.2), P = 0.02, respectively]. Four patients in the ACP group and one in the non-ACP group required peritoneal dialysis (P = 0.003). Postoperative plasma IL-6, IL-10, and CRP increased significantly in both groups. There were no significant differences between the ACP and non-ACP groups in any of the inflammatory parameters measured. Conclusions: No significant difference in the AKI occurrence or inflammatory response related to CPB modality could be found. In our study population, inflammation was not the key factor leading to AKI. Due to the limited number of patients, these findings should be interpreted with caution.


Assuntos
Injúria Renal Aguda , Procedimentos Cirúrgicos Cardíacos , Injúria Renal Aguda/etiologia , Biomarcadores , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Circulação Cerebrovascular , Humanos , Rim/fisiologia , Lipocalina-2 , Complicações Pós-Operatórias/epidemiologia
3.
Mymensingh Med J ; 30(4): 1051-1059, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34605476

RESUMO

Neutrophil Gelatinase-Associated Lipocalin (NGAL) is rapidly released by renal tubules after injury, potentially allowing early identification of acute kidney injury (AKI) after cardiac surgery. However, the diagnostic performance of NGAL has varied widely in clinical studies and it remains unknown what factors modify the relationship between NGAL and AKI. The main objective of the study was to determine the efficacy of NGAL in early detection of AKI among the CABG patients undergoing cardiopulmonary bypass (CPB). This prospective observational study was conducted in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh in collaboration with the Department of Biochemistry, BSMMU among 42 patients admitted into the Department of Cardiac Surgery, Ibrahim Cardiac Hospital and Research Institute, Dhaka Bangladesh from July 2014 to June 2015. For the measurement of NGAL, urine samples were obtained before surgery and 6 hours after commencement of CPB. Serum creatinine was measured preoperatively and 6, 24 and 48 hours postoperatively. Increase in the serum creatinine level at 6, 24 and 48 hours after surgery was used to analyze the diagnostic value of urinary NGAL. In this study 42 CABG patients with no known renal insufficiency planned to have CPB were included. Receiver-operator characteristic (ROC) was constructed by using NGAL, which gave a cut off value of ≥185.90ng/ml. Eight patients were AKI positive among them 6(75.0%) patients were NGAL positive and 2(25.0%) were NGAL negative. Diagnosis of AKI was delayed by 24-48 hours by serum creatinine measurement. This study has demonstrated that level of urinary NGAL concentration at 6 hours post CPB increased before the increase of serum creatinine level and NGAL is an early predictor of AKI in adult cardiac surgical patients. The early detection of renal injury by NGAL may allow earlier intervention in patients with high risk for AKI.


Assuntos
Injúria Renal Aguda , Ponte Cardiopulmonar , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/etiologia , Proteínas de Fase Aguda , Adulto , Bangladesh , Biomarcadores , Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária , Creatinina , Humanos , Lipocalina-2 , Lipocalinas , Valor Preditivo dos Testes , Proteínas Proto-Oncogênicas
4.
J Cardiothorac Surg ; 16(1): 319, 2021 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-34717700

RESUMO

BACKGROUND: To determine whether maintaining ventilation during cardiopulmonary bypass (CPB) with a different fraction of inspired oxygen (FiO2) had an impact on the occurrence of postoperative pulmonary complications (PPCs). METHODS: A total of 413 adult patients undergoing elective cardiac surgery with CPB were randomly assigned into three groups: 138 in the NoV group (received no mechanical ventilation during CPB), 138 in the LOV group (received a tidal volume (VT) of 3-4 ml/kg of ideal body weight with the respiratory rate of 10-12 bpm, and the positive end-expiratory pressure of 5-8 cmH2O during CPB; the FiO2 was 30%), and 137 in the HOV group (received the same ventilation parameters settings as the LOV group while the FiO2 was 80%). RESULTS: The primary outcomes were the incidence and severity of PPCs during hospitalization. The composite incidence of PPCs did not significantly differ between the NoV (63%), LOV (49%) and HOV (57%) groups (P = 0.069). And there was also no difference regarding the incidence of PPCs between the non-ventilation (NoV) and ventilation (the combination of LOV and HOV) groups. The LOV group was observed a lower proportion of moderate and severe pulmonary complications (grade ≥ 3) than the NoV group (23.1% vs. 44.2%, P = 0.001). CONCLUSION: Maintaining ventilation during CPB did not reduce the incidence of PPCs in patients undergoing cardiac surgery. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1800015261. Prospectively registered 19 March 2018. http://www.chictr.org.cn/showproj.aspx?proj=25982.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Adulto , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Humanos , Pulmão , Respiração Artificial/efeitos adversos , Volume de Ventilação Pulmonar
6.
Acta Clin Croat ; 60(1): 120-126, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34588731

