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Association between Endotoxin Activity and Acute Kidney Injury in Cardiac Patients Undergoing Cardiopulmonary Bypass
S41
ORAL ABSTRACT PRESENTATIONS
No RBC transfusion Cell saver n
Control
RBC transfusion p
Cell saver
Control
p
191
143
173
207
16 (8,4)
12 (8,4)
1.00
42 (24,2)
34 (16,4)
0,05
Interleukin-6 ⫾SD (pg.ml )
298,1⫾257,1
330,6⫾414,8
0,75
336,8⫾577,7
368,6⫾382,4
po0,01
Elastase [IQR] Myeloperoxidase [IQR]
2,26 [2,24] 1,64 [1,1]
3,62 [3,22] 1,75 [1,15]
po0,01 0,82
2,17 [1,78] 1,69 [1,21]
3,54 [2,17] 2,19 [1,81]
po0,01 po0,01
Infection n (%) -1
Table 1: Analysis of the association between cell saver use, inflammatory markers and infections, stratified for the use of RBCs. Interleukin-6 is expressed as mean⫾SD. Elastase en myeloperoxidase are expressed as quotient of postoperative and baseline values. Median and inter quartile range[IQR] are given.
Discussion. We showed that perioperative RBC transfusion is a strong risk factor for postoperative infections. Despite a significant reduction in inflammatory markers use of a cell saver increased the infection risk in patients with RBC transfusion. The immunomodulating effects of RBC transfusion may be aggrevated by the use of a cell saver. REFERENCES 1. Horvath KA, Acker MA, Chang H, et al: Blood Transfusion and Infection After Carduac Surgery. Ann Thorac Surg 95 (6):2194-2201, 2013. 2. Vermeijden WJ, van Klarenbosch J, Gu YJ, et al: Effects of Cell-Saving Devices and Filters on Transfusion in Cardiac Surgery: A Multicenter Randomized Study. Ann Thorac Surg 99:26-32, 2015 3. Damgaard S, Nielsen CH, Andersen LW, et al: Cell Saver for On-pump Coronary Operations Reduce Systemic Inflammatory Markers: A Randomized Trail. Ann Thorac Surg 89:1511-1517, 2010 OP-046 Acute massive bleeding after cardiac surgery: a new definition evaluated in a multicenter study 1,2
2
1,3
Pascal Colson , Philippe Gaudard , Jean Luc Fellahi Bertet2, Marie Faucanie2, Marie Christine Picot2
, Elena
1
ARCOTHOVA group, 2CHRU Montpellier, 3Hôpital cardiovasculaire et pneumologique Louis Pradel, Lyon, France
Introduction. Massive bleeding after cardiac surgery has been usually quantified indirectly but a more appropriate definition is needed (1). This observational multicenter study aimed at assessing the incidence of acute massive bleeding (AMB) defined more directly by bleeding flow. Methods. All adult patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) and bleeding 4 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or a reoperated for hemostasis during the first 12 postoperative hours in 29 French centers were included from October to December 2010. Perioperative data and administration of blood products were collected. Linear and logistic regressions analyses were used to identify risk factors of bleeding and of occurrence of postoperative complications. Results. Among 4904 patients, 129 experienced AMB (2.6% [2.1;3.1]) (52 underwent early reoperation, 40.3%). Mean bleeding volume (BV) during AMB was 1118⫾574 ml, and 1263⫾694 ml in patients who required reoperation. Mean BV at 24 hours was 1988⫾1090 ml. Preoperative plasma creatinine, peroperative administration of tranexamic acid, lower hemoglobin level and a higher platelet count at arrival in ICU were significantly associated with H24 BV
(po0.05). Preoperative plasma creatinine, emergency, postoperative acidosis and increased platelet administration were associated with the occurrence of postoperative complication (po0.03). Conclusion. Using the new definition, incidence of AMB is rather low but close to the rate reported other study which used similar criteria (3.7%) (2). Identifying bleeding patients with these timely but binding criteria may allow an aggressive therapeutic strategy that may help to reduce BV and transfusion. REFERENCES 1. Dyke C et al: Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg 147:1458-1463, 2014. 2. Ranucci M et al: Major Bleeding, Transfusions, and Anemia: The Deadly Triad of Cardiac Surgery. Ann Thorac Surg 96:478485, 2013.
