| 1. |
- Barbu, Mikael, et al.
(författare)
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Cardiopulmonary bypass management and acute kidney injury in cardiac surgery patients.
- 2024
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Ingår i: Acta anaesthesiologica Scandinavica. - 1399-6576. ; 68:3, s. 328-336
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Tidskriftsartikel (refereegranskat)abstract
- Cardiopulmonary bypass (CPB) ensures tissue oxygenation during cardiac surgery. New technology allows continuous registration of CPB variables during the operation. The aim of the present investigation was to study the association between CPB management and the risk of postoperative acute kidney injury (AKI).This observational study based on prospectively registered data included 2661 coronary artery bypass grafting and/or valve patients operated during 2016-2020. Individual patient characteristics and postoperative outcomes collected from the SWEDEHEART registry were merged with CPB variables automatically registered every 20s during CPB. Associations between CPB variables and AKI were analyzed with multivariable logistic regression models adjusted for patient characteristics.In total, 387 patients (14.5%) developed postoperative AKI. After adjustments, longer time on CPB and aortic cross-clamp, periods of compromised blood flow during aortic cross-clamp time, and lower nadir hematocrit were associated with the risk of AKI, while mean blood flow, bladder temperature, central venous pressure, and mixed venous oxygen saturation were not. Patient characteristics independently associated with AKI were advanced age, higher body mass index, hypertension, diabetes mellitus, atrial fibrillation, lower left ventricular ejection fraction, estimated glomerular filtration rate<60 or>90mL/min/m2 , and preoperative hemoglobin concentration below or above the normal sex-specific range.To reduce the risk of AKI after cardiac surgery, aortic clamp time and CPB time should be kept short, and low hematocrit and periods of compromised blood flow during aortic cross-clamp time should be avoided if possible.
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| 2. |
- Henningsson, Anna, et al.
(författare)
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Prehospital monitoring of cerebral circulation during out of hospital cardiac arrest ? : A feasibility study
- 2022
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 30:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundAbout two-thirds of the in-hospital deaths after out-of-hospital cardiac arrests (OHCA) are a consequence of anoxic brain injuries, which are due to hypoperfusion of the brain during the cardiac arrests. Being able to monitor cerebral perfusion during cardiopulmonary resuscitation (CPR) is desirable to evaluate the effectiveness of the CPR and to guide further decision making and prognostication.MethodsTwo different devices were used to measure regional cerebral oxygen saturation (rSO2): INVOS™ 5100 (Medtronic, Minneapolis, MN, USA) and Root® O3 (Masimo Corporation, Irvine, CA, USA). At the scene of the OHCA, advanced life support (ALS) was immediately initiated by the Emergency Medical Services (EMS) personnel. Sensors for measuring rSO2 were applied at the scene or during transportation to the hospital. rSO2 values were documented manually together with ETCO2 (end tidal carbon dioxide) on a worksheet specially designed for this study. The study worksheet also included a questionnaire for the EMS personnel with one statement on usability regarding potential interference with ALS.ResultsTwenty-seven patients were included in the statistical analyses. In the INVOS™5100 group (n = 13), the mean rSO2 was 54% (95% CI 40.3–67.7) for patients achieving a return of spontaneous circulation (ROSC) and 28% (95% CI 12.3–43.7) for patients not achieving ROSC (p = 0.04). In the Root® O3 group (n = 14), the mean rSO2 was 50% (95% CI 46.5–53.5) and 41% (95% CI 36.3–45.7) (p = 0.02) for ROSC and no ROSC, respectively. ETCO2 values were not statistically different between the groups. The EMS personnel graded the statement of interference with ALS to a median of 2 (IQR 1–6) on a 10-point Numerical Rating Scale.ConclusionOur results suggest that both INVOS™5100 and ROOT® O3 can distinguish between ROSC and no ROSC in OHCA, and both could be used in the pre-hospital setting and during transport with minimal interference with ALS.
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| 3. |
- Hjarpe, A. K., et al.
