龙村
中国医学科学院阜外医院 胸心血管外科学分会
The aims of this study were to evaluate the incidence, risk factors, and outcomes of hyperbilirubinemia in cardiac patients with veno-arterial (VA) ECMO. Data on 89 adult patients with cardiac diseases who received VA ECMO implantation in our hospital were retrospectively reviewed. All patients were divided into the following three groups: 24 in normal group (N, total bilirubin [TBIL] ≤3 mg/dL), 30 in high bilirubin group (HB, 6 mg/dL ≥ TBIL > 3 mg/dL), and 35 in severe high bilirubin group (SHB, TBIL > 6 mg/dL). lg(variables + 1) was performed for nonnormally distributed variables. The incidence of hyperbilirubinemia (>3 mg/dL) was 73%. In a multiple linear regression analysis, lg(peak TBIL + 1) was significantly associated with lg(peak AST + 1) (b-coefficient 0.188, P = 0.001), lg(peak pFHb + 1) (b-coefficient 0.201, P = 0.003), and basic TBIL (b-coefficient 0.006, P = 0.009). Repeated measurement analysis of variance revealed that the main effect for three groups in pFHb and lg(AST + 1) was significant at first 3 days during ECMO. The patients in SHB had low platelets during ECMO and low in-hospital survival rate. Hyperbilirubinemia remains common in patients with VA ECMO and is associated with low platelets and high in-hospital mortality. Hemolysis and liver dysfunction during ECMO and basic high bilirubin levels are risk factors of hyperbilirubinemia.
Artificial organs 2018
OBJECTIVE:To investigate whether human serum albumin coating before cardiopulmonary bypass (CPB) could improve platelet function and hemostasis and mitigate the inflammatory response among patients receiving aortic arch replacement with deep hypothermic circulatory arrest (DHCA).METHODS:Sixty patients were included and randomized into two groups: the Control Group (CG, receiving 40 g human albumin 5 minutes after the initiation of CPB) and the Study Group (SG, circulating the prime with 40 g albumin for 5 minutes before CPB). Rapid thromboelastography, complete blood count, coagulation tests and cytokines (IL-1, IL-6, IL-10, TNF-α and PAF) were measured at two intervals: after anesthesia induction and before CPB (T1) and 10 minutes after heparin reversal before any blood product transfusion (T2).RESULTS:Compared with T1, the fibrinogen and MA levels in both groups reduced significantly after heparin reversal and fell within the normal range for most patients. The platelet count reduction (ΔPLT) in the Study Group was significantly less than in the Control Group (p=0.031). Despite the inflammatory factor levels increasing after CPB (p<0.001), no differences were found between the Control Group and the Study Group. Fewer red blood cells were given in the Study Group, but this was not significant (p=0.05).CONCLUSION:Most patients receiving aortic arch replacement with DHCA have normal platelet function and fibrinogen levels after heparin reversal. Albumin coating before CPB may mitigate the platelet count reduction, but not platelet dysfunction. There is a trend that the patients treated with albumin coating received less red blood cell transfusions.
Perfusion 2016
OBJECTIVE:Hemolysis is a common and severe complication during extracorporeal membrane oxygenation (ECMO). Increased plasma free hemoglobin (PFHb) is related to renal injury. The aim of this study was to investigate whether increased PFHb during adult venous-arterial ECMO was associated with acute renal failure (ARF).DESIGN:A retrospective, observational, single-center study.SETTING:Fuwai Hospital in Beijing, China.PARTICIPANTS:The study comprised 84 venous-arterial ECMO patients.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:A total of 84 consecutive adult patients (≥18 years) with cardiac diseases requiring venous-arterial ECMO support were studied retrospectively. Demographics of patients, clinical and ECMO characteristics, and PFHb level were collected within the first 3 days after ECMO. ARF was defined as a≥300% rise in serum creatinine from baseline or application of dialysis. Repeated measurement analysis of variance revealed that the main effect for the non-ARF group and ARF group in PFHb (p = 0.002) was significant. A significant main effect for time points (p<0.001) and time×group interaction (p = 0.014) in PFHb was obtained. In a multiple logistic regression model, peak PFHb during ECMO (odds ratio 1.052, 95% confidence interval 1.016-1.089, p = 0.005) was a risk factor for ARF during ECMO and patients who underwent heart transplantation (odds ratio 0.240, 95% confidence interval 0.060-0.964, p = 0.044) experienced less ARF. There was a linear correlation between peak serum creatinine and peak PFHb (Spearman's r = 0.223, p = 0.042).CONCLUSIONS:Increased PFHb is a predictor of ARF among adult patients on venous-arterial ECMO support.