Oral Abstract Presentations 601 Thursday, June 25, 2015 9:30 a.m.–10:00 a.m., Room F4/F5 OP-061 Association between endotoxin activity and acute kidney injury in cardiac patients undergoing cardiopulmonary bypass Gianluca Paternoster Departement of Cardiovascular Anaesthesia and ICU San Calo Hospital Potenza Italy Introduction. Several studies identified CPB as a major cause of AKI following cardiac surgery, which is associated with an increased risk of mortality and morbidity, due to the combined effects of the extracorporeal circuit, ischemia-reperfusion, splanchnic ischemia and the initiation of endotoxemia (1). The aim of this observational study was to verify whether prolonged CPB could induce variations of endotoxin activity (EA) during the postsurgical period, and whether they are associated with kidney dysfunction, evaluated by creatinine variations.(2)(3) Methods and results. Eighteen patients were enrolled in the study. All patients underwent CPB for 4120 min. Median EA did not change over the first three observation times T0 (induction of anesthesia), ¼ 0.45 [0.04–0.79], T1 (20 min from unclamping) ¼ 0.45 [0.03–0.78] and T2 [1 h after unclamping] ¼ 0.42 [0.07– 0.71]], while a significant increase was observed at 12 h (T3) (0.58 [0.16–1.0], p ¼ 0.027]). A continuous increase in creatinine was observed over 12 h following CPB (ANOVA p ¼ 0.003; Table 1 ) as described in table 1. A linear correlation (R2 ¼ 0.38; p ¼ 0.007) was found between the variation of creatinine and the variation of EA being the last calculated from baseline to peak
S42
ORAL ABSTRACT PRESENTATIONS
values. The linear dependence was confirmed even when comparing peak EA to peak creatinine changes (R2¼0.41; p¼0.004). At T0, no significant difference in EA levels was observed between patients who did or did not develop AKI [0.47 (0.04–0.78) vs. 0.43 (0.15–0.79); p ¼ 0.74]. However, the AKI group was characterized by a continuous increase in EA from T0 to T3, becoming statistically significant at T3 [T0 ¼ 0.6 (0.32–1.0) vs. T3 ¼ 0.47 (0.04–0.78); p ¼ 0.004]. In contrast, the non-AKI group did not show any differences in EA [T0 ¼ 0.47 (0.16– 0.6) vs. T3 ¼ 0.43 (0.15–0.79); NS]. Table 2 reports all EA values among AKI and non-AKI groups.
Results. The MDRD model does not describe the overall trend of increasing bSCr with age at all, but instead predicts an opposite behavior. The LTV model correctly describes a positive correlation, but the results are entirely below the 25 % quantile. (Figure1)
Table 1
Creatinine (mg/dL)
T0
T1
T2
T3
1.10⫾0.38
1.37⫾0.38
1.53⫾0.44
1.59⫾0.46
ANOVA p¼0.003
Table 2 T0
T1
T2
EA non-AKI 0.43 [0.15-0.79] 0.28 [0.05-0.67] 0.23 [0.13-0.51] EA AKI
T3 0.47 [0.16-0.60]
0.47 [0.04-0.78] 0.47 [0.03-0.78] 0.54 [0.07-0.71]* 0.60 [0.32-1.00]§
Conclusion. Estimate bSCr is of limited accuracy, and whenever possible a recorded bSCr should be used. Further we determine that using these formulas in clinical investigations a bias is immanent.
