Leukocyte depletion during extracorporeal circulation allows better organ protection but does not change hospital outcomes

Background Leukocyte filtration has been reported to reduce inflammatory damage during cardiopulmonary bypass. We evaluated the role of leukocyte filtration on hospital outcome and postoperative morbidity. Methods Eighty-two consecutive patients who underwent isolated coronary artery bypass grafting were randomly assigned (1:1) to receive leukocyte filters on both arterial and cardioplegia lines or standard arterial filters during cardiopulmonary bypass. Hospital outcome, postoperative markers of morbidity, and biochemical assays were compared. Data were collected preoperatively, intraoperatively, and postoperatively. Costs for patients receiving intraoperative leukofiltration were compared with control patients getting standard arterial filters. Results Hospital mortality and intensive care unit and hospital length of stay were similar. Although duration of ventilation and incidence of pneumonia were comparable, leukocyte-depleted patients showed a higher ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (p = 0.008) and lower need for postoperative noninvasive ventilation (p = 0.041). Control patients showed higher need for continuous furosemide infusion (p = 0.013) and for renal replacement therapy (p = 0.014), in association with higher serum creatinine (p = 0.038) and blood urea (p = 0.18) and lower glomerular filtration rate (p = 0.038). Leukocyte-depleted patients required lower doses of inotropic agents (p = 0.56), whereas troponin I leakage and incidence of postoperative atrial fibrillation were comparable. No differences were found in terms of postoperative cerebral dysfunction or neutrophil and platelet counts, as well as postoperative bleeding and need for transfusions. Finally, leukodepletion proved significantly cost-beneficial, with a 37% cost reduction. Conclusions Although hospital outcomes were similar in terms of mortality and length of stay, the improvements in pulmonary, renal, and myocardial function, in association with the cost benefit, justify the use of leukocyte-depletion filters in the clinical practice

Meta-analysis of the influence of lifestyle changes for preoperative weight loss on surgical outcomes.

BACKGROUND: The aim was to investigate whether preoperative weight loss results in improved clinical outcomes in surgical patients with clinically significant obesity. METHODS: This was a systematic review and aggregate data meta-analysis of RCTs and cohort studies. PubMed, MEDLINE, Embase and CINAHL Plus databases were searched from inception to February 2018. Eligibility criteria were: studies assessing the effect of weight loss interventions (low-energy diets with or without an exercise component) on clinical outcomes in patients undergoing any surgical procedure. Data on 30-day or all-cause in-hospital mortality were extracted and synthesized in meta-analyses. Postoperative thromboembolic complications, duration of surgery, infection and duration of hospital stay were also assessed. RESULTS: A total of 6060 patients in four RCTs and 12 cohort studies, all from European and North American centres, were identified. Most were in the field of bariatric surgery and all had some methodological limitations. The pooled effect estimate suggested that preoperative weight loss programmes were effective, leading to significant weight reduction compared with controls: mean difference -7·42 (95 per cent c.i. -10·09 to -4·74) kg (P < 0·001). Preoperative weight loss interventions were not associated with a reduction in perioperative mortality (odds ratio 1·41, 95 per cent c.i. 0·24 to 8·40; I2  = 0 per cent, P = 0·66) but the event rate was low. The weight loss groups had shorter hospital stay (by 27 per cent). No differences were found for morbidity. CONCLUSION: This limited preoperative weight loss has advantages but may not alter the postoperative morbidity or mortality risk

Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery; systematic reviews, observational studies and randomised controlled trials

Background Anaemia, coagulopathic bleeding, and transfusion, are strongly associated with organ failure, sepsis and death following cardiac surgery. Aims Anaemia, coagulopathic bleeding, and transfusion, are strongly associated with organ failure, sepsis and death following cardiac surgery. Methods and Results Work Stream 1: In the COPTIC study (ISRCTN20778544) we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from Point-of-Care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of reference laboratory tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review (PROSPERO CRD42016033831) concluded that POC based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Work Stream 2: In the PASPORT Trial (ISRCTN 23557269), and a systematic review (PROSPERO CRD4201502769) we demonstrated that personalised Near Infra-red Spectroscopy based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically nor cost effective. Work Stream 3: In the REDWASH trial (SRCTN 27076315) we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed versus standard (unwashed) red cells. Limitations Existing studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy, or Near Infra-Red spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective. Conclusions A systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical or cost effectiveness. Further Research The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may to lead to more accurate diagnosis, more effective treatments, and potentially improved clinical outcomes.</p