Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a post dilution regional citrate anticoagulation continuous hemofiltration circuit

Background: Regional citrate anticoagulation (RCA) is the recommended standard for continuous renal replacement therapy (CRRT). This study assesses its efficacy in patients admitted to critical care following cardiovascular surgery and the influence of standard antithrombotic agents routinely used in this specific group. Methods: Consecutive cardiovascular surgery patients treated with post-dilution hemofiltration with RCA were included in this prospective observational study. The primary outcome of the study was CRRT circuit life-span adjusted for reasons other than clotting. The secondary outcome evaluated the influence of standard antithrombotic agents (acetylsalicylic acid [ASA], low molecular weight heparin [LMWH] or fondaparinux as thromboprophylaxis or treatment dose with or without ASA) on filter life. Results: Fifty-two patients underwent 193 sessions of CVVH, after exclusion of 15 sessions where unfractionated heparin was administered. The median filter life span was 58 hours. Filter life span was significantly longer in patients receiving therapeutic dose of LMWH or fondaparinux (79 h [2–110]), in comparison to patients treated with prophylactic dose of LMWH or fondaparinux (51 h [7–117], p < 0.001), and patients without antithrombotic prophylaxis (42 h [2–91], p < 0.0001). 12 bleeding episodes were observed; 8 occurred in patients receiving treatment dose anticoagulation, 3 in patients receiving prophylactic dose anticoagulation and 1 in a patient with no antithrombotic prophylaxis. Conclusions: A post dilution hemofiltration with RCA provides prolonged filter life span when adjusted for reasons other than clotting. Patients receiving treatment dose anticoagulation had a significantly longer filter life span than those who were on prophylactic doses or ASA alone

Wysokoobjętościowa ciągła żylno-żylna hemofiltracja jako leczenie wspomagające uporczywego wstrząsu po operacji serca w krążeniu pozaustrojowym. Opis przypadku

Znacznego stopnia aktywacja reakcji zapalnej wraz z niedokrwieniem mięśnia sercowego należą do najistotniejszych czynników prowadzących do ostrej niewydolności krążenia po operacjach serca. Wysokie stężenia prozapalnych cytokin odpowiadają nie tylko za obniżenie systemowego oporu naczyniowego i zwiększoną przepuszczalność śródbłonków, ale wykazują także silne działanie inotropowo ujemne. Niezależnie od prawdziwości tezy o skutecznej i znaczącej klinicznie eliminacji prozapalnych cytokin podczas wysokoobjętościowej hemofiltracji, wyniki badań eksperymentalnych i klinicznych jednoznacznie wskazują, że podczas hemofiltracji w sepsie i innych stanach przebiegających ze znaczną aktywacją reakcji zapalnej obserwuje się zmniejszenie zapotrzebowania na środki wazopresyjne. Autorzy przedstawiają przypadek pacjenta we wstrząsie po operacji wszczepienia protezy zastawki aortalnej i wykonania pomostów wieńcowych, u którego po rozpoczęciu wysokoobjętościowej żylno-żylnej hemofiltracji zaobserwowano stabilizację funkcji układu krążenia, zmniejszenie zapotrzebowania na katecholaminy i wyrównanie kwasicy mleczanowej. Leczenie za pomocą hemofiltracji zostało rozpoczęte, zanim stwierdzono u chorego obecność kryteriów ostrego uszkodzenia nerek według skali RIFLE. Rekomendowanie wysokoobjętościowej hemofiltracji jako leczenia wspomagającego we wstrząsie dystrybucyjnym po operacjach kardiochirurgicznych wymaga potwierdzenia skuteczności takiego postępowania w randomizowanym badaniu klinicznym

Mechaniczne wspomaganie krążenia w leczeniu ostrego zapalenia mięśnia sercowego powikłanego wstrząsem kardiogennym

Przedstawiono przypadek 27-letniego chorego z ostrym zapaleniem mięśnia sercowego powikłanym wstrząsem kardiogennym. Wdrożono leczenie mechanicznym wspomaganiem krążenia z zastosowaniem wszczepialnego dwukomorowego, zewnętrznego układu wspomagania pracy serca - systemu POLCAS. Ponadto pacjent otrzymywał leki steroidowe, immunoglobuliny i antybiotyki o szerokim spektrum działania. Po uzyskaniu regeneracji uszkodzonego mięśnia sercowego, potwierdzonej badaniem histopatologicznym, system wspomagający odłączono po 31 dobach pracy. Chorego wypisano ze szpitala w stanie ogólnym dobrym po 42 dniach leczenia. Podczas 2-letniej obserwacji stwierdzono pełną poprawę funkcji mięśnia sercowego oraz wydolności krążenia (I grupa wg klasyfikacji NYHA). (Folia Cardiol. 2004; 11: 677-680