(författare)
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Risk factors and treatment of oxygenator high-pressure excursions during cardiopulmonary bypass
- 2023
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Ingår i: Perfusion-Uk. - : SAGE Publications. - 0267-6591. ; 38:1, s. 156-164
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: A high-pressure excursion (HPE) is a sudden increase in oxygenator inlet pressure during cardiopulmonary bypass (CPB). The aims of this study were to identify factors associated with HPE, to describe a treatment protocol utilizing epoprostenol in severe cases, and to assess early outcome in HPE patients. Methods: Patients who underwent cardiac surgery with cardiopulmonary bypass at Sahlgrenska University Hospital 2016-2018 were included in a retrospective observational study. Pre- and post-operative data collected from electronic health records, local databases, and registries were compared between HPE and non-HPE patients. Factors associated with HPE were identified with logistic regression models. Results: In total, 2024 patients were analyzed, and 37 (1.8%) developed HPE. Large body surface area (adjusted Odds Ratio (aOR): 1.43 per 0.1 m(2); 95% confidence interval (CI): 1.16-1.76, p < 0.001), higher hematocrit during CPB (aOR: 1.20 per 1%; (1.09-1.33), p < 0.001), acute surgery (aOR: 2.98; (1.26-6.62), p = 0.018), and previous stroke (aOR: 2.93; (1.03-7.20), p = 0.027) were independently associated with HPE. HPE was treated with hemodilution (n = 29, 78.4%), and/or extra heparin (n = 23, 62.2%), and/or epoprostenol (n = 12, 32.4%). No oxygenator change-out was necessary. While there was no significant difference in 30-day mortality (2.7% vs 3.2%, p = 1.0), HPE was associated with a higher perioperative stroke rate (8.1% vs 1.8%, aOR 5.09 (1.17-15.57), p = 0.011). Conclusions: Large body surface area, high hematocrit during CPB, previous stroke and acute surgery were independently associated with HPE. A treatment protocol including epoprostenol appears to be a safe option. Perioperative stroke rate was increased in HPE patients.
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| 4. |
- Holmen, A., et al.
(författare)
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Whole Blood Adsorber During CPB and Need for Vasoactive Treatment After Valve Surgery in Acute Endocarditis: A Randomized Controlled Study
- 2022
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Ingår i: Journal of Cardiothoracic and Vascular Anesthesia. - : Elsevier BV. - 1053-0770. ; 36:8, s. 3015-3020
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: Patients with endocarditis requiring urgent valvular surgery with cardiopulmonary bypass are at a high risk of developing systemic inflammatory response syndrome and septic shock, necessitating intensive use of vasopressors after surgery. The use of a cytokine hemoadsorber (CytoSorb, CytoSorbents Europe GmbH, Germany) during cardiac surgery has been suggested to reduce the risk of inflammatory activation. The study authors hypothesized that adding a cytokine adsorber would reduce cytokine burden, which would translate into improved hemodynamic stability. Design: A randomized, controlled, nonblinded clinical trial. Setting: At a university hospital, tertiary referral center. Participants: Nineteen patients with endocarditis undergoing valve surgery. Intervention: A cytokine hemoadsorber integrated into the cardiopulmonary bypass circuit. Measurements and Main Results: The accumulated norepinephrine dose in the intervention group was half or less at all postoperative time points compared to the control group, although it did not reach statistical significance; at 24 and 48 hours (median 36 [25-75 percentiles; 12-57] mu g v 114 [25-559] mu g, p = 0.11 and 36 [12-99] mu g v 261 [25-689] mu g, p = 0.09). There was no significant difference in chest tube output, but there was a significantly lower need for the transfusion of red blood cells (285 [0-657] mL v 1,940 [883-2,148] mL, p = 0.03). Conclusions: There was no statistically significant difference between the groups with regard to vasopressor use after surgery for endocarditis with the use of a cytokine hemoadsorber during cardiopulmonary bypass. Additional, larger randomized controlled trials are needed to definitely assess the potential effect. (C) 2022 Elsevier Inc. All rights reserved.
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| 5. |
- Jildenstål, Pether, et al.