RESUMO

Cardiac surgery-associated acute kidney injury (CS-AKI) is a major complication associated with increased morbidity and mortality. There are multiple diagnostic criteria for CS-AKI. Despite many new investigations available for improved AKI diagnostics, creatinine and urea remain the cornerstone of diagnostics in everyday clinical practice. There are three major pathophysiological mechanisms that contribute to kidney injury, i.e. renal hypoperfusion, inflammation with oxidative stress, and use of nephrotoxic agents. Some risk factors have been identified that can be modified during the course of treatment (use of nephrotoxic agents, duration of cardiopulmonary bypass, type of extracorporeal circulation, postoperative low cardiac output or hypotension). The aim of AKI prevention should always be to prevent aggravation of renal failure and, if possible, to avoid progression to renal replacement therapy, which in turn brings worse long-term outcomes.


Assuntos
Injúria Renal Aguda , Procedimentos Cirúrgicos Cardíacos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/terapia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Humanos , Complicações Pós-Operatórias/diagnóstico , Terapia de Substituição Renal
8.
Khirurgiia (Mosk) ; (8): 39-48, 2021.
Artigo em Russo | MEDLINE | ID: mdl-34363444

RESUMO

OBJECTIVE: To determine the incidence and independent predictors of gastrointestinal complications (GICs) following on-pump cardiac surgery. MATERIAL AND METHODS: We retrospectively analyzed data of 9559 adults who underwent cardiac surgery in 2012-2017. Two groups of patients were distinguished: group 1 - 47 (0.5%) patients with abdominal complications followed by urgent surgery; group 2 - 9512 (95.5%) patients without complications or effective therapy. CONCLUSION: 1. Predictors of gastrointestinal complications: age >65 years, previous AF (p=0.011) and multifocal atherosclerosis (p=0.016), LV EF <40% (p=0.039), aortic cross-clamping time > 90 min (p=0.021), intraoperative blood loss over 600 ml (p=0.002), postoperative serum creatinine >140 µmol/l (p=0.005), mechanical ventilation >24 hours (p=0.023).2. Reduced hemodilution during CPB, warm blood cardioplegia, higher perioperative values of Hb, Ht and IDO2 during cardiopulmonary bypass can prevent ischemic injury of abdominal organs during prolonged cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Gastroenteropatias , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Parada Cardíaca Induzida , Humanos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
9.
Anesth Analg ; 133(4): 906-914, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34406128

RESUMO

BACKGROUND: Cardiac surgery with cardiopulmonary bypass induces a profound inflammatory response that, when severe, can lead to multiorgan system dysfunction. Preliminary data suggest that administration of hydroxyethyl starch (HES) solutions may mitigate an inflammatory response and improve pulmonary function. Our goal was to examine the effect of 6% HES 130/0.4 versus 5% human albumin given for intravascular plasma volume replacement on the perioperative inflammatory response and pulmonary function in patients undergoing cardiac surgery. METHODS: This was a subinvestigation of a blinded, parallel-group, randomized clinical trial of patients undergoing elective aortic valve replacement surgery at the Cleveland Clinic main campus, titled "Effect of 6% Hydroxyethyl Starch 130/0.4 on Kidney and Haemostatic Function in Cardiac Surgical Patients." Of 141 patients who were randomized to receive either 6% HES 130/0.4 or 5% human albumin for intraoperative plasma volume replacement, 135 patients were included in the data analysis (HES n = 66, albumin n = 69). We assessed the cardiopulmonary bypass-induced inflammatory response end points by comparing the 2 groups' serum concentrations of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and macrophage migration inhibitory factor (MIF), measured at baseline and at 1 and 24 hours after surgery. We also compared the 2 groups' postoperative pulmonary function end points, including the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (Pao2:Fio2 ratio), dynamic lung compliance, oxygenation index (OI), and ventilation index (VI) at baseline, within 1 hour of arrival to the intensive care unit, and before tracheal extubation. The differences in the postoperative levels of inflammatory response and pulmonary function between the HES and albumin groups were assessed individually in linear mixed models. RESULTS: Serum concentrations of the inflammatory markers (TNF-α, IL-6, MIF) were not significantly different (P ≥ .05) between patients who received 6% HES 130/0.4 or 5% albumin, and there was no significant heterogeneity of the estimated treatment effect over time (P ≥ .15). The results of pulmonary function parameters (Pao2:Fio2 ratio, dynamic compliance, OI, VI) were not significantly different (P ≥ .05) between groups, and there was no significant heterogeneity of the estimated treatment effect over time (P ≥ .15). CONCLUSIONS: Our investigation found no significant difference in the concentrations of inflammatory markers and measures of pulmonary function between cardiac surgical patients who received 6% HES 130/0.4 versus 5% albumin.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Hidratação , Derivados de Hidroxietil Amido/uso terapêutico , Inflamação/etiologia , Pulmão/efeitos dos fármacos , Substitutos do Plasma/uso terapêutico , Albumina Sérica Humana/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Citocinas/sangue , Feminino , Hidratação/efeitos adversos , Humanos , Derivados de Hidroxietil Amido/efeitos adversos , Inflamação/sangue , Inflamação/diagnóstico , Inflamação/prevenção & controle , Mediadores da Inflamação/sangue , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ohio , Substitutos do Plasma/efeitos adversos , Albumina Sérica Humana/efeitos adversos , Resultado do Tratamento
10.
Anesth Analg ; 133(5): 1180-1186, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34415867

