Optimising Organ Perfusion in Comorbid Patients

Aim: To evaluate the effectiveness of perfusion methods to remove inflammatory mediators and metabolites, as well as to reduce the incidence of postoperative organ dysfunction in patients with comorbidities following prolonged cardiopulmonary bypass.

Methods: 154 comorbid patients who underwent cardiac surgeries with cardiopulmonary bypass (CPB) over 90 min were included in a single-center retrospective non-randomized study. Patients received standard anaesthesia. All patients were assigned to three groups: group 1 (n=51) patients received extracorporeal circuit with a conventional roller pump, group 2 (n=31) patients received hemofiltration (HF) during CPB, and group 3 (n=67) patients - hemodiafiltration (HDF) with polymethyl methacrylate dialyzer (PMMA). The groups were comparable in clinical (severity of concomitant diseases – respiratory failure, renal failure, diabetes mellitus) and intraoperative parameters (CPB duration, aortic cross-clamp time). Levels of biochemical markers of organ failure, the oxygenation index (PaO2/FiO2), the degree of hemolysis by plasma free hemoglobin (fHb) and markers of the inflammatory response (interleukin-6 (IL-6), interleukin-10 (IL-10), procalcitonin (PCT), C-reactive protein (CRP), sTrem-1) were measured 1 hour after CPB initiation and 24 hours after its termination. The rate of respiratory and renal complications, postoperative drainage blood loss, the need for vasopressor support, and the length of in-hospital and IVU stay were assessed.

Results: The doses of vasopressor therapy were significantly lower in the PMMA dialyzer group with similar inotropic support. Importantly, patients in the HF group did not require vasopressor therapy. The degree of hemolysis, as well as the levels of lactate were lower in the conventional CPB group and the HF group, while in the PMMA dialyzer group they did not exceed the reference levels. The measurement of biomarker levels showed that filtration and sorption during CPB reduced the level of inflammatory cytokines and trigger molecules of the systemic inflammatory response. The recovery of adequate spontaneous breathing was significantly higher in the conventional CPB group, as well as the need for dialysis and filtration therapy.

Conclusion: Hemofiltration using polyionic buffer solution and polymethyl methacrylate filters with sorption capacity during prolonged cardiopulmonary bypass in comorbid patients can reduce the risk of developing organ failure in the postoperative period.

1. Asimakopoulos G. Systemic inflammation and cardiac surgery: an update. Perfusion. 2001; 16 (5): 353-360. doi: 10.1177/026765910101600505

2. Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory response to cardiac surgery: implications for the anesthesiologist. Anesthesiology 2002; 97 (1): 215-252. https://doi.org/10.1097/00000542-200207000-00030

3. Esper SA, Subramaniam K, Tanaka KA. Pathophysiology of Cardiopulmonary Bypass: Current Strategies for the Prevention and Treatment of Anemia, Coagulopathy, and Organ Dysfunction. Seminars in Cardiothoracic and Vascular Anesthesia. 2014;18(2):161-176. https://doi.org/10.1177/1089253214532375

4. Plotnikov GP, Grigoryev YV, Chizhov AV, Hayes BL, Barbarash LS. Early Extracorporeal Detoxification after Cardiosurgical Interventions. General Reanimatology. 2009;5(1):79. (In Russ.) https://doi.org/10.15360/1813-9779-2009-1-79

5. Barbarash LS, Plotnikov GP, Shukevich DL, Hayes BL, Shukevich LE, Churlyav YuA, Grigoryev EV. Rationale for Early Renal Replacement Therapy for Multiple Organ Dysfunction. General Reanimatology. 2010;6(6):29. (In Russ.) https://doi.org/10.15360/1813-9779-2010-6-29

6. Mlejnsky F, Klein AA, Lindner J, Maruna P, Kvasnicka J, Kvasnicka T, Zima T, Pecha O, Lips M, Rulisek J, Porizka M, Kopecky P, Kunstyr J. A randomised controlled trial of roller versus centrifugal cardiopulmonary bypass pumps in patients undergoing pulmonary endarterectomy. Perfusion. 2015;30(7):520-528. https://doi.org/10.1177/0267659114553283

7. Soliman R, Fouad E, Belghith M, Abdelmageed T. Conventional hemofiltration during cardiopulmonary bypass increases the serum lactate level in adult cardiac surgery. Ann Card Anaesth. 2016;19(1):45-51. https://doi.org/10.4103/0971-9784.173019

8. Rubtsov MS, Shukevich DL, Grigoriyev EV. Hemodynamic effects of dialyzers based on polysulfone and polymethyl methacrylate in online hemodiafiltration in cardiac surgery patients with unstable hemodynamics and acute kidney damage. Russian Journal of Anaesthesiology and Reanimatology. 2022;(3):25 31. (In Russ.) https://doi.org/10.17116/anaesthesiology202203125

9. Revishvili ASh, Chagirev VN, Plotnikov GP, Popov VA, Malyshenko ES, Soldatov AB, Shesteryakova MYu, inventors; AV Vishnivesky National Medical Research Center of Surgery, assignee. The method of intraoperative stabilization of the patient's homeostasis during cardiac surgery with prolonged cardiopulmonary bypass. Russian Federation patent RU 2723752. 2020 Jun 06.