*p¼0.004 AKI vs. non-AKI; p¼0.014 aKI vs. non-AKI; p¼0.004 T3 vs. T0
Discussion. This study confirms that creatinine is influenced by CPB during cardiac surgery. EA variations compared to baseline seem to associate to creatinine variations. If confirmed, these results might identify a role for specific anti-endotoxin therapies currently used predominantly in abdominal septic shock. The small amount of patients allowed us only to suggest that EA is influenced by CPB and that variations of EA may be associated with creatinine variations. REFERENCES 1. Chertow GM, Am J Med 1998;104:343–348. 2. Mangano Ann Int Med 1998;128:194–203. 3. Shaw A, Neph Phys. 2008;109(4):p55-60. OP-062 The opposite effect of age on creatinine baseline estimates M.H. Bernardi1, D. Schmidlin2, R. Ristl3, T. Neugebauer1, M. Hiesmayr1, A. Lassnigg1 1
Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria, 2 Department of Anaesthesiology and Intensive Care Medicine, Klinik Im Park, Zurich, Switzerland, 3Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria Background & Aim. The diagnosis of acute kidney injury (AKI) relies on accurately quantifying changes in serum creatinine. When baseline serum creatinine values (bSCr) are missing there are proposed estimations to calculate bSCr. (1) The aim of this study was to compare two recommended formulas to a cohort of cardiac surgery patients with known bSCr values and prove its reliability. Methods. 7241 patients (2215 female) out of two centers (Medical University Vienna (MUV), n¼4118; University Hospital Zurich (UHZ), n¼3123) who underwent cardiac surgery during a 46 month period were included. The formulas were: MDRD: bSCr ¼ [75/(186 age0.203 (0.742 if female) (1. 12 if black))]-0.887; LTV: bSCr¼0.74 – 0.2 (if female) þ 0.08 (if black) þ 0.003 age. The observed SCr were plotted versus age for men and women.
REFERENCE 1. Zavada J, et al. Nephrol Dial Transplant. 2010 Dec;25(12): 3911-8. OP-063 N-acetylcysteine versus dopamine to prevent acute kidney injury after cardiac surgery in patients with pre-existing moderate renal insufficiency Omer Faruk Savluk, Fusun Guzelmeric, Yasemin Yavuz, Halide Ogus, Tulay Orki, Canan Guler, Emre Gurcu, Atakan Erkılınc, Tuncer Kocak Kartal Kosuyolu High Education And Training Anesthesiology Introduction. The acute kidney injury ocurring due to the cardiac surgery is a common and important complication of cardiac surgery that cardiopulmonary bypass (CPB) is applied and it is the second most common cause of acute kidney injury in the intensive care unit (1). Acute kidney injury associated with cardiac surgery is characterized by deterioration.in kidney function which becomes symptomatic with a decrease in glomerular filtration rate following cardiac surgergy. It has been argued that antioxidants reduced oxidative stress by reducing ischemic reperfusion during cardiac surgery (2). Methods. 120 patients with coronary artery disease who had moderate renal impairment previously (GFRo60 ml/min) were divided into 3 groups randomly. Group N (40); the patients receiving NAC, Group D (40); the patients receiving renal-dose dopamine (2.5mcg/kg/min) and Group P(40); control group. In Group N; 50 mg/kg was administered as loading dose in 100 cc of 0.9% NaCl for 15 minutes and then 20 mg/kg/h as infusion in 100 cc of 0.9% NaCl during the operation. In Group D; 2.5mcg/ kg/min dopamine was started after induction and given during the operation (400 mg dopamine in 100 cc of 0.9% NaCl). In Group P; 100 cc of 0.9% NaCl was administered after induction as a placebo for 15 minutes. Results. March2013-March2014 120 patients with pre-existing moderate renal insufficiency were divided into 3 groups. Creatinine values significantly decreased in the PO 1st and 2nd days when compared with values in the preoperative value in Group N (po0,001). EGFR values significantly increased inthe PO 1st and
ORAL ABSTRACT PRESENTATIONS
No RBC transfusion Cell saver n
Control
RBC transfusion p
Cell saver
Control
p
191
143
173
207
16 (8,4)
12 (8,4)
1.00
42 (24,2)
34 (16,4)
0,05
Interleukin-6 ⫾SD (pg.ml )
298,1⫾257,1
330,6⫾414,8
0,75
336,8⫾577,7
368,6⫾382,4
po0,01
Elastase [IQR] Myeloperoxidase [IQR]
2,26 [2,24] 1,64 [1,1]
3,62 [3,22] 1,75 [1,15]
po0,01 0,82
2,17 [1,78] 1,69 [1,21]
3,54 [2,17] 2,19 [1,81]
po0,01 po0,01
Infection n (%) -1
Table 1: Analysis of the association between cell saver use, inflammatory markers and infections, stratified for the use of RBCs. Interleukin-6 is expressed as mean⫾SD. Elastase en myeloperoxidase are expressed as quotient of postoperative and baseline values. Median and inter quartile range[IQR] are given.
