Intensive Care Med. 2004 Feb 24   [Epub ahead of print] 

Transpulmonary lactate gradient after hypothermic cardiopulmonary bypass.

Bendjelid K, Treggiari MM, Romand JA.

Division of Surgical Intensive Care, Department of Anaesthesiology, Pharmacology
and Surgical Intensive Care, Geneva University Hospitals, 1211, Geneva,
Switzerland.

OBJECTIVE. Several studies demonstrated that the lungs could produce lactate in
patients with acute lung injury (ALI). Because after cardiopulmonary bypass
(CPB) some patients develop ALI, the effect of CPB on pulmonary lactate release
was investigated. DESIGN. Prospective observational clinical study. SETTING.
Twenty-beds, surgical ICU at a university hospital. PATIENTS. Sixteen deeply
sedated, ventilated and post-cardiac surgery patients, all equipped with a
pulmonary artery catheter. MEASUREMENTS AND RESULTS. Lactate concentration was
measured using a lactate analyser in simultaneously drawn arterial (A) and mixed
venous (V) blood samples. Three measurements per patients were taken at 30-min
interval, after body temperature reached 37 degrees C. Concomitantly,
measurements of cardiac output were also obtained. Pulmonary lactate release was
calculated as the product of transpulmonary A-V lactate and cardiac index. The
mean cardiopulmonary bypass duration was 100+/-44 min (SD), and the aortic
cross-clamping time was 71+/-33 min. After CPB, lactate release was
0.136+/-0.210 mmol/min m(-2). These values were not correlated with
cardiopulmonary bypass duration. CONCLUSION. The present study shows that in
patients receiving mechanical ventilation after CPB, the lung is a source of
lactate production. This pulmonary release was not dependent on cardiopulmonary
bypass duration.

J Cardiothorac Vasc Anesth.  2004 Feb;18(1):59-63.  

Postoperative intravenous iron used alone or in combination with low-dose
erythropoietin is not effective for correction of anemia after cardiac surgery.

Madi-Jebara SN, Sleilaty GS, Achouh PE, Yazigi AG, Haddad FA, Hayek GM, Antakly
MC, Jebara VA.

OBJECTIVES: The aim of this study was to examine whether intravenous iron
III-hydroxide sucrose complex (IHSC) used alone was sufficient to provide rapid
correction of anemia after cardiac surgery and whether additional stimulation of
erythropoiesis is possible by means of a single low dose of recombinant-human
erythropoietin (r-HuEPO) administration. DESIGN: Prospective, randomized,
double-blind study. SETTING: The study was conducted in a university hospital.
PARTICIPANTS: One hundred twenty American Society of Anesthesiologists II or III
patients, who underwent elective cardiac surgery using cardiopulmonary bypass
and in whom postpump hemoglobin ranged between 7 and 10 g/dL. INTERVENTIONS:
Patients were divided into 3 groups: group I = control; group II received
postoperative intravenous iron supplementation with an iron III-hydroxide
sucrose complex (IHSC); and group III received IV iron and a single dose of
r-HuEPO (300 U/kg). Measurements and results: No significant difference in
transfusion needs was observed among the 3 groups (22%, 25%, and 17% of patients
transfused in groups I, II, and III, respectively). Hemoglobin levels,
reticulocyte counts, and serum ferritin levels were evaluated at different time
intervals (until day 30 postoperatively). No side effects because of iron
administration were noted in the study. Reticulocyte counts increased rapidly at
day 5 (2.24% +/- 1.11%, 1.99% +/- 1.44%, and 3.84% +/- 2.02% in groups I, II,
and III, respectively) and decreased after day 15 in the 3 groups. Ferritin
levels increased significantly at day 5 in the 2 treated groups (899.33 +/-
321.55 ng/mL in group II, 845.75 +/- 289.96 ng/mL in group III v 463.15 +/-
227.74 ng/mL in group I). In group I, ferritin levels, after a slight elevation
on day 5, decreased at day 15 to lower than baseline levels. No significant
difference in hemoglobin increase was noted among the 3 groups. CONCLUSION:
Postoperative intravenous iron supplementation alone or in combination with a
single dose of r-HuEPO (300 U/kg) is not effective in correcting anemia after
cardiac surgery.