Journal of cardiothoracic and vascular anesthesia 2016
OBJECTIVE:Due to the weak ascending aorta, it is extremely challenging to establish an anterograde selective cerebral perfusion (ASCP) model in rabbits, especially when cardioplegic arrest is required. Herein, the aim of this study was to establish a rabbit ASCP model with cardiac arrest being easily performed and being similar to the clinical scenario.MATERIALS AND METHODS:Twenty-two adult New Zealand white rabbits were selected for ASCP model establishment and another 22 rabbits were utilized for blood donation. The cardiopulmonary bypass (CPB) circuit consisted of a roller pump, a membrane oxygenator, a heat-cooler system and a blood reservoir, which were connected by silicone tubing. The total priming volume of the circuit was 70 ml. Cannulations on the right and left subclavian arteries were used for arterial inflow and cardioplegia perfusion, respectively. Venous drainage was conducted through the right atrial appendage. ASCP was initiated by clamping the innominate artery; the flow rate was maintained 10 ml/kg/minute and sustained for 60 minutes. After 120 minutes of reperfusion, the rabbits were sacrificed. The mean arterial pressure, heart rate, electrocardiogram and urine output were monitored. Arterial blood samples were analyzed at the following time points: after anesthesia, immediately after CPB, after aorta cross-clamping and cardioplegia perfusion, 5 min after the re-opening of the aorta and at CPB termination.RESULTS:ASCP modeling was performed successfully on 18 rabbits and 4 rabbits unsuccessfully. Vital signs and blood gas indictors changed in an acceptable range throughout the experiments. One rabbit had ventricular fibrillation after re-opening of the ascending aorta. Obvious hemodilution occurred after the perfusion of cardioplegia, but the hematocrit improved after CPB termination.CONCLUSION:By using cannulation of the subclavian artery rather than the aorta and with a low priming volume, we established a modified rabbit model of ASCP with cardioplegic arrest. The model has excellent repeatability and operability, which is similar to the clinic process and is suitable for the study of cerebral, cardiac and renal protection.
Perfusion 2016
Acute renal failure (ARF) is associated with increased mortality in pediatric extracorporeal membrane oxygenation (ECMO). The aim of this study was to identify predictors of ARF during ECMO in pediatric patients after cardiac surgery. A retrospective study analyzed 42 children (≤15 years) after cardiac surgery requiring venous-arterial ECMO between December 2008 and December 2014 at Fuwai Hospital. ARF was defined as ≥300% rise in serum creatinine (SCr) concentration from baseline or application of dialysis. Multivariate logistic regression was performed to identify the predictors of ARF during ECMO. A total of 42 children (age, interquartile range [IQR], 13.0 [7.2-29.8] months; weight, IQR, 8.5 [6.7-11.0] kg) after cardiac surgery requiring ECMO were included in this study. The total survival rate was 52.4%, and the incidence of ARF was 40.5%. As the result of univariate analysis, ECMO duration, cardiopulmonary resuscitation, maximum free hemoglobin (FHB) during ECMO, lactate level, and mean blood pressure before initiation of ECMO were entered in multiple logistic regression analysis. In multiple logistic regression analysis, FHB during ECMO (OR 1.136, 95% CI 1.023-1.261) and lactate level before initiation of ECMO (OR 1.602, 95% CI 1.025-2.502) were risk factors for ARF during ECMO after pediatric cardiac surgery. There was a linear correlation between maximum SCr and maximum FHB (Pearson's r = 0.535, P = 0.001). Maximum SCr during ECMO has also a linear correlation with lactate level before initiation of ECMO (Pearson's r = 0.342, P = 0.044). Increased FHB during ECMO and high lactate level before initiation of ECMO were risk factors for ARF during ECMO in pediatric patients after cardiac surgery.
