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Intraoperative hemodialysis during cardiopulmonary bypass in chronic renal failure
Intraoperative hemodialysis during cardiopulmonary bypass in chronic renal failure This report describes the features and the course of a patient on maintenance hemodialysis in whom infective endocarditis of the aortic valve ensued. The subsequent development of intractable congestive heart failure necessitated aortic valve replacement. Use of intraoperative hemodialysis. facilitating the intraoperative and postoperative management of the patient. is described. Following valve replacement. the patient did well with no evidence of congestive heart failure.
O. Soffer, M.D., R. C. MacDonell, Jr., M.D., D. C. Finlayson, M.D., F.R.C.P.(C), T. J. Difu1co, M.D., J. K. Bradley, M.D., E. L. Jones, M.D., S. D. Clements, M.D., R. Rigatti, B.S., C.C.T., and E. C. Clark, M.D., F.A.C.P., Atlanta and Albany. Ga.
Cardiopulmonary bypass has been employed with increasing frequency in hemodialysis-dependent patients since the 1968 report by Lansing and associates. I Cardiac valve replacement":" and coronary bypass grafting": 8-11 have been performed with satisfactory results in patients having chronic renal failure. Lavelle and Dentino? have reviewed 13 patients with chronic renal failure undergoing valve replacement during a follow-up period of I to 3 years. The survival rate was 61 percent. The present report documents successful valve replacement in a dialysis-dependent patient with aortic insufficiency and intractable congestive heart failure. Intraoperative hemodialysis, a technique not reported previously, was employed.
Case report A 55-year-old woman with idiopathic, rapidly progressive glomerulonephritis was placed on a program of hemodialysis in June, 1977. In February, 1978, aortic regurgitation was diagnosed. There had been no antecedent history of congeniFrom the Department of Medicine, Division of Nephrology and Cardiology, Department of Anesthesiology; the Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Emory University School of Medicine, Atlanta, Ga.; and the Dialysis Clinic. Incorporated. Albany, Ga. Received for publication Oct. 4, 1978. Accepted for publication Jan. 30. 1979. Address for reprints: O. Soffer, M.D., Emory University School of Medicine, Division of Nephrology, GlennMemorial Building, 69 Butler St., S.E., Atlanta, Ga. 30303.
tal or rheumatic heart disease and no episodes of septicemia, fever, or arteriovenous fistula infections. Numerous blood cultures in the 6 weeks following diagnosis of aortic insufficiency were negative. Congestive heart failure progressed despite regular hemodialysis, and she was transferred to Emory University Hospital on April 4, 1978. On admission, blood pressure was 170/60 mm. Hg. Respiratory distress, bilateral rales, and a Grade 3/6 diastolic murmur along the left sternal border were present. Peripheral signs of endocarditis were absent. Echocardiography and cardiac angiography confirmed the diagnosis of aortic regurgitation with normal coronary arteries. Aortic valve vegetations were not seen. Congestive heart failure and severe hyperkalemia were managed with daily hemodialysis, polystyrene sulfonate enemas, and intravenous glucose, insulin, and bicarbonate. Because severe left-sided congestive heart failure persisted despite this regimen, we elected to replace the aortic valve with a Bjork-Shiley valve prosthesis on the tenth day of hospitalization. Weight at this time was 48.5 kilograms and height was 4 feet, II inches. After placement of electrocardiographic leads and the usual intravenous and arterial cannulas, a pulmonary artery catheter was inserted, anesthesia was induced, the operation was begun, and bypass was established with a Cobe Optiflo I oxygenator. The oxygenator prime consisted of 2 units of packed cells, with a volume of 500 ml., plasma 900 ml., and a balanced salt solution (Plasma-Lyte 148, Baxter) 300 ml. The resulting prime in the oxygenator had a hematocrit value of 17 percent and a potassium level of 6.2 mEq. per liter. Two units of whole blood were subsequently added to replace intraoperative losses, so that the hematocrit value was 26 percent at the end of bypass. A Travenol dialysis unit with 1.5 sq. M. Travenol coil (Travenol Laboratories, Inc., Deerfield, III.) was connected, in parallel, to the oxygenator to remove blood from the venous line and return it to the sump reservoir. Intraoperative hemodialysis was carried out with a potassi-
0022-5223/79/050789+03$00.30/0 © 1979 The C. V. Mosby Co.
