Article

Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: Implications on operative outcome*

Department of Cardiovascular Surgery, St. Vincent Mercy Medical Center, Toledo, OH, USA.
Critical Care Medicine (Impact Factor: 6.15). 08/2005; 33(8):1749-56. DOI: 10.1097/01.CCM.0000171531.06133.B0
Source: PubMed

ABSTRACT Acute renal injury and failure (ARF) after cardiopulmonary bypass (CPB) has been linked to low on-pump hematocrit (hematocrit). We aimed to 1) elucidate if and how this relation is modulated by the duration of CPB (TCPB) and on-pump packed red blood cell transfusions and 2) to quantify the impact of post-CPB renal injury on operational outcome and resource utilization.
Retrospective review.
A Northwest Ohio community hospital.
Adult coronary artery bypass surgery patients with CPB but no preoperative renal failure.
None.
We quantified post-CPB renal injury via 1) the peak postoperative change in serum creatinine (Cr) level relative to pre-CPB values (%DeltaCr) and 2) ARF, defined as the coincidence of post-CPB Cr > or =2.1 mg/dL and >2 times pre-CPB Cr. The separate effects of lowest hematocrit, intraoperative packed RBC transfusions, and TCPB on %DeltaCr and ARF were derived via multivariate regression, overlapping quintile subgroup analyses, and propensity matching. Lowest hematocrit (22.0% +/- 4.6% sd), TCPB (94 +/- 35 mins), and pre-CPB Cr (1.01 +/- 0.23 mg/dL) varied widely. %DeltaCr varied substantially (24 +/- 57%), and ARF was documented in 89 patients (5.1%). Both %DeltaCr (p < .001) and ARF (p < .001) exhibited sigmoidal dose-dependent associations to lowest hematocrit that were 1) modulated by TCPB such that the renal injury was exacerbated as TCPB increased, 2) worse in patients with relatively elevated pre-CPB Cr (> or =1.2 mg/dL), and 3) worse with intraoperative packed red blood cell transfusions (n = 385; 21.9%), in comparison with patients at similar lowest hematocrit. Operative mortality (p < .01) and hospital stays (p < .001) were increased systematically and significantly as a function of increased post-CPB renal injury.
CPB hemodilution to hematocrit <24% is associated with a systematically increased likelihood of renal injury (including ARF) and consequently worse operative outcomes. This effect is exacerbated when CPB is prolonged with intraoperative packed red blood cell transfusions and in patients with borderline renal function. Our data add to the concerns regarding the safety of currently accepted CPB practice guidelines.