Artif Organs.  2004 Feb;28(2):189-95.  

Outcome of the perioperative use of percutaneous cardiopulmonary support for
adult cardiac surgery: factors affecting hospital mortality.

Murashita T, Eya K, Miyatake T, Kamikubo Y, Shiiya N, Yasuda K, Sasaki S.

Department of Cardiovascular Surgery, Hokkaido University Hospital, Sapporo
Division of Medical Sciences, Health Science University of Hokkaido,
Ishikari-Tobetsu, Japan.

Percutaneous cardiopulmonary bypass support (PCPS) has become a widespread
standard modality for the treatment of circulatory collapse; however, its
clinical use for postcardiotomy low cardiac output syndrome (LOS) has been
reported to be unsatisfactory. We reviewed the clinical outcomes of twenty-three
patients undergoing cardiac surgery and treated with PCPS. Solitary coronary
artery grafting was undertaken for nine patients, while three had concomitant
procedures. The remaining patients underwent valvular surgery. The indications
for PCPS were preoperative shock in two patients and postcardiotomy LOS or shock
in twenty-one patients. All patients except one underwent an intraaortic balloon
pump. Sixteen of the twenty-three patients (69.6%) were weaned from PCPS and
twelve patients (52.2%) reached hospital discharge. A univariate analysis
revealed that risk factors for hospital mortality were age older than seventy
years (P = 0.05), PCPS running time (P = 0.017), low cardiac function at the
institution of PCPS (P = 0.004), and urine output within the initial 24 h (P =
0.041). The cardiac index (CI) in survivors was improved within 24 h, and eleven
of the twelve survivors were weaned off PCPS within 48 h, whereas ten of the
twelve nonsurvivors required PCPS for more than 48 h (P = 0.0006). There is
little possibility of weaning patients from PCPS who do not show any signs of
hemodynamic recovery within 48 h after its institution. Limited use of PCPS
within 48 h may be applicable for postcardiotomy patients, but other
cardiopulmonary support, such as a left ventricular assist device, may be
required when hemodynamic recovery is not obtained within 48 h.

J Thorac Cardiovasc Surg.  2004 Feb;127(2):525-34.  

Can the use of methylprednisolone, vitamin C, or alpha-trinositol prevent
cold-induced fluid extravasation during cardiopulmonary bypass in piglets?

Farstad M, Heltne JK, Rynning SE, Onarheim H, Mongstad A, Eliassen F, Husby P.

Department of Anesthesia and Intensive Care, University of Bergen, Haukeland
University Hospital, Norway.

OBJECTIVE: Hypothermic cardiopulmonary bypass is associated with capillary fluid
leakage, resulting in edema and occasionally organ dysfunction. Systemic
inflammatory activation is considered responsible. In some studies
methylprednisolone has reduced the weight gain during cardiopulmonary bypass.
Vitamin C and alpha-trinositol have been demonstrated to reduce the
microvascular fluid and protein leakage in thermal injuries. We therefore tested
these three agents for the reduction of cold-induced fluid extravasation during
cardiopulmonary bypass. METHODS: A total of 28 piglets were randomly assigned to
four groups of 7 each: control group, high-dose vitamin C group,
methylprednisolone group, and alpha-trinositol-group. After 1 hour of
normothermic cardiopulmonary bypass, hypothermic cardiopulmonary bypass was
initiated in all animals and continued to 90 minutes. The fluid level in the
extracorporeal circuit reservoir was kept constant at the 400-mL level and used
as a fluid gauge. Fluid needs, plasma volume, changes in colloid osmotic
pressure in plasma and interstitial fluid, hematocrit, and total water contents
in different tissues were recorded, and the protein masses and the fluid
extravasation rate were calculated. RESULTS: Hemodilution was about 25% after
start of normothermic cardiopulmonary bypass. Cooling did not cause any further
changes in hemodilution. During steady-state normothermic cardiopulmonary
bypass, the fluid need in all groups was about 0.10 mL/(kg.min), with a 9-fold
increase during the first 30 minutes of cooling (P <.001). This increased fluid
need was due mainly to increased fluid extravasation from the intravascular to
the interstitial space at a mean rate of 0.6 mL/(kg.min) (range 0.5-0.7
mL/[kg.min]; P <.01) and was reflected by increased total water content in most
tissues in all groups. The albumin and protein masses remained constant in all
groups throughout the study. CONCLUSION: Pretreatment with methylprednisolone,
vitamin C, or alpha-trinositol was unable to prevent the increased fluid
extravasation rate during hypothermic cardiopulmonary bypass. These findings,
together with the stability of the protein masses throughout the study, support
the presence of a noninflammatory mechanism behind the cold-induced fluid
leakage seen during cardiopulmonary bypass.