RESUMO

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse reaction to heparin. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are routinely anticoagulated with heparin before the initiation of bypass. Heparin is contraindicated, however, in patients with acute HIT, and alternatives to routine practice are often used. While guidelines have recently been published addressing this topic 10, there remains variance between institutions in how these cases are treated. Our goal was to better delineate practice trends in the diagnosis and management of HIT patients requiring CPB. METHODS: We surveyed members of the Society of Cardiovascular Anesthesiologists (SCA) and the American Society for Extracorporeal Technology (AmSECT) using an online survey tool. RESULTS: We received 304 completed surveys (5.8% response rate), 75% completed by an anesthesiologist, and 24% by a perfusionist. The majority of respondents used clinical history and/or antibody testing (71% and 63%, respectively) to diagnose HIT. Seventy-five percent of respondents reported using an institutional protocol for HIT-CPB cases. Most respondents (89%) reported having at least 1 case in the last 3 years, with a total case experience of at least 785 cases (785 = the minimum number of cases in each case volume category × the number of respondents choosing that category). The strategy recommended in published guidelines, bivalirudin, was the most commonly reported alternative anticoagulation strategy (75%) used by respondents in HIT cases, with most (83%) using the activated clotting time (ACT) to monitor anticoagulation. CONCLUSIONS: Most responding SCA and AmSECT members reported that their institution used a protocol or guideline for HIT/CPB cases, and most guidelines directed the use of bivalirudin as an alternative anticoagulant. Various other methods such as plasmapheresis are also being used with success in this patient population. Further research, including comparison studies of alternative anticoagulant strategies, is required to elucidate the best approach to these difficult cases.


Assuntos
Anticoagulantes/administração & dosagem , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Heparina/efeitos adversos , Padrões de Prática Médica/tendências , Trombocitopenia/terapia , Anticoagulantes/imunologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Contraindicações de Procedimentos , Monitoramento de Medicamentos/tendências , Substituição de Medicamentos/tendências , Fidelidade a Diretrizes/tendências , Pesquisas sobre Serviços de Saúde , Heparina/imunologia , Hirudinas , Humanos , Fragmentos de Peptídeos/uso terapêutico , Plasmaferese/tendências , Guias de Prática Clínica como Assunto , Proteínas Recombinantes/uso terapêutico , Medição de Risco , Fatores de Risco , Trombocitopenia/induzido quimicamente , Trombocitopenia/diagnóstico , Trombocitopenia/imunologia , Tempo de Coagulação do Sangue Total/tendências
11.
J Card Surg ; 36(10): 3749-3760, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34251716