Mechaniczne wspomaganie krążenia w leczeniu ostrego zapalenia mięśnia sercowego powikłanego wstrząsem kardiogennym

Przedstawiono przypadek 27-letniego chorego z ostrym zapaleniem mięśnia sercowego powikłanym wstrząsem kardiogennym. Wdrożono leczenie mechanicznym wspomaganiem krążenia z zastosowaniem wszczepialnego dwukomorowego, zewnętrznego układu wspomagania pracy serca - systemu POLCAS. Ponadto pacjent otrzymywał leki steroidowe, immunoglobuliny i antybiotyki o szerokim spektrum działania. Po uzyskaniu regeneracji uszkodzonego mięśnia sercowego, potwierdzonej badaniem histopatologicznym, system wspomagający odłączono po 31 dobach pracy. Chorego wypisano ze szpitala w stanie ogólnym dobrym po 42 dniach leczenia. Podczas 2-letniej obserwacji stwierdzono pełną poprawę funkcji mięśnia sercowego oraz wydolności krążenia (I grupa wg klasyfikacji NYHA). (Folia Cardiol. 2004; 11: 677-680

Patient with chronic kidney disease after heart transplantation due to severe chronic heart failure

W pracy przedstawiono przypadek 55-letniego mężczyzny zakwalifikowanego do przeszczepienia serca w trybie elektywnym z powodu ciężkiej niewydolności serca na podłożu kardiomiopatii niedokrwiennej i z przewlekłą chorobą nerek, którego hospitalizowano z powodu zaostrzenia niewydolności serca. Po początkowym ustabilizowaniu stanu hemodynamicznego u chorego doszło do nagłego zatrzymania krążenia. Po skutecznej resuscytacji pacjenta przekazano do Kliniki Kardiochirurgii GUMed w celu leczenia urządzeniem wspomagającym pracę komór i po 70 dniach wykonano u niego przeszczepienie serca. Po przeszczepieniu nastąpiło pogorszenie funkcji nerek. W pracy omówiono możliwe przyczyny pogorszenia funkcji nerek u pacjentów poddawanych przeszczepieniu serca.A 55-year-old male qualified for heart transplantationdue to severe ischaemic heart failure and withchronic kidney disease was admitted to hospitalbecause of heart failure decompensation. Afterinitial stabilization of hemodynamic state a suddencardiac arrest occurred. The patient was transferredto Cardiac Surgery Clinic and was treated with leftventricular assist device. After 70 days of mechanicalsupport a heart transplantation was performed.Shortly after transplantation worsening of chronickidney disease was observed. The possible causesof chronic kidney disease in patients undergoingheart transplantation are discussed in the article

Transfermoral transcatheter aortic valve implantation using self-expanding Allegra bioprosthesis: One-year single-center outcomes

Background: The NAUTILUS study aimed to evaluate the safety and performance of the Allegra bioprosthesis in high-risk recipients undergoing transcatheter aortic valve implantation and were reported on 30-day outcomes. Hence, are the presented 1-year results of the trial. Methods: Twenty-seven recipients with severe, symptomatic aortic valve stenosis at high surgical risk, who underwent treatment using the next-generation self-expanding Allegra via transfemoral approach were prospectively enrolled. Clinical endpoints assessed were: mortality, stroke, permanent pacemaker implantation, New York Heart Association class and re-hospitalizations. Prosthetic valve performance evaluation comprised of: mean gradient, effective orifice area and paravalvular leak. Results: Patients were elderly (82.8 ± 4.2 years) and predominantly female (n = 19, 70.4%). All of them were deemed to be at high surgical risk with a mean logistic EuroSCORE of 12.5 ± 6.7. The bioprosthesis was successfully implanted in 92.6% of the cases (n = 25). At 1-year, all-cause mortality was 12.0% (n = 3) and stroke was 4.0% (n = 1). Three (12%) of patients developed complete atrioventricular block and received permanent pacemakers. 84% of patients were in New York Heart Association class II or lower. Need for subsequent hospitalization arose in 48% patients. The echocardiographic assessment confirmed an acceptable hemodynamic profile of the Allegra with low mean transprosthetic gradient (9.5 ± 3.4 mmHg), absence of severe paravalvular leak and a 20%-presence of moderate paravalvular leak. Conclusions: The current follow-up observation study shows that the Allegra was associated with a satisfactory safety profile and hemodynamic performance at 1-year after implantation