Ann Thorac Surg.  2004 Feb;77(2):644-50.  

Effects of nafamostat mesilate and minimal-dose aprotinin on blood-foreign
surface interactions in cardiopulmonary bypass.

Kaminishi Y, Hiramatsu Y, Watanabe Y, Yoshimura Y, Sakakibara Y.

Division of Cardiovascular Surgery, Jichi Medical School, Tochigi, Japan.

BACKGROUND: The pharmacological inhibition of blood-foreign surface interactions
is an attractive strategy for reducing the morbidity associated with
cardiopulmonary bypass. We compared the inhibitory effects of nafamostat
mesilate (a broad-spectrum synthetic protease inhibitor) and minimal-dose
aprotinin on blood-surface interactions in clinical cardiopulmonary bypass.
METHODS: Eighteen patients undergoing coronary surgery were divided into three
groups: (1) the control group (heparin, 4 mg/kg; n = 6), (2) the nafamostat
mesilate group (heparin plus nafamostat, 0.2 mg/kg bolus followed by 2.0 mg/kg/h
during cardiopulmonary bypass; n = 6), and (3) the aprotinin group (heparin plus
aprotinin, 2.0 x 10(4) KIU/kg; n = 6). Platelet count, platelet aggregation,
beta-thromboglobulin, prothrombin fragment F1.2, thrombin-antithrombin complex,
plasminogen activator inhibitor-1, alpha2-plasmin inhibitor-plasmin complex,
D-dimer, neutrophil elastase, and interleukin-6 were measured before, during,
and after bypass. Bleeding times and blood loss were recorded. RESULTS: There
were no significant differences between groups in platelet count,
beta-thromboglobulin, plasminogen activator inhibitor-1, interleukin-6, bleeding
times, or blood loss. Platelet aggregation was better preserved at 12 hours
after surgery in the nafamostat and aprotinin groups than in the control group.
Prothrombin fragment F1.2, thrombin-antithrombin complex and neutrophil elastase
levels were significantly reduced by aprotinin, but not by nafamostat as
compared with the control group. The alpha2-plasmin inhibitor-plasmin complex
and D-dimer were significantly lower with either of the drugs. Aprotinin showed
better control of D-dimer than did nafamostat. CONCLUSIONS: Nafamostat mesilate
fails to reduce thrombin formation and neutrophil elastase release, whereas
minimal-dose aprotinin inhibits both. Neither nafamostat nor aprotinin inhibits
platelet activation. Nafamostat reduces fibrinolysis during cardiopulmonary
bypass, although its effect is not as potent as aprotinin.

Ann Thorac Surg.  2004 Feb;77(2):500-5.  

Clinical outcome after cardiac operations in patients with cirrhosis.

Hayashida N, Shoujima T, Teshima H, Yokokura Y, Takagi K, Tomoeda H, Aoyagi S.