789
The Journal of Thoracic and Cardiovascular Surgery
790 Soffer et al.
urn-free dialysate, blood flow of 180 ml. per minute, and dialysate flow of 500 ml. per minute. Dialysis was carried out for 60 of the 85 minutes of the bypass period. Despite the elevated serum potassium in the prime, the addition of 2 units of whole blood, and the use of 400 ml. of cardioplegic solution (27.9 mEq. per liter of potassium};" the serum potassium level did not rise. The serum potassium was 4.3 mEq. per liter prior to bypass, ranged from 3.2 to 4.3 mEq. per liter during bypass, and was 3.4 mEq. per liter after its conclusion. The hematocrit value was 30 percent at the beginning and 29 percent at the end of operation. At the completion of the operation, blood pressure was 120/60 mm. Hg, pulmonary wedge pressure was II mm. Hg, and serum potassium was 4.2 mEq. per liter. During the operation the patient received a total of 1,000 c.c, of fluid (whole blood and crystalloid). Thereafter, the volume of fluid infused was 20 c.c. per hour plus the amount lost through drainage tubes. On the first postoperative day her weight was 48 kilograms. The immediate postoperative period was uneventful. Pulmonary wedge pressure ranged from II to 14 mm. Hg in the first 3 days. The next hemodialysis was performed on the third postoperative day with a Travenol dialysis unit (1.5 sq. M. coil) without complication. Thrice weekly hemodialysis was continued thereafter. Anticoagulation with warfarin was begun on the second postoperative day. Two weeks later she was ambulatory, having a blood pressure of 160/60 mm. Hg and no evidence of congestive heart failure. Microscopic examination of the resected aortic valve revealed a thickened, sclerosed valve with focal necrotic inflammatory changes, neovascularization, and superimposed acute suppurative inflammation. No organisms were seen and cultures were negative. Despite negative cultures, the pathological changes in the aortic valve suggestive of endocarditis in a dialysis-dependent patient who is susceptible to bacterial endocarditis justify antimicrobial therapy. Antibiotic therapy (gentamicin and cephalothin) was instituted on the fifth postoperative day and was continued for 6 weeks. The origin and the causative organism of bacterial endocarditis are unknown. Eight months after the operation, she is doing well, free of symptoms and septicemia.
provides an excellent means of hemodialysis, as efficient as needed, and without cardiopulmonary sequelae. In patients with end-stage renal disease, severe hyperkalemia may ensue in the intraoperative and postoperative periods from acidosis, hemolysis, blood transfusion, and inadequate ability to excrete potassium. Correction of acidosis, use of potassium exchange resins, and early postoperative hemodialysis are common measures for reducing serum potassium levels. Intraoperative hemodialysis, as used in our patient, provides an excellent means for the control of hyperkalemia, by maintaining serum potassium in an acceptable range throughout the operative procedure, and permits the use of cardioplegic solutions. Positive fluid balance at the end of cardiopulmonary bypass is poorly tolerated by patients with renal failure and may be hazardous to the patient with compromised cardiac function. As demonstrated in the aforementioned case (by pulmonary wedge pressure and the weight), extracellular fluid volume during the operation was easily controlled by ultrafiltration during dialysis. Early initiation of hemodialysis (first postoperative day), a common practice" following cardiopulmonary bypass, is undesirable because of the hazards of anticoagulation. Intraoperative hemodialysis eliminates the need for obligatory heparinization in the immediate postoperative period.