Zastosowanie oksymetrii tkankowej w anestezjologii i intensywnej terapii

Conventional monitoring during surgery and intensive care is not sufficiently sensitive to detect acute changes in vital organs perfusion, while its good quality is critical for maintaining their function. Disturbed vital organ perfusion may lead to the development of postoperative complications, including neurological sequel and renal failure. Near-infra-red spectroscopy (NIRS) represents one of up-to-date techniques of patient monitoring which is commonly used for the assessment of brain oximetry in thoracic aorta surgery, and – increasingly more often -in open-heart surgery. Algorithms for maintaining adequate brain saturation may result in a decrease of neurological complications and cognitive dysfunction following cardiac surgery. The assessment of kidney and visceral perfusion with tissue oximetry is gaining increasing interest during pediatric cardiac surgery. Attempts at decreasing complications by the use of brain oximetry during carotid endarterectomy, as well as thoracic and abdominal surgery demonstrated conflicting results. In recent years NIRS technique was proposed as a tool for muscle perfusion assessment under short term ischemia and reperfusion, referred to as vascular occlusion test (VOT). This monitoring extension allows for the identification of early disturbances in tissue perfusion. Results of recent studies utilizing VOT suggest that the muscle saturation decrease rate is reduced in septic shock patients, while decreased speed of saturation recovery on reperfusion is related to disturbed microcirculation. Being non-invasive and feasible technique, NIRS offers an improvement of preoperative risk assessment in cardiac surgery and promises more comprehensive intraoperative and ICU patient monitoring allowing for better outcome.Conventional monitoring during surgery and intensive care is not sufficiently sensitive to detect acute changes in vital organs perfusion, while its good quality is critical for maintaining their function. Disturbed vital organ perfusion may lead to the development of postoperative complications, including neurological sequel and renal failure. Nearinfra- red spectroscopy (NIRS) represents one of up-to-date techniques of patient monitoring which is commonly used for the assessment of brain oximetry in thoracic aorta surgery, and – increasingly more often -in open-heart surgery. Algorithms for maintaining adequate brain saturation may result in a decrease of neurological complications and cognitive dysfunction following cardiac surgery. The assessment of kidney and visceral perfusion with tissue oximetry is gaining increasing interest during pediatric cardiac surgery. Attempts at decreasing complications by the use of brain oximetry during carotid endarterectomy, as well as thoracic and abdominal surgery demonstrated conflicting results. In recent years NIRS technique was proposed as a tool for muscle perfusion assessment under short term ischemia and reperfusion, referred to as vascular occlusion test (VOT). This monitoring extension allows for the identification of early disturbances in tissue perfusion. Results of recent studies utilizing VOT suggest that the muscle saturation decrease rate is reduced in septic shock patients, while decreased speed of saturation recovery on reperfusion is related to disturbed microcirculation. Being non-invasive and feasible technique, NIRS offers an improvement of preoperative risk assessment in cardiac surgery and promises more comprehensive intraoperative and ICU patient monitoring allowing for better outcome

Zaktualizowany protokół postępowania u chorych wymagających zastosowania pozaustrojowej oksygenacji krwi (ECMO) w leczeniu ostrej niewydolności oddechowej dorosłych. Zalecenia i wytyczne Zespołu ds. Terapii ECMO Żylno-Żylnym, powołanego przez konsultanta