(författare)
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Cerebral autoregulation in infants during sevoflurane anesthesia for craniofacial surgery
- 2021
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Ingår i: Pediatric Anesthesia. - : Wiley. - 1155-5645 .- 1460-9592. ; 31:5, s. 563-569
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Tidskriftsartikel (refereegranskat)abstract
- Background: Data on cerebral pressure-flow autoregulation in the youngest children are scarce. We studied the correlation between mean arterial pressure and cerebral tissue oxygen saturation (rSO(2)) by near-infrared spectroscopy (NIRS) in patients undergoing nose, lip, and palate surgery. Aim: We tested the hypothesis that cerebral pressure-flow autoregulation is impaired in children less than 1 year undergoing surgery and general anesthesia with sevoflurane under controlled mechanical ventilation. Method: After approval from the Ethical board, 15 children aged <1 year were included. Before anesthesia induction, a NIRS sensor (INVOS (TM), Medtronic, Minneapolis, USA) was placed over the cerebral frontal lobe. Frontal rSO(2), a surrogate for cerebral perfusion, mean arterial pressure, end-tidal CO2- and sevoflurane concentration, and arterial oxygen saturation were sampled every minute after the induction. A repeated measures correlation analysis was performed to study correlation between mean arterial pressure and cerebral rSO(2), and the repeated measures correlation coefficient (r(rm)) was calculated. Results: Fifteen patients, aged 7.7 +/- 1.9 months, were studied. rSO(2) showed a positive correlation with mean arterial pressure ([95% CI: 9.0-12.1], P < 0.001) with a moderate to large effect size (r(rm) = 0.462), indicating an impaired cerebral pressure-flow autoregulation. The slopes of the rSO(2)-mean arterial pressure correlations were steeper in patients who were hypotensive (mean arterial pressure <50 mm Hg) compared to patients having a mean arterial pressure >= 50 mm Hg, indicating that at lower mean arterial pressure, the cerebral pressure dependence of cerebral oxygenation is even more pronounced. Conclusion: During sevoflurane anesthesia in the youngest pediatric patients, cerebral perfusion is pressure-dependent, suggesting that the efficiency of the cerebral blood flow autoregulation is limited.
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| 6. |
- Lannemyr, Lukas, 1974
(författare)
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Cardiopulmonary bypass and the kidney - studies on patients undergoing cardiac surgery
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Acute kidney injury is a common complication after cardiac surgery with cardiopulmonary bypass (CPB), and has a major impact on morbidity, mortality and costs. The mechanism of CPB-related renal impairment is not fully understood. The aim of this thesis was to describe how CPB affects the kidneys, and whether increased CPB flow might improve renal oxygenation. In addition, we compared the systemic and renal effects of two inotropes in patients with impaired cardiac and renal function. Methods: In patients undergoing cardiac surgery we used urine measurement of N-acetyl-ß-D-glucosaminidase (NAG) to assess tubular cell injury (n=61). Renal vein catheterization was used to study renal blood flow, oxygenation, and filtration during normothermic CPB at 2.5 L/min/m2 (n=18), and at different CPB flow levels (2.4, 2.7 and 3.0 L/min/m2) applied in a randomized order (n=17). In 32 patients with cardiac and renal impairment, pulmonary artery and renal vein catheters were used to study the differential effects of levosimendan and dobutamine in a randomized blinded trial. Results: NAG was elevated already after 30 minutes of CPB, and increased to a six-fold peak early after discontinuation of CPB. In a multivariate analysis, the duration of CPB and the degree of rewarming were independent predictors of peak NAG excretion. Renal oxygenation was impaired during CPB, mainly through reduced oxygen delivery due to hemodilution and renal vasoconstriction. After CPB, renal oxygenation was further impaired due to increased oxygen consumption and inefficient sodium transport. At higher than normal CPB flow rates, renal oxygen extraction was reduced by 12–23 % at an unchanged filtration fraction, indicating that renal oxygenation was improved. In contrast to dobutamine, levosimendan did not only increase cardiac output and renal blood flow, but also increased the glomerular filtration rate by 22%. Conclusions: Cardiopulmonary bypass impairs renal oxygenation due to renal vasoconstriction and hemodilution during and after cardiopulmonary bypass, accompanied by increased release of a tubular injury marker. The postoperative tubular injury is increased after longer CPB times and higher degree of rewarming. Increasing the CPB flow rate may ameliorate the impaired oxygenation seen during CPB. In patients with heart failure and renal impairment, levosimendan may be the inotrope of choice.