RESUMO

BACKGROUND: Vasoplegic syndrome (VPS) is defined as systemic hypotension due to profound vasodilatation and loss of systemic vascular resistance (SVR), despite normal or increased cardiac index, and characterized by inadequate response to standard doses of vasopressors, and increased morbidity and mortality. It occurs in 9%-44% of cardiac surgery patients after cardiopulmonary bypass (CPB). The underlying pathophysiology following CPB consists of resistance to vasopressors (inactivation of Ca2+ voltage gated channels) on the one hand and excessive activation of vasodilators (SIRS, iNOS, and low AVP) on the other. Use of angiotensin-converting enzyme inhibitor (ACE-I), calcium channel blockers, amiodarone, heparin, low cardiac reserve (EF < 35%), symptomatic congestive heart failure, and diabetes mellitus are the perioperative risk factors for VPS after cardiac surgery in adults. Till date, there is no consensus about the outcome-oriented therapeutic management of VPS. Vasopressors such as norepinephrine (NE; 0.025-0.2 µg/kg/min) and vasopressin (0.06 U/min or 6 U/h median dose) are the first choice for the treatment. The adjuvant therapy (hydrocortisone, calcium, vitamin C, and thiamine) and rescue therapy (methylene blue [MB] and hydroxocobalamin) are also considered when perfusion goals (meanarterial pressure [MAP] > 60-70 mmHg) are not achieved with nor-epinephrine and/or vasopressin. AIMS: The aims of this systematic review are to collect all the clinically relevant data to describe the VPS, its potential risk factors, pathophysiology after CPB, and to assess the efficacy, safety, and outcome of the therapeutic management with catecholamine and non-catecholamine vasopressors employed for refractory vasoplegia after cardiac surgery. Also, to elucidate the current and practical approach for management of VPS after cardiac surgery. MATERIAL AND METHODS: "PubMed," "Google," and "Medline" weresearched, and over 150 recent relevant articles including RCTs, clinical studies, meta-analysis, reviews, case reports, case series and Cochrane data were analyzed for this systematic review. The filter was applied specificallyusing key words like VPS after cardiac surgery, perioperative VPS following CPB, morbidity, and mortality in VPS after cardiac surgery, vasopressors for VPS that improve outcomes, VPS after valve surgery, VPS after CABG surgery, VPS following complex congenital cardiac anomalies corrective surgery, rescue therapy for VPS, adjuvant therapy for VPS, definition of VPS, outcome in VPS after cardiac surgery, etiopathology of VPS following CPB. This review did not require any ethical approval or consent from the patients. RESULTS: Despite the recent advances in therapy, the mortality remains as high as 30%-50%. NE has been recommended the most frequent used vasopressor for VPS. It restores and maintain the MAP and provides the outcome benefits. Vasopressin rescue therapy is an alternative approach, if catecholamines and fluid infusions fail to improve hemodynamics. It effectively increases vascular tone and lowers CO, and significantly decreases the 30 days mortality. Hence, suggested a first-line vasopressor agent in postcardiac surgery VPS. Terlipressin (1.3µg/kg/h), a longer acting and more specific vasoconstrictor prevents the development of VPS after CPB in patients treated with ACE-I. MB significantly reduces morbidity and mortality of VPS. The Preoperative MB (1%, 2mg/kg/30min, 1h before surgery) administration in high risk (on ACE-I) patients for VPS undergoing CABG surgery, provides 100% protection against VPS, and early of MB significantly reduces operative mortality, and recommended as a rescue therapy for VPS. Hydroxocobalamin (5 g) has been recommended as a rescue agent in VPS refractory to multiple vasopressors. A combination of ascorbic acid (6 g), hydrocortisone (200 mg/day), and thiamine (400 mg/day) as an adjuvant therapy significantly reduces the vasopressors requirement, and provides mortality and morbidity benefits. CONCLUSION: Currently, the VPS is frequently encountered (9%-40%) in cardiac surgical patients with predisposing patient-specific risk factors and combined with inflammatory response to CPB. Multidrug therapy (NE, MB, AVP, ATII, terlipressin, hydroxocobalamin) targeting multiple receptor systems is recommended in refractory VPS. A combination of high dosage of ascorbic acid, hydrocortisone and thiamine has been used successfully as adjunctive therapyto restore the MAP. We also advocate for the early use of multiagent vasopressors therapy and catecholamine sparing adjunctive agents to restore the systemic perfusion pressure with a goal of preventing the progressive refractory VPS.


Assuntos
Vasoplegia , Adulto , Ponte Cardiopulmonar/efeitos adversos , Quimioterapia Combinada , Humanos , Hidroxocobalamina/uso terapêutico , Hansenostáticos/uso terapêutico , Vasoplegia/tratamento farmacológico , Vasoplegia/etiologia
12.
BMJ Open ; 11(7): e044424, 2021 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-34244250