Artificial organs 2016
OBJECTIVE:Blood and crystalloid cardioplegia are the main myocardial protective solutions used in pediatric cardiac surgery. However, the effectiveness of these two solutions on myocardial metabolism, reperfusion injury and clinical outcomes in pediatric patients is still under debate. The purpose of this meta-analysis was to compare the efficacy of these two cardioplegia solutions in pediatric cardiac surgery.METHODS:Keyword searches were performed on PUBMED, EMBASE and The Cochrane Library for randomized, controlled, clinical studies which were primarily comparing blood and crystalloid cardioplegia in pediatric cardiac surgery and provided data of postoperative cardiac troponin I (cTnI), lactate, mechanical ventilation time, length of intensive care unit (ICU) stay and inotropic support. Databases were searched from 1966 to June 2013 and were restricted to peer-reviewed English language publications of human subjects. We summarized the combined results of the data as mean difference (MD, when outcome measurements were made on the same scale) or standard mean difference (SMD, when the studies assess the same outcome with different scales), with 95% confidence intervals.RESULTS:Five studies were identified, with a total of 323 patients. Lactate level after cardiopulmonary bypass (CPB) was significantly lower after blood cardioplegia compared with crystalloid cardioplegia (SMD 1.09, 95%CI 0.12 to 2.06, p=0.03); cTnI release postoperatively at 4-6 h (MD 0.92 ng/ml, 95%CI -0.13 to 1.97, p=0.09), 12 h (MD 0.2 ng/ml, 95% CI -0.43 to 0.84, p=0.53) and 24 h (MD 0.98 ng/ml, 95%CI -0.26 to 2.22, p=0.12) was not significantly different between the groups; ventilation duration (MD 5.15 hours, 95%CI -7.51 to 17.81, p=0.42) and length of ICU stay (SMD -0.3, 95%CI -0.80 to 0.21, p=0.25) were not significantly different between the groups either.CONCLUSION:Myocardial metabolism was better in the blood cardioplegia group compared with the crystalloid cardioplegia group. However, there was no evidence of improvement in myocardial damage or clinical outcome for either cardioplegia solution.
Perfusion 2015
Extracorporeal membrane oxygenation (ECMO) is a kind of technique that uses extracorporeal circulation system to draw patients' blood into the circuit, and then oxygenate the blood when it passes along the membrane, followed by returning the blood into patients. At present, ECMO is mainly used in treating patients with respiratory failure and circulatory failure, for whom the conventional treatment such as mechanical ventilation and vasoactive drugs are invalid. ECMO can provide cardiopulmonary support for burn patients with respiratory failure or circulatory failure, and put the heart and lung at rest. The purpose of this paper is to review the application of ECMO in the treatment of severe burn.
Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns 2015
Whether modified histidine-tryptophan-ketoglutarate (HTK) solution offers myocardial protection to newborn heart has not been documented. The purpose of this study was to compare myocardial protection using HTK added by ebselen with HTK in a piglet model of cardiopulmonary bypass (CPB). Fifteen piglets were randomly assigned to three groups: the control group (C group, n = 5), HTK solution group (HTK group, n = 5), and HTK added by 10 nM ebselen group (HTK+E group, n = 5). Animals in the two experimental groups were placed on hypothermic CPB, after which the ascending aorta had been clamped for 2 h. The control animals underwent normothermic CPB without cardiac arrest. Myocardial antioxidant activities, myocytes apoptosis and mitochondrial structures, as well as the release of cytochrome c and the expression of Bax, Bcl-2, and HSP72 protein in myocardium were measured. Increased myocardial superoxide dismutase (SOD) and Mn-SOD activities, decreased TUNEL-positive cells, and reduced release of cytochrome c were noted in the HTK+E group compared with those in the HTK group (P = 0.021, P = 0.020, P = 0.045, and P = 0.010, respectively). The Bax/Bcl-2 ratio in the HTK group was significantly higher than that in the C group (P = 0.024). The expression of HSP72 protein and mRNA in the HTK+E group was higher than that in the HTK group (P = 0.039 and P = 0.035, respectively). Mitochondrial score under electron microscope in the HTK+E group was lower than that in the HTK group (P = 0.047). Improved antioxidant defense, reduced myocytes apoptosis, and better preserved mitochondrial structure were observed in the HTK+E group. Ebselen added to HTK provides better myocardioprotection to HTK solution for the neonatal heart.