Department of Surgery, Kurume University, Kurume, Japan.
nobuhiko@med-kurume-u.ac.jp

BACKGROUND: To evaluate the clinical outcome after cardiac operations in
patients with cirrhosis, a retrospective study was undertaken. METHODS: Between
1989 and 2003, 18 patients with cirrhosis who underwent cardiac operations were
identified. Their preoperative status and postoperative clinical results were
assessed. RESULTS: Ten patients were classified as having Child-Pugh class A
cirrhosis, 7 as having class B cirrhosis, and 1 as having class C cirrhosis.
Fifteen of 18 patients underwent cardiac surgery using cardiopulmonary bypass,
and the remaining 3 patients with class B cirrhosis received coronary artery
bypass grafting without cardiopulmonary bypass. In patients undergoing
cardiopulmonary bypass, 60% of those with class A cirrhosis and 100% of those
with class B cirrhosis and class C cirrhosis had postoperative major
complications, including infection, respiratory failure, renal failure,
bleeding, and gastrointestinal disorder. One of 3 patients (33%) with class B
cirrhosis undergoing coronary artery bypass grafting without cardiopulmonary
bypass had major complications. The overall postoperative mortality rate was
17%. Hospital mortality of patients with class A cirrhosis, class B cirrhosis,
and class C cirrhosis undergoing cardiopulmonary bypass was 0%, 50%, and 100%,
respectively. None of 3 patients with class B cirrhosis undergoing coronary
artery bypass grafting without cardiopulmonary bypass died in this study.
CONCLUSIONS: Although the incidence of major complications was high, patients
with Child-Pugh class A cirrhosis tolerated cardiac surgery satisfactorily.
Patients with more advanced cirrhosis, however, may not be suitable for elective
cardiac operations with cardiopulmonary bypass. Although our results are not
conclusive, coronary artery bypass grafting without cardiopulmonary bypass can
be an alternative therapeutic strategy for patients with advanced cirrhosis
requiring surgical revascularization.

Eur J Cardiothorac Surg.  2004 Feb;25(2):261-6.  

Clinical evaluation of a new fat removal filter during cardiac surgery.

de Vries AJ, Gu YJ, Douglas YL, Post WJ, Lip H, van Oeveren W.

Department of Anesthesiology, University Hospital Groningen, Hanzeplein 1, P.O.
Box 30.001, 9700 RB, Groningen, The Netherlands

Fat microemboli are generated during cardiac surgery that are associated with
post-operative organ injury. Recently, a fat removal filter has been developed,
based on a polyester leukocyte depletion filter. However, the efficacy of such a
filter in a clinical setting is unknown. In this study we tested the efficacy of
this filter.Coronary artery bypass patients were randomly divided into two
groups. Group I: filtration of cardiotomy suction blood during cardiopulmonary
bypass with a fat removal filter (n=14). Group II: control patients without
filtration (n=14). Filter efficacy was evaluated in group I using biochemical
assays and thin layer chromatography of blood samples taken simultaneously
before and after the filter. In addition, clinical and biochemical markers for
organ injury were determined in both groups.The fat filter removed triglycerides
(0.9+/-0.08 vs. 0.63+/-0.08 mmol l(-1), P=0.004, paired t-test), leukocytes
(4.3+/-0.8x10(9) vs. 2.3+/-0.6x10(9)l(-1), P=0.03), and platelets
(116+/-26x10(9) vs. 75+/-21x10(9)l(-1), P=0.003) from the blood samples taken
before and after the filter. Chromatography showed a significant reduction in
free fatty acids, phospholipids and triglycerides. Clinically, leukocyte counts
were similar, but platelet counts were higher (181+/-14x10(9) vs.
117+/-8.6x10(9)l(-1) control, P<0.001) in group I on the first postoperative
day.The fat filter removed 40% fat, leukocytes and platelets from cardiotomy
suction blood during cardiac surgery. A larger scale study is necessary to
determine clinical effects on organ damage.

Anesth Analg.  2004 Feb;98(2):291-7, table of contents.  