2
Comment The incidence of infective endocarditis in dialysisdependent patients varies from l. 3 to 6 percent? with predominant involvement of the aortic valve. The aortic valve was involved in 10 of 13 patients in the report by Lavelle and Dentino," and in all patients undergoing valve replacement in the report by Chawla and associates." The favorable results of valve replacement in dialysis-dependent patients": 7 as opposed to the fatal outcome in those treated with antibiotics alone? encouraged us to operate upon our patient. Hemodialysis is extremely difficult to use in the critically ill patient with compromised cardiac function. Usually, hypotensive episodes occur that limit the efficacy of dialysis. With intraoperative hemodialysis, the mechanical pump in the cardiopulmonary bypass circuit provides a steady propulsive energy for the hemodialysis. Thus the aforementioned procedure
3
4
5
6
7
REFERENCES Lansing AM, Leb DE, Berman LB: Cardiovascular surgery in endstage renal failure. lAMA 204:682-686. 1968 Ribot S, Gilbert L, Rothfeld EL, Parsonnet V, lacobs MG: Bacterial endocarditis with pulmonary edema necessitating mitral valve replacement in a hemodialysisdependent patient. 1 THoRAc CARDIOVASC SURG 62:5962, 1971 Wilcox BR, Asaph lW. Brown DR: Aortic valve replacement in anephric patient. Ann Thorac Surg 20:282288, 1975 Posner MA, Reves lG. Lell WA: Aortic valve replacement in a hemodialysis-dependent patient. Anesthetic consideration. A case report. Anesth Analg 54:24-28, 1975 Fishbein MC, Gissen SA, Collins 11, Barsamian EM, Cohn LH: Pathologic findings after cardiac valve replacement with glutaraldehyde-fixed porcine valve. Am 1 Cardiol 40:331-337, 1977 Chawla R, Gailianus P Jr. Lazarus 1M, Gottlieb MN, Lawrie EG, Collins 11, Merril lP: Cardiopulmonary bypass surgery in chronic hemodialysis and transplant patients. Trans Am Soc Artif Intern Organs 23:694-697, 1977 Lavelle Kl, Dentino MM: Surgical treatment of infective
Volume
n
Hemodialysis during CPR in chronic renal failure
Number 5 May, 1979
endocarditis in hemodialysis patients. Clin Neph 9:6- 10, 1978 8 North LB: Coronary surgery in patient receiving hemodialysis. Arch Intern Med 137:25-26, 1977 9 Diamond HL, Schreiner GE: Coronary artery bypass surgery in hemodialysis. Arch Intern Med 137:26-27, 1977 10 Siegel SM, Norfleet EA, Gitelman HJ: Coronary artery bypass surgery in a patient receiving hemodialysis. Arch Intern Med 137:83-84, 1977
79 1
I I Crawford FA Jr, Selby JH Jr, Brower JD, Lehan PH: Coronary revascularization in patient maintained on chronic hemodialysis. Circulation 56:684-687, 1977 12 Finlayson DC, Kaplan JA: Support of the circulation in cardiac anesthesia, New York, Grone & Stratton, Inc. In press
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January I, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: "The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors." Authors will be consulted, when possible, regarding republication of their material.
O. Soffer, M.D., R. C. MacDonell, Jr., M.D., D. C. Finlayson, M.D., F.R.C.P.(C), T. J. Difu1co, M.D., J. K. Bradley, M.D., E. L. Jones, M.D., S. D. Clements, M.D., R. Rigatti, B.S., C.C.T., and E. C. Clark, M.D., F.A.C.P., Atlanta and Albany. Ga.
Cardiopulmonary bypass has been employed with increasing frequency in hemodialysis-dependent patients since the 1968 report by Lansing and associates. I Cardiac valve replacement":" and coronary bypass grafting": 8-11 have been performed with satisfactory results in patients having chronic renal failure. Lavelle and Dentino? have reviewed 13 patients with chronic renal failure undergoing valve replacement during a follow-up period of I to 3 years. The survival rate was 61 percent. The present report documents successful valve replacement in a dialysis-dependent patient with aortic insufficiency and intractable congestive heart failure. Intraoperative hemodialysis, a technique not reported previously, was employed.
Case report A 55-year-old woman with idiopathic, rapidly progressive glomerulonephritis was placed on a program of hemodialysis in June, 1977. In February, 1978, aortic regurgitation was diagnosed. There had been no antecedent history of congeniFrom the Department of Medicine, Division of Nephrology and Cardiology, Department of Anesthesiology; the Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Emory University School of Medicine, Atlanta, Ga.; and the Dialysis Clinic. Incorporated. Albany, Ga. Received for publication Oct. 4, 1978. Accepted for publication Jan. 30. 1979. Address for reprints: O. Soffer, M.D., Emory University School of Medicine, Division of Nephrology, GlennMemorial Building, 69 Butler St., S.E., Atlanta, Ga. 30303.