Discussion. We showed that perioperative RBC transfusion is a strong risk factor for postoperative infections. Despite a significant reduction in inflammatory markers use of a cell saver increased the infection risk in patients with RBC transfusion. The immunomodulating effects of RBC transfusion may be aggrevated by the use of a cell saver. REFERENCES 1. Horvath KA, Acker MA, Chang H, et al: Blood Transfusion and Infection After Carduac Surgery. Ann Thorac Surg 95 (6):2194-2201, 2013. 2. Vermeijden WJ, van Klarenbosch J, Gu YJ, et al: Effects of Cell-Saving Devices and Filters on Transfusion in Cardiac Surgery: A Multicenter Randomized Study. Ann Thorac Surg 99:26-32, 2015 3. Damgaard S, Nielsen CH, Andersen LW, et al: Cell Saver for On-pump Coronary Operations Reduce Systemic Inflammatory Markers: A Randomized Trail. Ann Thorac Surg 89:1511-1517, 2010 OP-046 Acute massive bleeding after cardiac surgery: a new definition evaluated in a multicenter study 1,2
2
1,3
Pascal Colson , Philippe Gaudard , Jean Luc Fellahi Bertet2, Marie Faucanie2, Marie Christine Picot2
, Elena
1
ARCOTHOVA group, 2CHRU Montpellier, 3Hôpital cardiovasculaire et pneumologique Louis Pradel, Lyon, France
Introduction. Massive bleeding after cardiac surgery has been usually quantified indirectly but a more appropriate definition is needed (1). This observational multicenter study aimed at assessing the incidence of acute massive bleeding (AMB) defined more directly by bleeding flow. Methods. All adult patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) and bleeding 4 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or a reoperated for hemostasis during the first 12 postoperative hours in 29 French centers were included from October to December 2010. Perioperative data and administration of blood products were collected. Linear and logistic regressions analyses were used to identify risk factors of bleeding and of occurrence of postoperative complications. Results. Among 4904 patients, 129 experienced AMB (2.6% [2.1;3.1]) (52 underwent early reoperation, 40.3%). Mean bleeding volume (BV) during AMB was 1118⫾574 ml, and 1263⫾694 ml in patients who required reoperation. Mean BV at 24 hours was 1988⫾1090 ml. Preoperative plasma creatinine, peroperative administration of tranexamic acid, lower hemoglobin level and a higher platelet count at arrival in ICU were significantly associated with H24 BV
(po0.05). Preoperative plasma creatinine, emergency, postoperative acidosis and increased platelet administration were associated with the occurrence of postoperative complication (po0.03). Conclusion. Using the new definition, incidence of AMB is rather low but close to the rate reported other study which used similar criteria (3.7%) (2). Identifying bleeding patients with these timely but binding criteria may allow an aggressive therapeutic strategy that may help to reduce BV and transfusion. REFERENCES 1. Dyke C et al: Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg 147:1458-1463, 2014. 2. Ranucci M et al: Major Bleeding, Transfusions, and Anemia: The Deadly Triad of Cardiac Surgery. Ann Thorac Surg 96:478485, 2013.