10. Grigoriev EV, Plotnikov GP, Matveeva VG, Radivilko AS, Rubtsov MS, Sardin ES, Shukevich DL, inventors; NII KPSSZ, assignee. The method for preventing the development of systemic inflammatory response in cardiac patients after cardiopulmonary bypass. Russian Federation patent RU 2016142860. 2018 Oct 31.

11. Kibzun AI, Goryainova ER, Naumov AV, Sirotin AN. Teoriya veroyatnostey i matematicheskaya statistika. Bazovyy kurs s primerami i zadachami M.: FIZMAT-LIT 2002. - 224 s. (In Russ).

12. Warren OJ, Smith AJ, Alexiou C, Rogers PL, Jawad N, Vincent C, Darzi AW, Athanasiou T. The inflammatory response to cardiopulmonary bypass: part 1--mechanisms of pathogenesis. J Cardiothorac Vasc Anesth. 2009;23(2):223-231. https://doi.org/10.1053/j.jvca.2008.08.007

13. Kalinichenko AP, Lomivorotov VV, Knyazkova LG, Kornilov IA. Effect of Methylprednisolone on Capillary Permeability at Surgery under Extracorporeal Circulation. General Reanimatology 2011;7(2):39-44. (In Russ.) https://doi.org/10.15360/1813-9779-2011-2-39

14. Harmoinen A, Kaukinen L, Porkkala T, Tarkka M, Kaukinen S. Off-pump surgery does not eliminate microalbuminuria or other markers of systemic inflammatory response to coronary artery bypass surgery. Scand Cardiovasc J.2006;40(2):110-116. https://doi.org/10.1080/14017430500401220

15. Pillai JB, Suri RM. Coronary artery surgery and extracorporeal circulation: the search for a new standard. J Cardiothorac Vasc Anesth. 2008;22(4):594-610. https://doi.org/10.1053/j.jvca.2008.02.004

16. Charnaya MA, Morozov YuA, Gladysheva VG, Krapivkin IA. Vliyaniye tekhnicheskikh kharakteristik ekstrakorporalnykh konturov na trombotsitarnoye zveno gemostaza. sistemu fibrinoliza i razvitiye gemoliza. Patologiya krovoobrashcheniya i kardiokhirurgiya. 2005;3:34–37. (In Russ).

17. Averina TB. Prakticheskiy opyt i obosnovaniye primeneniya biosovmestimykh pokrytiy ekstrakorporalnogo kontura dlya profilaktiki postperfuzionnykh oslozhneniy u detey. Detskiye bolezni serdtsa i sosudov. 2007;5:39-44. (In Russ).

18. Fujii Y. The potential of the novel leukocyte removal filter in cardiopulmonary bypass. Expert Rev Med Devices. 2016;13(1):5-14. https://doi.org/10.1586/17434440.2016.1126179

19. Johnston KA, Westover AJ, Rojas-Pena A, Haft JW, Toomasian JM, Johnson T, Buffington DA, Humes HD. Novel Leukocyte Modulator Device Reduces the Inflammatory Response to Cardiopulmonary Bypass. ASAIO J. 2019;65(4):401-407. https://doi.org/10.1097/MAT.0000000000000822

20. Tallman RD, Dumond M, Brown D. Inflammatory mediator removal by zero-balance ultrafiltration during cardiopulmonary bypass. Perfusion. 2002;17(2):111-115. https://doi.org/10.1191/0267659102pf540oa

21. Hubulava GG, Marchenko SP, Dubova EV, Suvorov VV. The role of modified ultrafiltration in reducing systemic manifestations of inflammation in cardiac surgery. Pediatr. 2016;7:106–10. (in Russ.). https://doi.org/10.17816/PED71106-110

22. Solovievа IN, Belov YuV. High-volume plasmapheresis in cardiac and aortic surgery. Messenger of Anesthesiology and Resuscitation 2018;15(2):25-31. (In Russ.). https://doi.org/10.21292/2078-5658-2018-15-2-25-31