RESUMO

INTRODUCTION: Cytokine storm and endotoxin release during cardiac surgery with cardiopulmonary bypass (CPB) have been related to vasoplegic shock and organ dysfunction. We hypothesised that early (during CPB) cytokine adsorption with oXiris membrane for patients at high risk of inflammatory syndrome following cardiac surgery may improve microcirculation, endothelial function and outcomes. METHODS AND ANALYSIS: The Oxicard trial is a prospective, monocentric trial, randomising 70 patients scheduled for cardiac surgery. The inclusion criterion is patients aged more than 18 years old undergoing elective cardiac surgery under CPB with an expected CPB time >90 min (double valve replacement or valve replacement plus coronary arterial bypass graft). Patients will be allocated to the intervention group (n=35) or the control group (n=35). In the intervention group, oXiris membrane will be used on the Prismaflex device (Baxter) at blood pump flow of 450 mL/min during cardiac surgery under CPB. In the control group, cardiac surgery under CPB will be conducted as usual without oXiris membrane. An intention-to-treat analysis will be performed. The primary endpoint will be the microcirculatory flow index measured by sublingual microcirculation device at day 1 following cardiac surgery. The secondary endpoints will be other microcirculation variables at CPB end, 6 hours after CPB, at day 1 and at day 2. We also aim to evaluate the occurrence of major cardiovascular and cerebral events (eg, myocardial infarction, stroke, ischaemic mesenteric, resuscitated cardiac arrest, acute kidney injury) within the first 30 days. Cumulative catecholamine use, intensive care unit length of stay, endothelium glycocalyx shedding parameters (syndecan-1, heparan-sulfate and hyaluronic acid), inflammatory cytokines (tumour necrosis factor (TNF) alpha, interleukin 1 (IL1) beta, IL 10, IL 6, lipopolysaccharide, endothelin) and endothelial permeability biomarkers (angiopoietin 1, angiopoietin 2, Tie2 soluble receptor and Vascular Endothelial Growth Factor (VEGF) will also be evaluated. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Institutional Review Board of the University Hospital of Amiens (registration number ID RDB: 2019-A02437-50 in February 2020). Results of the study will be disseminated via peer-reviewed publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: NCT04201119.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Adolescente , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Humanos , Microcirculação , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fator A de Crescimento do Endotélio Vascular
13.
J Card Surg ; 36(10): 3577-3585, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34327740

RESUMO

BACKGROUND: Acute kidney injury (AKI) is common after cardiac surgery requiring cardiopulmonary bypass. Renal hypoxia may precede clinically detectable AKI. We compared the efficacy of two indices of renal hypoxia, (i) intraoperative urinary oxygen tension (UPO2 ) and (ii) the change in plasma erythropoietin (pEPO) during surgery, in predicting AKI. We also investigated whether the performance of these prognostic markers varies with preoperative patient characteristics. METHODS: In 82 patients undergoing on-pump cardiac surgery, blood samples were taken upon induction of anesthesia and upon entry into the intensive care unit. UPO2 was continuously measured throughout surgery. RESULTS: Thirty-two (39%) patients developed postoperative AKI. pEPO increased during surgery, but this increase did not predict AKI, regardless of risk of postoperative mortality assessed by EuroSCORE-II. For patients categorized at higher risk by EuroSCORE-II >1.98 (median score for the cohort), UPO2 ≤10 mmHg at any time during surgery predicted a 4.04-fold excess risk of AKI (p = .04). However, UPO2 did not significantly predict AKI in lower-risk patients. UPO2 significantly predicted AKI in patients who were older, had previous myocardial infarction, diabetes, lower preoperative serum creatinine, or shorter bypass times. pEPO and UPO2 were only weakly correlated. CONCLUSIONS: Intraoperative change in pEPO does not predict AKI. However, UPO2 shows promise, particularly in patients with higher risk of operative mortality. The disparity between these two markers of renal hypoxia may indicate that UPO2 reflects medullary oxygenation whereas pEPO reflects cortical oxygenation.


Assuntos
Injúria Renal Aguda , Procedimentos Cirúrgicos Cardíacos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Humanos , Hipóxia/etiologia , Complicações Pós-Operatórias , Fatores de Risco
14.
Redox Biol ; 46: 102086, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34332210

RESUMO

After cardiopulmonary bypass (CPB), the occurrence of systemic inflammatory response is often accompanied by a persistent compensatory anti-inflammatory response syndrome that can lead to a compromised immune competence termed immunoparalysis, rendering the patients susceptible to infections which is a leading complication following cardiac surgery. However, the underlying mechanisms of CPB-elicited immunoparalysis remain obscure. In this study we showed that peroxiredoxin 1 (Prdx1), a putative cytosolic antioxidant, was released immediately after CPB in a cohort of pediatric patients receiving congenital cardiac surgery. This increased Prdx1 was correlated to a reduced human leukocyte antigen-DR expression and an elevated interleukin-10 (IL-10) production, as well as a hypo-responsiveness of macrophages to endotoxin and a higher incidence of nosocomial infection. We demonstrated that substitution of Ser83 for Cys83 prevented Prdx1 from oligomerization and subsequent binding and internalization to macrophages. These effects mitigated Prdx1-induced IL-10 induction and endotoxin tolerance. Furthermore, after engagement with toll-like receptor (TLR) 4, clathrin-dependent endocytosis is crucial for Prdx1 to elicit IL-10 production in phagocytes. Congruently, inhibition of Prdx1/TLR4 endocytosis in phagocytes reversed the Prdx1/IL-10-mediated hypo-responsiveness to endotoxin. Our findings unveiled the possible mechanisms by which Prdx1 undertakes to cause immunoparalysis, and targeting endocytosis of Prdx1 could be a novel therapeutic approach for postoperative infections associated with CPB.