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| 7. |
- Lannemyr, Lukas, 1974, et al.
(författare)
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Differential Effects of Levosimendan and Dobutamine on Glomerular Filtration Rate in Patients With Heart Failure and Renal Impairment:ARandomized Double-Blind Controlled Trial.
- 2018
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Ingår i: Journal of the American Heart Association. - 2047-9980. ; 7:16
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Tidskriftsartikel (refereegranskat)abstract
- Background The management of the cardiorenal syndrome in advanced heart failure is challenging, and the role of inotropic drugs has not been fully defined. Our aim was to compare the renal effects of levosimendan versus dobutamine in patients with heart failure and renal impairment. Methods and Results In a randomized double-blind study, we assigned patients with chronic heart failure (left ventricular ejection fraction <40%) and impaired renal function (glomerular filtration rate <80mL/min per 1.73m2) to receive either levosimendan (loading dose 12μg/kg+0.1μg/kg per minute) or dobutamine (7.5 μg/kg per minute) for 75minutes. A pulmonary artery catheter was used for measurements of systemic hemodynamics, and a renal vein catheter was used to measure renal plasma flow by the infusion clearance technique for PAH (para-aminohippurate) corrected by renal extraction of PAH . Filtration fraction was measured by renal extraction of chromium ethylenediamine tetraacetic acid. A total of 32 patients completed the study. Following treatment, the levosimendan and dobutamine groups displayed similar increases in renal blood flow (22% and 26%, respectively) with no significant differences between groups. Glomerular filtration rate increased by 22% in the levosimendan group but remained unchanged in the dobutamine group ( P=0.012). Filtration fraction was not affected by levosimendan but decreased by 17% with dobutamine ( P=0.045). Conclusions In patients with chronic heart failure and renal impairment, levosimendan increases glomerular filtration rate to a greater extent than dobutamine and thus may be the preferred inotropic agent for treating patients with the cardiorenal syndrome. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT 02133105.
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| 8. |
- Lannemyr, Lukas, 1974, et al.
(författare)
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Effects of Cardiopulmonary Bypass on Renal Perfusion, Filtration, and Oxygenation in Patients Undergoing Cardiac Surgery.
- 2017
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Ingår i: Anesthesiology. - 1528-1175. ; 126:2, s. 205-213
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Tidskriftsartikel (refereegranskat)abstract
- Acute kidney injury is a common complication after cardiac surgery with cardiopulmonary bypass. The authors evaluated the effects of normothermic cardiopulmonary bypass on renal blood flow, glomerular filtration rate, renal oxygen consumption, and renal oxygen supply/demand relationship, i.e., renal oxygenation (primary outcome) in patients undergoing cardiac surgery.Eighteen patients with a normal preoperative serum creatinine undergoing cardiac surgery procedures with normothermic cardiopulmonary bypass (2.5 l · min · m) were included after informed consent. Systemic and renal hemodynamic variables were measured by pulmonary artery and renal vein catheters before, during, and after cardiopulmonary bypass. Arterial and renal vein blood samples were taken for measurements of renal oxygen delivery and consumption. Renal oxygenation was estimated from the renal oxygen extraction. Urinary N-acetyl-β-D-glucosaminidase was measured before, during, and after cardiopulmonary bypass.Cardiopulmonary bypass induced a renal vasoconstriction and redistribution of blood flow away from the kidneys, which in combination with hemodilution decreased renal oxygen delivery by 20%, while glomerular filtration rate and renal oxygen consumption were unchanged. Thus, renal oxygen extraction increased by 39 to 45%, indicating a renal oxygen supply/demand mismatch during cardiopulmonary bypass. After weaning from cardiopulmonary bypass, renal oxygenation was further impaired due to hemodilution and an increase in renal oxygen consumption, accompanied by a seven-fold increase in the urinary N-acetyl-β-D-glucosaminidase/creatinine ratio.Cardiopulmonary bypass impairs renal oxygenation due to renal vasoconstriction and hemodilution during and after cardiopulmonary bypass, accompanied by increased release of a tubular injury marker.