Hydroxyethyl starch as a priming solution for cardiopulmonary bypass impairs
hemostasis after cardiac surgery.

Kuitunen AH, Hynynen MJ, Vahtera E, Salmenpera MT.

Department of Anesthesia and Intensive Care Medicine, Helsinki University
Central Hospital, Meilahti Hospital, Helsinki, Finland. anne.kuitunen@hus.fi

We investigated the influence of hydroxyethyl starch (HES) as a priming solution
for the cardiopulmonary bypass (CPB) circuit on postoperative hemostasis in 45
patients undergoing elective coronary artery bypass grafting. In a randomized
sequence, 20 mL/kg of low-molecular-weight HES (HES 120; molecular weight
120,000 daltons), high-molecular-weight HES (HES 400; molecular weight 400,000
daltons), or 4% human albumin (ALB) was used as the main component of the CPB
priming solution. The thromboelastographic values indicating the speed of solid
clot formation (alpha-angle) and the strength of the fibrin clot (maximum
amplitude and shear elastic modulus) were decreased up to 2 h after CPB in both
HES groups. Four hours after the operation, blood loss through the chest tubes
had increased in the HES groups: HES 120, mean 804 mL (range, 330-1390 mL); HES
400, mean 1008 mL (range, 505-1955 mL); and ALB, mean 681 mL (range, 295-1500
mL) (P < 0.05 between the HES 400 and ALB groups). We conclude that HES
solutions, when given in doses of 20 mL/kg in connection with the CPB prime,
compromise hemostasis after cardiac surgery. This effect appears related to
formation of a less stable thrombus compared with that formed in the presence of
ALB. IMPLICATIONS: The influence of hydroxyethyl starch (HES) on postoperative
hemostasis was investigated in cardiac surgery. The thromboelastographic values
indicated that HES solutions, when given in connection with the cardiopulmonary
bypass prime, compromise hemostasis after cardiac surgery. This effect seems to
occur through the formation of a less stable clot.

Br J Anaesth.  2004 Feb;92(2):178-86.  

Comparison of structured use of routine laboratory tests or near-patient
assessment with clinical judgement in the management of bleeding after cardiac
surgery.

Avidan MS, Alcock EL, Da Fonseca J, Ponte J, Desai JB, Despotis GJ, Hunt BJ.

Department of Anesthesiology, Washington University School of Medicine, St
Louis, MO 63110, USA. avidanm@msnotes.wustl.edu

BACKGROUND: Using algorithms based on point of care coagulation tests can
decrease blood loss and blood component transfusion after cardiac surgery. We
wished to test the hypothesis that a management algorithm based on near-patient
tests would reduce blood loss and blood component use after routine coronary
artery surgery with cardiopulmonary bypass when compared with an algorithm based
on routine laboratory assays or with clinical judgement. METHODS: Patients
(n=102) undergoing elective coronary artery surgery with cardiac bypass were
randomized into two groups. In the point of care group, the management algorithm
was based on information provided by three devices, the Hepcon,
thromboelastography and the PFA-100 platelet function analyser. Management in
the laboratory test group depended on rapidly available laboratory clotting
tests and transfusion of haemostatic blood components only if specific criteria
were met. Blood loss and transfusion was compared between these two groups and
with a retrospective case-control group (n=108), in which management of bleeding
had been according to the clinician's discretion. RESULTS: All three groups had
similar median blood losses. The transfusion of packed red blood cells (PRBCs)
and blood components was greater in the clinician discretion group (P<0.05) but
there was no difference in the transfusion of PRBCs and blood components between
the two algorithm-guided groups. CONCLUSION: Following algorithms based on point
of care tests or on structured clinical practice with standard laboratory tests
does not decrease blood loss, but reduces the transfusion of PRBCs and blood
components after routine cardiac surgery, when compared with clinician
discretion. Cardiac surgery services should use transfusion guidelines based on
laboratory-guided algorithms, and the possible benefits of point of care testing
should be tested against this standard.