Assuntos
Ponte Cardiopulmonar , Peroxirredoxinas , Ponte Cardiopulmonar/efeitos adversos , Criança , Endocitose , Antígenos HLA-DR , Humanos , Inflamação , Peroxirredoxinas/genética
15.
Thorac Cardiovasc Surg ; 69(6): 542-547, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34233365

RESUMO

BACKGROUND: Systemic inflammation contributes to cardiac surgery-associated acute kidney injury (AKI). Cardiomyocytes and other organs experience hypothermia and hypoxia during cardiopulmonary bypass (CPB), which induces the secretion of cold-inducible RNA-binding protein (CIRP). Extracellular CIRP may induce a proinflammatory response. MATERIALS AND METHODS: The serum CIRP levels in 76 patients before and after cardiac surgery were determined to analyze the correlation between CIRP levels and CPB time. The risk factors for AKI after cardiac surgery and the in-hospital outcomes were also analyzed. RESULTS: The difference in the levels of CIRP (ΔCIRP) after and before surgery in patients who experienced cardioplegic arrest (CA) was 26-fold higher than those who did not, and 2.7-fold of those who experienced CPB without CA. The ΔCIRP levels were positively correlated with CPB time (r = 0.574, p < 0.001) and cross-clamp time (r = 0.54, p < 0.001). Multivariable analysis indicated that ΔCIRP (odds ratio: 1.003; 95% confidence interval: 1.000-1.006; p = 0.027) was an independent risk factor for postoperative AKI. Patients who underwent aortic dissection surgery had higher levels of CIRP and higher incidence of AKI than other patients. The incidence of AKI and duration of mechanical ventilation in patients whose serum CIRP levels more than 405 pg/mL were significantly higher than those less than 405 pg/mL (65.8 vs. 42.1%, p = 0.038; 23.1 ± 18.2 vs. 13.8 ± 9.2 hours, p = 0.007). CONCLUSION: A large amount of CIRP was released during cardiac surgery. The secreted CIRP was associated with the increased risk of AKI after cardiac surgery.


Assuntos
Injúria Renal Aguda/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Proteínas de Ligação a RNA/sangue , Injúria Renal Aguda/sangue , Injúria Renal Aguda/diagnóstico , Biomarcadores/sangue , China/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
16.
Pediatr Cardiol ; 42(8): 1862-1870, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34296332

RESUMO

During cardiopulmonary bypass (CPB), high flows can allow an adequate perfusion to kidneys, but, on the other hand, they could cause emboli production, increased vascular pressure, and a more intense inflammatory response, which are in turn causes of renal damage. Along with demographic variables, other intra-operative management and post-operative events, this might lead to Acute kidney injury (AKI) in infants undergoing cardiac surgery. The aim of our study was to investigate if a CPB strategy with flow requirements based on monitoring of continuous metabolic and hemodynamic parameters could have an impact on outcomes, with a focus on renal damage. Thirty-four consecutive infants and young children undergoing surgery requiring CPB, comparable as for demographic and patho-physiological profile, were included. In Group A, 16 patients underwent, for a variable period of 20 min, CPB aiming for the minimal flow that could maintain values of MVO2 > 70% and frontal NIRS (both left and right) > 45%, and renal NIRS > 65%. In Group B, 18 patients underwent nominal flows CPB. Tapered CPB allowed for a mean reduction of flows of 34%. No difference in terms of blood-gas analysis, spectroscopy trend, laboratory analyses, and hospital outcome were recorded. In patients developing AKI (20%), renal damage was correlated with demographic characteristics and with renal NIRS during the first 6 h in the ICU. A safe individualized strategy for conduction of CPB, which allows significant flow reduction while maintaining normal hemodynamic and metabolic parameters, does not impact on renal function and hospital outcomes.


