A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery (original) (raw)
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Clinical outcomes of pulsatile and non-pulsatile mode of perfusion
The Journal of extra-corporeal technology, 2009
A longstanding debate remains over whether or not pulsatile flow provides better perfusion during cardiopulmonary bypass (CPB). This paper provides a guide for clinical investigation, as well as current laboratory and clinical evidence concerning pulsatile and non-pulsatile perfusion. This evidence is in the form of in vitro and in vivo experiments and clinical trials. We review the literature and provide personal experience from the Pediatric Cardiac Research Laboratories at the Penn State Hershey Children's Hospital. Pulsatility is emerging as the preferred perfusion method for CPB. Clinical evidence show better cardiac, renal, and pulmonary outcomes in patients receiving pulsatile perfusion. Furthermore, better cytokine, endothelin, and hormone levels and a higher respiratory index are shown in pulsatile perfusion modes compared with non-pulsatile perfusion modes. In recent years, evidence has amounted that supports a shift toward pulsatility in these procedures over non-puls...
Turkish Journal of Thoracic and Cardiovascular Surgery, 2012
Bu çalışmanın amacı, pulsatil ve pulsatil olmayan perfüzyonun hemoliz parametreleri ve kan komponentlerinin korunması üzerindeki etkilerini araştırmaktır. Ça lış mapla nı:Randomize kontrollü ve prospektif olarak tasarlanmış bu çalışmaya, açık kalp ameliyatı yapılan 27 pulsatil olmayan (NP) ve 24 pulsatil (P) olgudan oluşan iki bağımsız grup dahil edildi. Demografik ve hemodinamik veriler kaydedildi. Perfüzyon türlerinin etkisi serbest hemoglobin (serbest Hb), haptoglobin (Hp), laktat dehidrogenaz (LDH), potasyum (K +), trombosit sayısı (plt) ve idrarda Hb açısından değerlendirildi. Bu düzeyler ameliyat öncesinde, kardiyopulmoner baypas (KPB) başlatıldıktan sonra 30. ve 60. dakikalarda ve ameliyat sonrasında iki ve 24. saatte ölçüldü. Ayrıca total göğüs drenajı ve transfüzyon gerekliliği de değerlendirildi. Bul gu lar: Demografik ve hemodinamik ölçümler gruplar arasında farklı değildi. NP grubunun ortalama arteriyel basıncı, 30. dakikada istatistiksel olarak yüksekti. Serbest Hb, Hp, LDH ve K + düzeyleri tüm zaman noktalarında iki grup arasında da farklı değildi. İdrar Hb düzeyleri, 30. dakikada P grubunda anlamlı düzeyde yüksekti. Total göğüs drenaj miktarları ve transfüze edilen eritrosit hücre paketlerinin sayısı açısından bir farka rastlanmadı. So nuç: Laboratuvar esaslı ölçümlerde yalnızca idrarda Hb ölçümü açısından fark olsa da, pulsatil perfüzyonun klinik açıdan anlamlı olmayan hemolitik etkisinden söz edilebilir. Anah tar söz cük ler: Kardiyopulmoner baypas; hemoliz; pulsatilite. Background:The aim of this study was to investigate the effects of pulsatile and nonpulsatile perfusion on hemolysis parameters and protection of blood components. Methods: This randomized, controlled and prospectively designed study included two independent groups, consisting of 27 nonpulsatile (NP) and 24 pulsatile (P) cases who had undergone open heart surgical procedures. Demographic and hemodynamic data were recorded. The effects of perfusion types were evaluated in terms of free hemoglobin (free Hb), haptoglobin (Hp), lactate dehydrogenase (LDH), potassium (K +), platelet number (plt) and urine Hb. These levels were measured in preoperative period, 30 and 60 minutes after initiation of cardiopulmonary bypass (CPB), two and 24 hours postoperatively. Also, total chest drainage and transfusion requirement were assessed. Results: Demographic and hemodynamic measurements did not differ between the groups. The mean arterial pressure of the NP group was statistically higher at the 30 th minute. Free Hb, Hp, LDH and K + levels did not differ in both groups in all time points. The urine Hb levels were significantly higher in the P group in the 30 th minute. There was no difference regarding total chest drainage amounts and number of transfused erythrocyte cell packages. Conclusion: A clinically nonsignificant hemolytic effect of pulsatile perfusion can be outlined, although it is mentioned only in the urine Hb measurements on the laboratory basis.
The International journal of artificial organs, 2009
To evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves body perfusion. 158 coronary artery bypass graft (CABG) patients were randomized to linear cardiopulmonary bypass (CPB) (n=71, Group A) or automatic 80 bpm intra-aortic balloon pump (IABP) induced pulsatile CPB (n=87, Group B). We evaluated hemodynamic response by Swan-Ganz catheter, inflammation by cytokines, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate and renal function (estimated glomerular filtration rate (eGFR), creatinine, and incidence of renal insufficiency and failure). IABP induced Surplus Hemodynamic Energy was 15.8-/+4.9 mmHg, with higher mean arterial pressure during cross-clamping (p=0.001), and lower indexed systemic vascular resistances during cross-clamping (p=0.001) and CPB discontinuation (p=0.034). IL-2 and IL-6 were lower, while IL-10 proved higher in Group B (p<0.05). Group B showed lower chest drainage (p<0.05), transfusions (p<...