Oral Abstract Presentations 601 Thursday, June 25, 2015 9:30 a.m.–10:00 a.m., Room F4/F5 OP-061 Association between endotoxin activity and acute kidney injury in cardiac patients undergoing cardiopulmonary bypass Gianluca Paternoster Departement of Cardiovascular Anaesthesia and ICU San Calo Hospital Potenza Italy Introduction. Several studies identified CPB as a major cause of AKI following cardiac surgery, which is associated with an increased risk of mortality and morbidity, due to the combined effects of the extracorporeal circuit, ischemia-reperfusion, splanchnic ischemia and the initiation of endotoxemia (1). The aim of this observational study was to verify whether prolonged CPB could induce variations of endotoxin activity (EA) during the postsurgical period, and whether they are associated with kidney dysfunction, evaluated by creatinine variations.(2)(3) Methods and results. Eighteen patients were enrolled in the study. All patients underwent CPB for 4120 min. Median EA did not change over the first three observation times T0 (induction of anesthesia), ¼ 0.45 [0.04–0.79], T1 (20 min from unclamping) ¼ 0.45 [0.03–0.78] and T2 [1 h after unclamping] ¼ 0.42 [0.07– 0.71]], while a significant increase was observed at 12 h (T3) (0.58 [0.16–1.0], p ¼ 0.027]). A continuous increase in creatinine was observed over 12 h following CPB (ANOVA p ¼ 0.003; Table 1 ) as described in table 1. A linear correlation (R2 ¼ 0.38; p ¼ 0.007) was found between the variation of creatinine and the variation of EA being the last calculated from baseline to peak
S42
ORAL ABSTRACT PRESENTATIONS
values. The linear dependence was confirmed even when comparing peak EA to peak creatinine changes (R2¼0.41; p¼0.004). At T0, no significant difference in EA levels was observed between patients who did or did not develop AKI [0.47 (0.04–0.78) vs. 0.43 (0.15–0.79); p ¼ 0.74]. However, the AKI group was characterized by a continuous increase in EA from T0 to T3, becoming statistically significant at T3 [T0 ¼ 0.6 (0.32–1.0) vs. T3 ¼ 0.47 (0.04–0.78); p ¼ 0.004]. In contrast, the non-AKI group did not show any differences in EA [T0 ¼ 0.47 (0.16– 0.6) vs. T3 ¼ 0.43 (0.15–0.79); NS]. Table 2 reports all EA values among AKI and non-AKI groups.
Results. The MDRD model does not describe the overall trend of increasing bSCr with age at all, but instead predicts an opposite behavior. The LTV model correctly describes a positive correlation, but the results are entirely below the 25 % quantile. (Figure1)
Table 1
Creatinine (mg/dL)
T0
T1
T2
T3
1.10⫾0.38
1.37⫾0.38
1.53⫾0.44
1.59⫾0.46
ANOVA p¼0.003
Table 2 T0
T1
T2
EA non-AKI 0.43 [0.15-0.79] 0.28 [0.05-0.67] 0.23 [0.13-0.51] EA AKI
T3 0.47 [0.16-0.60]
0.47 [0.04-0.78] 0.47 [0.03-0.78] 0.54 [0.07-0.71]* 0.60 [0.32-1.00]§
Conclusion. Estimate bSCr is of limited accuracy, and whenever possible a recorded bSCr should be used. Further we determine that using these formulas in clinical investigations a bias is immanent.