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    • "It has been shown that low preoperative haematocrit, small body size and female gender predispose patients to severe haemodilution , necessitating intraoperative blood transfusion [15] [16]. The latter, however, carries an increased risk of postoperative complications such as sternal wound infections, renal and pulmonary dysfunction, prolonged intensive care and hospital stay and increased operative mortality [17] [18]. "
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    ABSTRACT: OBJECTIVES Many cardiac procedures using cardiopulmonary bypass (CPB) still require intraoperative transfusion. Retrograde autologous priming (RAP) has been introduced to decrease haemodilution and the blood transfusion rate. This study is designed to determine the influence or RAP on intraoperative haematocrit, transfusion and its clinical consequences.METHODS The RAP effect was retrospectively studied in 753 patients during contemporary cardiac surgery, targeting a haematocrit of 25%. Multivariate linear regression analysis was performed to identify the independent factors influencing intraoperative haematocrit, transfusion rate and transfusion quantity.RESULTSRAP was used in 498 patients and compared with 255 controls. RAP decreased the haemodilution level (nadir haematocrit 26.8 standard deviation [SD] 4.0% in RAP vs 25.8 SD 3.6% in controls; P = 0.001) and transfusion frequency (26.1 vs 33.3%, P = 0.04), despite smaller patients (body surface area [BSA] 1.86 SD 0.20 m2 vs 1.91 SD 0.21 m2 in RAP vs controls; P = 0.002) with lower preoperative haematocrit (38.9 SD 4.4% vs 40.5 SD 4.6%; P < 0.001). Optimal RAP volume was overall 475 ml (ROC area 0.55; 95% confidence interval [CI] 0.50-0.60; P = 0.04) and 375 ml in patients with BSA <1.7 m2 (ROC area 0.63; 95% CI 0.54-0.73; P = 0.008) to decrease the transfusion incidence. Multivariate analysis revealed RAP volume as a significant determinant of nadir haematocrit (β = 0.003, 95% CI 0.002-0.004, P < 0.001) and transfusion rate (odds ratio (OR) = 0.997, 95% CI 0.996-0.999, P < 0.001), independent of BSA, gender and preoperative haematocrit.CONCLUSION Retrograde autologous priming is an effective adjunct to decrease the blood transfusion rate, coping with the CPB-related haemodilution and its adverse clinical effects. A RAP volume individualized to each patient offers most benefit as part of a multidisciplinary blood conservation approach.
    Interactive Cardiovascular and Thoracic Surgery 03/2013; 16(6). DOI:10.1093/icvts/ivt085 · 1.11 Impact Factor
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    • "Recent clinical studies have indicated that the use of an ECC system may be associated with depressed organ function and poor outcome following CABG surgery [23] [24]. In this respect, the kidneys are especially susceptible due to their particularly complex microvascular organization and their high demand for oxygen [25]. "
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    ABSTRACT: OBJECTIVES To reduce the complications associated with cardiopulmonary bypass (CPB) during cardiac surgery, many modifications have been made to conventional extracorporeal circulation systems. This trend has led to the development of miniaturized extracorporeal circulation systems. Cardiac surgery using conventional extracorporeal circulation systems has been associated with significantly reduced microcirculatory perfusion, but it remains unknown whether this could be prevented by an mECC system. Here, we aimed to test the hypothesis that microcirculatory perfusion decreases with the use of a conventional extracorporeal circulation system and would be preserved with the use of an miniaturized extracorporeal circulation system. METHODS Microcirculatory density and perfusion were assessed using sublingual side stream dark-field imaging in patients undergoing on-pump coronary artery bypass graft (CABG) surgery before, during and after the use of either a conventional extracorporeal circulation system (n = 10) or a miniaturized extracorporeal circulation system (n = 10). In addition, plasma neutrophil gelatinase-associated lipocalin and creatinine levels and creatinine clearance were assessed up to 5 days post-surgery to monitor renal function. RESULTS At the end of the CPB, one patient in the miniaturized extracorporeal circulation-treated group and five patients in the conventional extracorporeal circulation-treated group received one bag of packed red blood cells (300 ml). During the CPB, the haematocrit and haemoglobin levels were slightly higher in the miniaturized extracorporeal circulation-treated patients compared with the conventional extracorporeal circulation-treated patients (27.7 ± 3.3 vs 24.7 ± 2.0%; P = 0.03; and 6.42 ± 0.75 vs 5.41 ± 0.64 mmol/l; P < 0.01). The density of perfused vessels with a diameter <25 µm (i.e. perfused vessel density) decreased slightly in the conventional extracorporeal circulation-treated group from 16.4 ± 3.8 to 12.8 ± 3.3 mm/mm(2) (P < 0.01) and remained stable in the miniaturized extracorporeal circulation-treated group (16.3 ± 2.7 and 15.2 ± 2.9 mm/mm(2) before and during the pump, respectively). Plasma neutrophil gelatinase-associated lipocalin levels were increased following the use of extracorporeal circulation in both groups, and no differences were observed between the groups. Plasma creatinine levels and creatinine clearance were not affected by CABG surgery or CPB. CONCLUSIONS The results from this relatively small study suggest that the use of the miniaturized extracorporeal circulation system is associated with a statistically significant (but clinically insignificant) reduction in haemodilution and microcirculatory hypoperfusion compared with the use of the conventional extracorporeal circulation system.
    Interactive Cardiovascular and Thoracic Surgery 06/2012; 15(3):364-70. DOI:10.1093/icvts/ivs271 · 1.11 Impact Factor
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    • "In-hospital mortality 14% all patients Lowest Hct associated with increased mortality 17% high-risk patients Karkouti et al., 2005 52 9080 ARF requiring dialysis Ͻ21% or Ͼ25% Hct values Ͻ21% or Ͼ25% associated with increased risk of ARF Habib et al., 2005 53 1760 Charge in serum creatinine 24% Lowest Hct on CPB associated with increased risk of creatinine rise and ARF ARF Swaminathan et al., 2003 54 1404 Change in serum creatinine None identified Lowest Hct associated with creatinine rise Ranucci et al., 2006 56 1766 In-hospital mortality 23% Lowest Hct associated with cardiac low output syndrome and ARF morbidity Karkouti et al., 2005 "
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    ABSTRACT: In this review, we summarize the best available evidence to guide the conduct of adult cardiopulmonary bypass (CPB) to achieve "optimal" perfusion. At the present time, there is considerable controversy relating to appropriate management of physiologic variables during CPB. Low-risk patients tolerate mean arterial blood pressures of 50-60 mm Hg without apparent complications, although limited data suggest that higher-risk patients may benefit from mean arterial blood pressures >70 mm Hg. The optimal hematocrit on CPB has not been defined, with large data-based investigations demonstrating that both severe hemodilution and transfusion of packed red blood cells increase the risk of adverse postoperative outcomes. Oxygen delivery is determined by the pump flow rate and the arterial oxygen content and organ injury may be prevented during more severe hemodilutional anemia by increasing pump flow rates. Furthermore, the optimal temperature during CPB likely varies with physiologic goals, and recent data suggest that aggressive rewarming practices may contribute to neurologic injury. The design of components of the CPB circuit may also influence tissue perfusion and outcomes. Although there are theoretical advantages to centrifugal blood pumps over roller pumps, it has been difficult to demonstrate that the use of centrifugal pumps improves clinical outcomes. Heparin coating of the CPB circuit may attenuate inflammatory and coagulation pathways, but has not been clearly demonstrated to reduce major morbidity and mortality. Similarly, no distinct clinical benefits have been observed when open venous reservoirs have been compared to closed systems. In conclusion, there are currently limited data upon which to confidently make strong recommendations regarding how to conduct optimal CPB. There is a critical need for randomized trials assessing clinically significant outcomes, particularly in high-risk patients.
    Anesthesia and analgesia 05/2009; 108(5):1394-417. DOI:10.1213/ane.0b013e3181875e2e · 3.42 Impact Factor
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