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| 9. |
- Lannemyr, Lukas, 1974, et al.
(författare)
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Effects of milrinone on renal perfusion, filtration and oxygenation in patients with acute heart failure and low cardiac output early after cardiac surgery
- 2020
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Ingår i: Journal of Critical Care. - : Elsevier BV. - 0883-9441. ; 57, s. 225-230
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: Early postoperative heart failure is common after cardiac surgery, and inotrope treatment may impact renal perfusion and oxygenation. We aimed to study the renal effects of the inodilator milrinone when used for the treatment of heart failure after weaning from cardiopulmonary bypass (CPB). Material and methods: In 26 patients undergoing cardiac surgery with CPB, we used renal vein catheterization to prospectively measure renal blood flow (RBF), glomerular filtration rate (GFR), and renal oxygenation. Patients who developed acute heart failure and lowcardiac output (cardiac index b2.1 L/min/m2) at 30min afterweaning fromCPB (n= 7) were given milrinone, and the remaining patients (n= 19) served as controls. Additionalmeasurements were made at 60 min after CPB. Results: In patientswith acute postoperative heart failure, before receiving milrinone, renal blood flow was lower (-33%, p b.05) while renal oxygen extraction was higher (41%, p b.05) compared to the control group. Milrinone increased cardiac index (21%, p b.001), RBF (36%, p b.01) and renal oxygen delivery (35%, p b.01), with no significant change in GFR and oxygen consumption compared to the control group. Conclusions: In patients with acute heart failure after weaning from CPB, the milrinone-induced increase in cardiac output was accompanied by improved renal oxygenation. Trial registration: ClinicalTrials.gov; identifier NCT02405195, date of registration; March 27, 2015, and NCT02549066, date of registration; 9 September 2015. (c) 2020 Elsevier Inc. All rights reserved.
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| 10. |
- Lannemyr, Lukas, 1974, et al.
(författare)
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Impact of Cardiopulmonary Bypass Flow on Renal Oxygenation in Patients Undergoing Cardiac Operations
- 2019
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Ingår i: The Annals of thoracic surgery. - : Elsevier BV. - 1552-6259 .- 0003-4975. ; 107:2, s. 505-511
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Tidskriftsartikel (refereegranskat)abstract
- Cardiac surgery with cardiopulmonary bypass (CPB) is associated with acute kidney injury, and the risk increases with low oxygen delivery during CPB. We hypothesized that renal oxygenation could be improved at higher than normal CPB flow rates.After ethical approval and informed consent, 17 patients with normal serum creatinine undergoing normothermic CPB were included and received pulmonary artery and renal vein catheters after anesthesia induction for measurements of systemic and renal variables. Renal oxygen extraction (RO2Ex), a direct measure of the renal oxygen delivery /renal oxygen consumption ratio, and renal filtration fraction were measured, the latter by renal extraction of 51chromium-EDTA. After start of CPB and aortic cross-clamp, the pump flow rate was randomly varied between 2.4, 2.7 and 3.0 l·min-1·m-2 and measurements were made after 10 minutes at each flow rate.RO2Ex increased by 30% at a flow rate of 2.4 l·min-1·m-2 vs. pre-CPB (p<0.05). At a flow rate of 2.7 and 3.0 l·min-1·m-2, RO2Ex was 12% (p<0.05) and 23% (p<0.01) lower, respectively, compared to 2.4 l·min-1·m-2. This corresponds to a 14% and 30% improvement, respectively, of the renal oxygen supply/demand relationship. Filtration fraction was not affected by changes in flow rate, indicating that the glomerular filtration rate increased in proportion to the increase in renal perfusion.The impaired renal oxygenation seen during CPB is ameliorated by an increase in CPB flow rate. Thus, one way to protect the kidneys, during CPB, could be to use a higher flow rate than the one traditionally used.
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