Assuntos
Ponte Cardiopulmonar , Cardiopatias Congênitas , Ponte Cardiopulmonar/efeitos adversos , Criança , Pré-Escolar , Cardiopatias Congênitas/cirurgia , Hospitais , Humanos , Lactente , Rim/fisiologia , Projetos Piloto
17.
Am J Case Rep ; 22: e930890, 2021 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-34143764

RESUMO

BACKGROUND Cardiac vasoplegic syndrome is a form of vasodilatory shock characterized by profound vasodilation and low systemic vascular resistance, which results in significant hypotension despite high cardiac output and appropriate fluid resuscitation. In up to 45% of patients, cardiopulmonary bypass (CPB) can precipitate vasoplegic syndrome. Vasoplegic syndrome after CPB that is refractory to other vasopressors, such as catecholamine and vasopressin, has been successfully treated with inhibitors of the nitric oxide (NO) system, such as methylene blue and hydroxocobalamin. Methylene blue has been the treatment of choice because of its effectiveness for both prevention and rescue therapy. Hydroxocobalamin has demonstrated efficacy in combination with methylene blue, and also on its own when vasoplegic syndrome is refractory to methylene blue. CASE REPORT We present 2 cases that expand upon the existing evidence supporting the efficacy of hydroxocobalamin as a first-line option for inhibiting the NO system in vasoplegic syndrome that is refractory to other vasopressors. Specifically, we demonstrate the appropriate and successful use of hydroxocobalamin alone to treat refractory vasoplegic syndrome after CPB. CONCLUSIONS Refractory vasoplegic syndrome that occurs after CPB has been successfully treated with inhibitors of the NO system, such as methylene blue and hydroxocobalamin. The present cases expand upon the scant existing evidence of the efficacy of hydroxocobalamin as an appropriate option for refractory vasoplegic syndrome.


Assuntos
Hipotensão , Vasoplegia , Ponte Cardiopulmonar/efeitos adversos , Humanos , Hidroxocobalamina/uso terapêutico , Azul de Metileno/uso terapêutico , Vasoplegia/tratamento farmacológico , Vasoplegia/etiologia
18.
Biomolecules ; 11(5)2021 05 17.
Artigo em Inglês | MEDLINE | ID: mdl-34067880

RESUMO

(1) Alkaline phosphatase (AP) is consumed during cardiopulmonary bypass (CPB). A high AP depletion leads to an impaired outcome after cardiac surgery. However, data is scarce on the postoperative course of AP under venoarterial ECMO (VA-ECMO) support. (2) A total of 239 patients with VA-ECMO support between 2000 and 2019 at the Department of Cardiac Surgery (Vienna General Hospital, Austria) were included in this retrospective analysis. Blood samples were collected at several timepoints (baseline, postoperative day (POD) 1-7, POD 14 and 30). Patients were categorized according to the relative AP drop (<60% vs. ≥60%) and ECMO duration (<5 days vs. ≥5 days). (3) Overall, 44.4% reached the baseline AP values within 5 days-this was only the case for 28.6% with a higher AP drop (compared to 62.7% with a lower drop; p = 0.000). A greater AP drop was associated with a significantly higher need for renal replacement therapy (40.9% vs. 61.9%; p = 0.002) and an impaired 1-year survival (51.4% vs. 66.0%; p = 0.031). (4) CPB exceeds the negative impact of VA-ECMO; still, ECMO seems to delay alkaline phosphatase recovery. A greater initial AP drop bears the risk of higher morbidity and mortality.


Assuntos
Fosfatase Alcalina/sangue , Ponte Cardiopulmonar/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
19.
PLoS Med ; 18(6): e1003658, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34097705