tal or rheumatic heart disease and no episodes of septicemia, fever, or arteriovenous fistula infections. Numerous blood cultures in the 6 weeks following diagnosis of aortic insufficiency were negative. Congestive heart failure progressed despite regular hemodialysis, and she was transferred to Emory University Hospital on April 4, 1978. On admission, blood pressure was 170/60 mm. Hg. Respiratory distress, bilateral rales, and a Grade 3/6 diastolic murmur along the left sternal border were present. Peripheral signs of endocarditis were absent. Echocardiography and cardiac angiography confirmed the diagnosis of aortic regurgitation with normal coronary arteries. Aortic valve vegetations were not seen. Congestive heart failure and severe hyperkalemia were managed with daily hemodialysis, polystyrene sulfonate enemas, and intravenous glucose, insulin, and bicarbonate. Because severe left-sided congestive heart failure persisted despite this regimen, we elected to replace the aortic valve with a Bjork-Shiley valve prosthesis on the tenth day of hospitalization. Weight at this time was 48.5 kilograms and height was 4 feet, II inches. After placement of electrocardiographic leads and the usual intravenous and arterial cannulas, a pulmonary artery catheter was inserted, anesthesia was induced, the operation was begun, and bypass was established with a Cobe Optiflo I oxygenator. The oxygenator prime consisted of 2 units of packed cells, with a volume of 500 ml., plasma 900 ml., and a balanced salt solution (Plasma-Lyte 148, Baxter) 300 ml. The resulting prime in the oxygenator had a hematocrit value of 17 percent and a potassium level of 6.2 mEq. per liter. Two units of whole blood were subsequently added to replace intraoperative losses, so that the hematocrit value was 26 percent at the end of bypass. A Travenol dialysis unit with 1.5 sq. M. Travenol coil (Travenol Laboratories, Inc., Deerfield, III.) was connected, in parallel, to the oxygenator to remove blood from the venous line and return it to the sump reservoir. Intraoperative hemodialysis was carried out with a potassi-
0022-5223/79/050789+03$00.30/0 © 1979 The C. V. Mosby Co.
789
The Journal of Thoracic and Cardiovascular Surgery
790 Soffer et al.
urn-free dialysate, blood flow of 180 ml. per minute, and dialysate flow of 500 ml. per minute. Dialysis was carried out for 60 of the 85 minutes of the bypass period. Despite the elevated serum potassium in the prime, the addition of 2 units of whole blood, and the use of 400 ml. of cardioplegic solution (27.9 mEq. per liter of potassium};" the serum potassium level did not rise. The serum potassium was 4.3 mEq. per liter prior to bypass, ranged from 3.2 to 4.3 mEq. per liter during bypass, and was 3.4 mEq. per liter after its conclusion. The hematocrit value was 30 percent at the beginning and 29 percent at the end of operation. At the completion of the operation, blood pressure was 120/60 mm. Hg, pulmonary wedge pressure was II mm. Hg, and serum potassium was 4.2 mEq. per liter. During the operation the patient received a total of 1,000 c.c, of fluid (whole blood and crystalloid). Thereafter, the volume of fluid infused was 20 c.c. per hour plus the amount lost through drainage tubes. On the first postoperative day her weight was 48 kilograms. The immediate postoperative period was uneventful. Pulmonary wedge pressure ranged from II to 14 mm. Hg in the first 3 days. The next hemodialysis was performed on the third postoperative day with a Travenol dialysis unit (1.5 sq. M. coil) without complication. Thrice weekly hemodialysis was continued thereafter. Anticoagulation with warfarin was begun on the second postoperative day. Two weeks later she was ambulatory, having a blood pressure of 160/60 mm. Hg and no evidence of congestive heart failure. Microscopic examination of the resected aortic valve revealed a thickened, sclerosed valve with focal necrotic inflammatory changes, neovascularization, and superimposed acute suppurative inflammation. No organisms were seen and cultures were negative. Despite negative cultures, the pathological changes in the aortic valve suggestive of endocarditis in a dialysis-dependent patient who is susceptible to bacterial endocarditis justify antimicrobial therapy. Antibiotic therapy (gentamicin and cephalothin) was instituted on the fifth postoperative day and was continued for 6 weeks. The origin and the causative organism of bacterial endocarditis are unknown. Eight months after the operation, she is doing well, free of symptoms and septicemia.