*p¼0.004 AKI vs. non-AKI; p¼0.014 aKI vs. non-AKI; p¼0.004 T3 vs. T0
Discussion. This study confirms that creatinine is influenced by CPB during cardiac surgery. EA variations compared to baseline seem to associate to creatinine variations. If confirmed, these results might identify a role for specific anti-endotoxin therapies currently used predominantly in abdominal septic shock. The small amount of patients allowed us only to suggest that EA is influenced by CPB and that variations of EA may be associated with creatinine variations. REFERENCES 1. Chertow GM, Am J Med 1998;104:343–348. 2. Mangano Ann Int Med 1998;128:194–203. 3. Shaw A, Neph Phys. 2008;109(4):p55-60. OP-062 The opposite effect of age on creatinine baseline estimates M.H. Bernardi1, D. Schmidlin2, R. Ristl3, T. Neugebauer1, M. Hiesmayr1, A. Lassnigg1 1
Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria, 2 Department of Anaesthesiology and Intensive Care Medicine, Klinik Im Park, Zurich, Switzerland, 3Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria Background & Aim. The diagnosis of acute kidney injury (AKI) relies on accurately quantifying changes in serum creatinine. When baseline serum creatinine values (bSCr) are missing there are proposed estimations to calculate bSCr. (1) The aim of this study was to compare two recommended formulas to a cohort of cardiac surgery patients with known bSCr values and prove its reliability. Methods. 7241 patients (2215 female) out of two centers (Medical University Vienna (MUV), n¼4118; University Hospital Zurich (UHZ), n¼3123) who underwent cardiac surgery during a 46 month period were included. The formulas were: MDRD: bSCr ¼ [75/(186 age0.203 (0.742 if female) (1. 12 if black))]-0.887; LTV: bSCr¼0.74 – 0.2 (if female) þ 0.08 (if black) þ 0.003 age. The observed SCr were plotted versus age for men and women.
REFERENCE 1. Zavada J, et al. Nephrol Dial Transplant. 2010 Dec;25(12): 3911-8. OP-063 N-acetylcysteine versus dopamine to prevent acute kidney injury after cardiac surgery in patients with pre-existing moderate renal insufficiency Omer Faruk Savluk, Fusun Guzelmeric, Yasemin Yavuz, Halide Ogus, Tulay Orki, Canan Guler, Emre Gurcu, Atakan Erkılınc, Tuncer Kocak Kartal Kosuyolu High Education And Training Anesthesiology Introduction. The acute kidney injury ocurring due to the cardiac surgery is a common and important complication of cardiac surgery that cardiopulmonary bypass (CPB) is applied and it is the second most common cause of acute kidney injury in the intensive care unit (1). Acute kidney injury associated with cardiac surgery is characterized by deterioration.in kidney function which becomes symptomatic with a decrease in glomerular filtration rate following cardiac surgergy. It has been argued that antioxidants reduced oxidative stress by reducing ischemic reperfusion during cardiac surgery (2). Methods. 120 patients with coronary artery disease who had moderate renal impairment previously (GFRo60 ml/min) were divided into 3 groups randomly. Group N (40); the patients receiving NAC, Group D (40); the patients receiving renal-dose dopamine (2.5mcg/kg/min) and Group P(40); control group. In Group N; 50 mg/kg was administered as loading dose in 100 cc of 0.9% NaCl for 15 minutes and then 20 mg/kg/h as infusion in 100 cc of 0.9% NaCl during the operation. In Group D; 2.5mcg/ kg/min dopamine was started after induction and given during the operation (400 mg dopamine in 100 cc of 0.9% NaCl). In Group P; 100 cc of 0.9% NaCl was administered after induction as a placebo for 15 minutes. Results. March2013-March2014 120 patients with pre-existing moderate renal insufficiency were divided into 3 groups. Creatinine values significantly decreased in the PO 1st and 2nd days when compared with values in the preoperative value in Group N (po0,001). EGFR values significantly increased inthe PO 1st and