RESUMO

BACKGROUND: The dose of protamine required following cardiopulmonary bypass (CPB) is often determined by the dose of heparin required pre-CPB, expressed as a fixed ratio. Dosing based on mathematical models of heparin clearance is postulated to improve protamine dosing precision and coagulation. We hypothesised that protamine dosing based on a 2-compartment model would improve thromboelastography (TEG) parameters and reduce the dose of protamine administered, relative to a fixed ratio. METHODS AND FINDINGS: We undertook a 2-stage, adaptive randomised controlled trial, allocating 228 participants to receive protamine dosed according to a mathematical model of heparin clearance or a fixed ratio of 1 mg of protamine for every 100 IU of heparin required to establish anticoagulation pre-CPB. A planned, blinded interim analysis was undertaken after the recruitment of 50% of the study cohort. Following this, the randomisation ratio was adapted from 1:1 to 1:1.33 to increase recruitment to the superior arm while maintaining study power. At the conclusion of trial recruitment, we had randomised 121 patients to the intervention arm and 107 patients to the control arm. The primary endpoint was kaolin TEG r-time measured 3 minutes after protamine administration at the end of CPB. Secondary endpoints included ratio of kaolin TEG r-time pre-CPB to the same metric following protamine administration, requirement for allogeneic red cell transfusion, intercostal catheter drainage at 4 hours postoperatively, and the requirement for reoperation due to bleeding. The trial was listed on a clinical trial registry (ClinicalTrials.gov Identifier: NCT03532594). Participants were recruited between April 2018 and August 2019. Those in the intervention/model group had a shorter mean kaolin r-time (6.58 [SD 2.50] vs. 8.08 [SD 3.98] minutes; p = 0.0016) post-CPB. The post-protamine thromboelastogram of the model group was closer to pre-CPB parameters (median pre-CPB to post-protamine kaolin r-time ratio 0.96 [IQR 0.78-1.14] vs. 0.75 [IQR 0.57-0.99]; p < 0.001). We found no evidence of a difference in median mediastinal/pleural drainage at 4 hours postoperatively (140 [IQR 75-245] vs. 135 [IQR 94-222] mL; p = 0.85) or requirement (as a binary outcome) for packed red blood cell transfusion at 24 hours postoperatively (19 [15.8%] vs. 14 [13.1%] p = 0.69). Those in the model group had a lower median protamine dose (180 [IQR 160-210] vs. 280 [IQR 250-300] mg; p < 0.001). Important limitations of this study include an unblinded design and lack of generalisability to certain populations deliberately excluded from the study (specifically children, patients with a total body weight >120 kg, and patients requiring therapeutic hypothermia to <28°C). CONCLUSIONS: Using a mathematical model to guide protamine dosing in patients following CPB improved TEG r-time and reduced the dose administered relative to a fixed ratio. No differences were detected in postoperative mediastinal/pleural drainage or red blood cell transfusion requirement in our cohort of low-risk patients. TRIAL REGISTRATION: ClinicalTrials.gov Unique identifier NCT03532594.


Assuntos
Anticoagulantes/administração & dosagem , Coagulação Sanguínea/efeitos dos fármacos , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Antagonistas de Heparina/administração & dosagem , Heparina/administração & dosagem , Protaminas/administração & dosagem , Idoso , Anticoagulantes/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Cálculos da Dosagem de Medicamento , Monitoramento de Medicamentos , Inglaterra , Feminino , Heparina/efeitos adversos , Antagonistas de Heparina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Protaminas/efeitos adversos , Tromboelastografia , Fatores de Tempo , Resultado do Tratamento , Vitória
20.
J Cardiothorac Surg ; 16(1): 135, 2021 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-34001213

RESUMO

BACKGROUND: It's necessary to analyze the related risk factors and complications of low cardiac output syndrome (LCOS) after operation in children with congenital heart disease (CHD), to elucidate the management strategy of LCOS. METHODS: CHD children admitted to the department of cardiology in our hospital from January 15, 2019 to October 31, 2020 were included. The personal and clinical data of CHD children with LCOS and without LCOS were collected and compared. Logistic regression analyses were conducted to identify the risk factors of postoperative LCOS. Besides, the complication and mortality of LCOS and no LCOS patients were compared. RESULTS: A total of 283 CHD patients were included, the incidence of postoperative LCOS in CHD patients was 12.37%. There were significant differences in the age, preoperative oxygen saturation, two-way ventricular shunt, duration of CPB and postoperative residual shunt between two groups (all p < 0.05). Logistic regression analyses indicated that age ≤ 4y(OR2.426, 95%CI1.044 ~ 4.149), preoperative oxygen saturation ≤ 93%(OR2.175, 95%CI1.182 ~ 5.033), two-way ventricular shunt (OR3.994, 95%CI1.247 ~ 6.797), duration of CPB ≥ 60 min(OR2.172, 95%CI1.002 ~ 4.309), postoperative residual shunt (OR1.487, 95%CI1.093 ~ 2.383) were the independent risk factors of LCOS in patients with CHD (all p < 0.05). There were significant differences in the acute liver injury, acute kidney injury, pulmonary infection, tracheotomy, duration of mechanical ventilation, length of ICU stay and mortality (all p < 0.05), no significant difference in the 24 h drainage was found(p = 0.095). CONCLUSION: LCOS after CHD is common, more attentions should be paid to those patients with age ≤ 4y, preoperative oxygen saturation ≤ 93%, two-way ventricular shunt, duration of CPB ≥ 60 min, postoperative residual shunt to improve the prognosis of CHD patients.


Assuntos
Baixo Débito Cardíaco/etiologia , Ponte Cardiopulmonar/efeitos adversos , Cardiopatias Congênitas/cirurgia , Complicações Pós-Operatórias/etiologia , Injúria Renal Aguda/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Masculino , Período Pós-Operatório , Prognóstico , Análise de Regressão , Respiração Artificial/efeitos adversos , Fatores de Risco
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