provides an excellent means of hemodialysis, as efficient as needed, and without cardiopulmonary sequelae. In patients with end-stage renal disease, severe hyperkalemia may ensue in the intraoperative and postoperative periods from acidosis, hemolysis, blood transfusion, and inadequate ability to excrete potassium. Correction of acidosis, use of potassium exchange resins, and early postoperative hemodialysis are common measures for reducing serum potassium levels. Intraoperative hemodialysis, as used in our patient, provides an excellent means for the control of hyperkalemia, by maintaining serum potassium in an acceptable range throughout the operative procedure, and permits the use of cardioplegic solutions. Positive fluid balance at the end of cardiopulmonary bypass is poorly tolerated by patients with renal failure and may be hazardous to the patient with compromised cardiac function. As demonstrated in the aforementioned case (by pulmonary wedge pressure and the weight), extracellular fluid volume during the operation was easily controlled by ultrafiltration during dialysis. Early initiation of hemodialysis (first postoperative day), a common practice" following cardiopulmonary bypass, is undesirable because of the hazards of anticoagulation. Intraoperative hemodialysis eliminates the need for obligatory heparinization in the immediate postoperative period.
2
Comment The incidence of infective endocarditis in dialysisdependent patients varies from l. 3 to 6 percent? with predominant involvement of the aortic valve. The aortic valve was involved in 10 of 13 patients in the report by Lavelle and Dentino," and in all patients undergoing valve replacement in the report by Chawla and associates." The favorable results of valve replacement in dialysis-dependent patients": 7 as opposed to the fatal outcome in those treated with antibiotics alone? encouraged us to operate upon our patient. Hemodialysis is extremely difficult to use in the critically ill patient with compromised cardiac function. Usually, hypotensive episodes occur that limit the efficacy of dialysis. With intraoperative hemodialysis, the mechanical pump in the cardiopulmonary bypass circuit provides a steady propulsive energy for the hemodialysis. Thus the aforementioned procedure
3
4
5
6
7
REFERENCES Lansing AM, Leb DE, Berman LB: Cardiovascular surgery in endstage renal failure. lAMA 204:682-686. 1968 Ribot S, Gilbert L, Rothfeld EL, Parsonnet V, lacobs MG: Bacterial endocarditis with pulmonary edema necessitating mitral valve replacement in a hemodialysisdependent patient. 1 THoRAc CARDIOVASC SURG 62:5962, 1971 Wilcox BR, Asaph lW. Brown DR: Aortic valve replacement in anephric patient. Ann Thorac Surg 20:282288, 1975 Posner MA, Reves lG. Lell WA: Aortic valve replacement in a hemodialysis-dependent patient. Anesthetic consideration. A case report. Anesth Analg 54:24-28, 1975 Fishbein MC, Gissen SA, Collins 11, Barsamian EM, Cohn LH: Pathologic findings after cardiac valve replacement with glutaraldehyde-fixed porcine valve. Am 1 Cardiol 40:331-337, 1977 Chawla R, Gailianus P Jr. Lazarus 1M, Gottlieb MN, Lawrie EG, Collins 11, Merril lP: Cardiopulmonary bypass surgery in chronic hemodialysis and transplant patients. Trans Am Soc Artif Intern Organs 23:694-697, 1977 Lavelle Kl, Dentino MM: Surgical treatment of infective
Volume
n
Hemodialysis during CPR in chronic renal failure
Number 5 May, 1979
endocarditis in hemodialysis patients. Clin Neph 9:6- 10, 1978 8 North LB: Coronary surgery in patient receiving hemodialysis. Arch Intern Med 137:25-26, 1977 9 Diamond HL, Schreiner GE: Coronary artery bypass surgery in hemodialysis. Arch Intern Med 137:26-27, 1977 10 Siegel SM, Norfleet EA, Gitelman HJ: Coronary artery bypass surgery in a patient receiving hemodialysis. Arch Intern Med 137:83-84, 1977
79 1
I I Crawford FA Jr, Selby JH Jr, Brower JD, Lehan PH: Coronary revascularization in patient maintained on chronic hemodialysis. Circulation 56:684-687, 1977 12 Finlayson DC, Kaplan JA: Support of the circulation in cardiac anesthesia, New York, Grone & Stratton, Inc. In press
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January I, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: "The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors." Authors will be consulted, when possible, regarding republication of their material.