Artificial organs 2015
OBJECTIVE:Although fresh frozen plasma (FFP) is one of the most commonly used hemostatic agents in clinical specialties today, there is little evidence available supporting its administration. Our present study observed the effects of a priming strategy without FFP during cardiopulmonary bypass (CPB) on postoperative coagulation and clinical recovery in pediatric patients, aiming to supply new evidence for evidence-based use of FFP.METHOD:Eighty pediatric patients with congenital heart disease undergoing cardiac surgery with CPB were randomized to receive either 10-20 ml/kg 4% succinylated gelatin (Gelofusine, GEL group, n = 40) or 1-2 units FFP (FFP group, n = 40) in the pump prime. Rapid-thromboelastography (r-TEG) and functional fibrinogen level were measured before skin incision and 15 minutes after heparin reversal. We recorded the volume of chest tube drainage, transfusion requirements and the dosage of pharmacological agents. The ventilation time, ICU length of stay and hospitalization time after surgery were also collected.RESULTS:After heparin neutralization, there were significantly elevated levels of fibrinogen in the FFP group, which were manifested by r-TEG parameters MAf and FLEV. No significant differences were observed between the two groups in postoperative bleeding, transfusion requirements and the usage of pharmacological agents. Recovery time was also comparable between the two groups.CONCLUSION:In conclusion, prophylactic use of FFP in the priming solution does not provide clinical benefits as presumed. Artificial colloids, such as Gelofusine, can be used safely and effectively as a substitute for FFP in the pump prime. TEG is an effective assessment tool to evaluate postoperative coagulation function in pediatric patients.
Perfusion 2015
UNLABELLED:Transfusion guidelines have been produced for the evidence-based use of fresh frozen plasma (FFP). However, the inappropriate use of FFP is still a worldwide problem, especially in the prophylactic settings. In the present study, 100 cyanotic pediatric patients (age 6 months to 3 years) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were randomized to receive either 10-20 ml/kg FFP (FFP group, n = 50) or 10-20 ml/kg 4 % succinylated gelatin (Gelofusine, GEL group, n = 50) in the priming solution. Rapid thromboelastography (r-TEG) was measured before skin incision and 15 min after heparin neutralization. Postoperative renal and hepatic function, mediastinal chest tube drainage, transfusion requirements, and recovery time were observed. The relationships between hematologic and demographic data and postoperative bleeding volume were also analyzed. The results showed that there were significantly elevated levels of fibrinogen (r-TEG parameters: fibrinogen contribution to maximal amplitude (MAf) and fibrinogen level (FLEV)) in the FFP group compared to the GEL group. The postoperative blood loss, total transfusion requirements, and recovery time were not significantly different between the two groups, indicating that there were no obvious clinical benefits of using FFP in the priming. The maximal amplitude (MA) of r-TEG measured after heparin neutralization was correlated with the 6-h postoperative bleeding volume. In addition, preoperative fibrinogen level rather than FFP priming was an independent predictor of postoperative blood loss.CONCLUSION:Prophylactic use of FFP in the priming solution does not have obvious clinical benefits in cyanotic congenital heart disease (CCHD) patients. Gelofusine, an artificial colloid, is a safe and effective substitute of FFP in the priming solution. Furthermore, r-TEG can be used as a "real-time" assessment tool to evaluate postoperative bleeding and guide transfusion after cardiac surgery in pediatric patients.
European journal of pediatrics 2014