Extracorporeal Membrane Oxygenation (ECMO) has become well established technique of the treatment of severe acute respiratory failure (Veno-Venous ECMO) or circulatory failure (Veno-Arterial ECMO) which enables effective blood oxygenation and carbon dioxide removal for several weeks. Veno-Venous ECMO (V-V ECMO ) is a lifesaving treatment of patients in whom severe ARDS makes artificial lung ventilation unlikely to provide satisfactory blood oxygenation for preventing further vital organs damage and progression to death. The protocol below regards exclusively veno-venous ECMO treatment as a support for blood gas conditioning by means of extracorporeal circuit in adult patients with severe ARDS. V-V ECMO does not provide treatment for acutely and severely diseased lungs, but it enables patient to survive the critical phase of severe ARDS until recovery of lung function. Besides avoiding patients death from hypoxemia, this technique can also prevent further progression of the lung damage due to artificial ventilation. Recent experience of ECMO treatment since the outbreak of AH1N1 influenza pandemic in 2009, along with technical progress and advancement in understanding pathophysiology of ventilator-induced lung injury, have contributed to significant improvement of the results of ECMO treatment. Putative factors related to increased survival include patients retrieval after connecting them to ECMO, and less intensive anticoagulation protocols. The aim of presenting this revised protocol was to improve the effects of ECMO treatment in patients with severe ARDS, to enhance ECMO accessibility for patients who might possibly benefit from this treatment, to reduce time until patient’s connection to ECMO, and to avoid ECMO treatment in futile cases. The authors believe that this protocol, based on recent papers and their own experience, can provide help and advice both for the centers which develop V-V ECMO program, and for doctors who will refer their patients for the treatment in an ECMO center.  Extracorporeal membrane oxygenation (ECMO), which enables effective blood oxygenation and carbon dioxide removal for several weeks, has become a well established technique for the treatment of severe acute respiratory failure (V-V ECMO, veno-venous ECMO) or circulatory failure (veno-arterial ECMO). Veno-venous ECMO is a life-saving treatment in patients in whom severe acute respiratory distress syndrome (ARDS) makes mechanical ventilation unlikely to provide satisfactory blood oxygenation for preventing further vital organ damage and progression to death. The protocol below refers only to V-V ECMO therapy as a measure to support blood gas exchange by means of an extracorporeal circuit in adult patients with severe ARDS. Veno-venous ECMO does not provide treatment for acutely and severely diseased lungs but it enables the patient to survive the critical phase of severe ARDS until recovery of lung function. In addition to preventing death from hypoxemia, this technique can also prevent further progression of lung damage due to mechanical ventilation. Recent experience in ECMO therapy since the outbreak of an influenza A(H1N1) pandemic in 2009, along with technical progress and better understanding of the pathophysiology of ventilatorinduced lung injury, have contributed to a significant improvement in ECMO treatment outcomes. Postulated factors related to an increased survival include wider use of ECMO during patient transfer and less intensive anticoagulation protocols. The aim of presenting this revised protocol was to improve ECMO treatment outcomes in patients with 93 Romuald Lango i wsp., Protokół ECMO severe ARDS, to enhance ECMO accessibility for patients who might possibly benefit from this treatment, to reduce the time until institution of ECMO therapy, and to avoid ECMO therapy in futile cases. The authors believe that this protocol, based on recent papers and their own experience, can provide help and advice both for the centers which develop V-V ECMO program, and for doctors who will refer their patients for treatment in an ECMO center.  

Brain and Muscle Oxygen Saturation Combined with Kidney Injury Biomarkers Predict Cardiac Surgery Related Acute Kidney Injury

Background: Early identification of patients at risk for cardiac surgery-associated acute kidney injury (CS-AKI) based on novel biomarkers and tissue oxygen saturation might enable intervention to reduce kidney injury. Aims: The study aimed to ascertain whether brain and muscle oxygenation measured by near-infrared spectroscopy (NIRS), in addition to cystatin C and NGAL concentrations, could help with CS-AKI prediction. Methods: This is a single-centre prospective observational study on adult patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). Brain and muscle NIRS were recorded during surgery. Cystatin C was measured on the first postoperative day, while NGAL directly before and 3 h after surgery. Results: CS-AKI was diagnosed in 18 (16%) of 114 patients. NIRS values recorded 20 min after CPB (with cut-off value ≤ 54.5% for muscle and ≤ 62.5% for the brain) were revealed to be the most accurate predictors of CS-AKI. Preoperative NGAL ≥ 91.5 ng/mL, postoperative NGAL ≥ 140.5 ng/mL, and postoperative cystatin C ≥ 1.23 mg/L were identified as independent and significant CS-AKI predictors. Conclusions: Brain and muscle oxygen saturation 20 min after CPB could be considered early parameters possibly related to CS-AKI risk, especially in patients with increased cystatin C and NGAL levels