2000
Supplemental material is available online. C ardiopulmonary bypass (CPB) can be used during cardiac surgery to oxygenate and subsequently recirculate blood that has been diverted from the heart and lungs. The practice of CPB has changed-and continues to change-dramatically since its advent in the 1950s. Although structured reviews of the evidence supporting the practice of cardiac surgery have been in the literature for more than a decade and continue to be refined in the wake of new and emerging evidence, E1,E2 additional targeted reviews, focusing on issues such as minimizing the effect of the inflammatory response or minimizing neurologic injury, are warranted. E3-E5 Previous attempts, by Edwards and colleagues E6 and Bartels and associates, E7 at synthesizing the evidence base to support the principles of CPB have selectively reviewed the cardiac surgery literature or focused on unique patient populations. Additionally, the development of these reviews has not involved all members of the clinical team, most notably the individuals tasked with operating the CPB circuit. This gap in knowledge is in stark contrast with the shared goal of the cardiac team, namely to improve the conduct of CPB to reduce the patient's risk of adverse outcomes caused by cardiac surgery.
The Annals of Thoracic Surgery, 2012
Background. Controversy exists regarding the optimal perfusion modality during cardiopulmonary bypass (CPB). Here we compare the effects of pulsatile versus nonpulsatile perfusion on microvascular blood flow during and after CPB. Methods. High-risk cardiac surgical patients were randomly assigned to have pulsatile (n ؍ 10) or nonpulsatile (n ؍ 10) flow during CPB. The sublingual microcirculation was assessed using orthogonal polarization spectral imaging. Hemodynamic and microvascular variables were obtained after anesthesia (baseline), during CPB, and post-CPB. Results. Compared with baseline, a normal microcirculatory blood flow pattern was accomplished at all time points under pulsatile flow conditions. Peaking 24 hours postoperatively, a higher proportion of normally perfused microvessels occurred under pulsatile versus nonpulsatile flow (56.0% ؎ 3.9% vs 33.3% ؎ 4.1%; p < 0.05). Concurrently, pulsatility resulted in a reduction in the prevalence of pathologic hyper-dynamically perfused vessels (6.0% ؎ 3.4% vs 19.6% ؎ 8.8%; p < 0.05). Leukocyte adherence decreased relative to the nonpulsatile group both during and after CPB. Furthermore, peak lactate levels were reduced under pulsatile flow conditions postoperatively. Conclusions. Pulsatile perfusion is superior to nonpulsatile perfusion at preserving the microcirculation, which may reflect attenuation of the systemic inflammatory response during CPB. We suggest the implementation of pulsatile flow can better optimize microvascular perfusion, and may lead to improved patient outcomes in high-risk cardiac surgical procedures requiring prolonged CPB time.
Journal of Clinical Medicine
Background: The role of pulsatile (PP) versus non-pulsatile (NP) flow during a cardiopulmonary bypass (CPB) is still debated. This study’s aim was to analyze hemodynamic effects, endothelial reactivity and erythrocytes response during a CPB with PP or NP. Methods: Fifty-two patients undergoing an aortic valve replacement were prospectively randomized for surgery with either PP or NP flow. Pulsatility was evaluated in terms of energy equivalent pressure (EEP) and surplus hemodynamic energy (SHE). Systemic (SVRi) and pulmonary (PVRi) vascular resistances, endothelial markers levels and erythrocyte nitric-oxide synthase (eNOS) activity were collected at different perioperative time-points. Results: In the PP group, the resultant EEP was 7.3% higher than the mean arterial pressure (MAP), which corresponded to 5150 ± 2291 ergs/cm3 of SHE. In the NP group, the EEP and MAP were equal; no SHE was produced. The PP group showed lower SVRi during clamp-time (p = 0.06) and lower PVRi after prot...
The Journal of Thoracic and Cardiovascular Surgery, 2013
Objective: To evaluate how pulsed versus nonpulsed cardiopulmonary bypass influences microvascular fluid exchange in an experimental setup combining a nonpulsatile perfusion pump and an intra-aortic balloon pump. Methods: A total of 16 pigs were randomized to pulsatile cardiopulmonary bypass perfusion with an intra-aortic balloon pump switched to an automatic 80 beats/min mode after the start of cardiopulmonary bypass (pulsatile perfusion [PP] group, n ¼ 8) or to nonpulsatile cardiopulmonary bypass with the pump switched to the off position (nonpulsatile [NP] group, n ¼ 8). Normothermic cardiopulmonary bypass was initiated after 60 minutes of stabilization and continued for 3 hours. The fluid needs, plasma volume, colloid osmotic pressure in plasma, colloid osmotic pressure in interstitial fluid, hematocrit, and total tissue water content were recorded, and the protein masses and fluid extravasation rates were calculated. Results: After cardiopulmonary bypass was started, the mean arterial pressure increased in the PP group and decreased in the NP group. At 180 minutes, the mean arterial pressure of the PP and NP groups was 70.9 AE 2.7 mm Hg and 55.9 AE 2.7 mm Hg, respectively (P ¼ .004). The central venous pressure (right atrium) had decreased in the NP group (P ¼ .002). A decreasing trend was seen in the PP group. No between-group differences were present. The hematocrit and colloid osmotic pressure in plasma and interstitial fluid had decreased similarly in both study groups during cardiopulmonary bypass. The plasma volume of the PP group had decreased initially but then returned gradually to precardiopulmonary bypass levels. In the NP group, the plasma volume remained contracted (P ¼ .02). No significant differences in the fluid extravasation rate were obtained. The fluid extravasation rate of the PP group tended to stay slightly higher than the fluid extravasation rate of the NP group at all measurement intervals. The total tissue water content increased significantly in a number of organs compared with that in the control animals. However, differences in the total tissue water content between pulsed and nonpulsed perfusion were absent. Conclusions: No significant differences in the fluid extravasation rates were present between pulsed and nonpulsed cardiopulmonary bypass perfusion in the present experimental setup.