ultrafiltration for cirrhotic patients during cardiopulmonary bypass: egyptian experience. dr....
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Ultrafiltration for Cirrhotic Patients during Cardiopulmonary Bypass:
Egyptian Experience.
Dr. Mohamed R. El–Tahan, M.D.
Assistant Prof of Anaesthesia & SICU, Dammam University ,
Dammam, Saudi Arabia,
Associate Prof. of Cardiothoracic Anaesthesia, Mansoura
University, Mansoura, Egypt,
Member of the European Association of Cardio-Thoracic
Anaesthetists,
Member of the Association of Cardio-Thoracic Anaesthetists of
UK,
Member of the Association of Anaesthetists of Great Britain and
Ireland, UK
Instructor for ALS & EPLS, European Resuscitation Council, UK.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Objectives
The hill of
schistosomiasis in
the Nile Delta,
Lower and Upper
Egypt
Egypt is the Gift of the Nile
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Egypt has possibly the highest HCV
prevalence worldwide (10%–20%)
and is the leading cause of chronic
liver disease and hepatocellular
carcinoma.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Patients with mild or moderate cirrhosis have
prolonged hospitalization and high mortality
and morbidity rates after cardiac surgery using
cardiopulmonary bypass.
Child-Pugh A Child-Pugh B Child-Pugh C0%
10%20%30%40%50%60%70%80%90%
100%
60%
100% 100%
0%
50%
100%Complications Mortality
Chest-tube output
1113
849
Propensity-score pair-matched control group Cirrhosis
*
Re-exploration rate Postcardiotomy syndrome and pleurisy
0%1%2%3%4%5%6%7%8%9%
9% 9%
0% 0%
Cirrhosis Propensity-score pair-matched control group
* *
Thirty-day mortality 8 years survival0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
19.10%
70.20%
8.50%
85.70%
Cirrhosis Propensity-score pair-matched control group
*
*
Worsening postoperative function of vital
organs may be attributed to the SIRS and
capillary leak syndrome caused by CPB.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The concept of removing excess fluid from the
intravascular space of patients in renal failure
by the filtration of blood through an
ultraporous membrane dates back to 1928.
• Brull L. Realization de l'ultrafiltration in vivo. C R Soc Biol (Paris) 1928;99:1605–1608.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Unfortunately, the first clinical applications of
ultrafiltration in patients with renal failure did
not occur until the 1952.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
During the 1970s, Lee West Henderson was the
first who used the UF during open heart
surgery.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Ultrafiltration is the selective separation of
plasma water and LMW solutes from the
intravascular cellular components and plasma
proteins, using a semipermeable membrane
filter.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
UF is being categorized by the timing and
technique used in the UF process:
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Conventional ultrafiltration is performed during
CPB (usually during the rewarming phase) and
the volume removed is based on the volume
within the CPB circuit.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Modified ultrafiltration refers to the use of
ultrafiltration after the stabilization of the
patient’s hemodynamics after CPB.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
An ultrafilter is placed with the inlet connected to the aortic cannula and the outlet
connected to the right atrium via the venous catheter.
Blood flow rate through the filter is maintained
at 200 to 300 mL/min to produce an UF rate of
100 to 150 mL/min
Infusion rates is adjusted to maintain
appropriate CVP or LAP.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The MUF removed volume after CPB is 20 to 30
mL/kg.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
TRAPtest ASPItest ADPtest0
10203040506070
44
22 28
65
52
39
Control N-MUF
**
*
Chest tube output 24 hrs Chest tube output 48 hrs0
200400600800
100012001400 1075
1400
890 900
Control N-MUF
* *
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Continuous ultrafiltration (CUF+MUF) is a
technique that using both CUF and MUF during
and after the cessation of CPB, respectively.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
CUF attenuates the inflammatory response,
increases hemoglobin conc. and platelets,
improves hemodynamics, decreases the need
for transfusion, postoperative ventilation and
ICU stay.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Extubation time ICU stay0
10203040506070
10
56
8
66
9
44
CUF MUF Both
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Semi-continuous UF throughout CPB but it is
interrupted during weaning from CPB.
Allow UF rate = the crystalloid cardioplegia
volume + 40–70 mL/kg/hr.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Adding small aliquots of crystalloid < 20 mL/kg
as necessary to maintain a safe blood level in
the venous reservoir.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Contributing factors for adverse outcome in cirrhotic
patients after CPB include:
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
no pulsatile flow,
hemodilution,
hemolysis,
activation of the inflammatory cascade,
anticoagulation,
hypothermia,
and reduced end-organ perfusion.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The Royal Hall Harrogate International Centre, King’s Road, Harrogate, 2008.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
We postulated that CUF + MUF may decrease
the need for transfusion and shorten the
durations of ventilation and ICU stay in the
cirrhotic patients after valve surgery.
Hypothesis
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
A priori power analysis indicated that 30
patients in each group would be a sufficiently
sample size to detect a 20% reduction in
aminotransferase values, with a type-I error of
0.05 and a power of 87%.
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Sixty cirrhotic ASA II – IV patients (Child-Pugh
Grade A–C) scheduled for valvular heart
surgery using CPB were studied.
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Patients with history of IHD, LV dysfunction,
cirrhotic cardiomyopathy, thyrotoxicosis,
neurological, renal diseases, pregnancy,
preoperative circulatory or ventilatory
support, or re-do or emergency surgery were
excluded.
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The CUF group (n = 30) conventional
ultrafiltration was used.
CUF volume of 20 – 30 mL kg-1 was removed
during CPB and it was stopped if the venous
reservoir level fell low.
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The CUF+MUF group (n = 30) conventional
ultrafiltration was performed during CPB and
MUF was performed after termination of CPB.
MUF volume of 20 – 30 mL kg-1 was removed
after CPB.
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The target volume for UF removal was:
(priming solution + any additional fluid during
CPB) – (CUF fluid + UOP during bypass).
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Perioperative LFTs, haematocrit, platelet
count, doses of inotropic support, the time to
extubation, the durations of the postoperative
ventilation and ICU and hospital stays were
recorded.
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
MELD Score
71.3% mortality
52.6% mortality
19.6% mortality
6.0% mortality
1.9% mortality
Un-paired student t- test and Mann-Whitney U
test were used as appropriate with repeated
measure analysis of variance.
Methods
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The main causes of hepatic cirrhosis were
hepatitis C in 47 (78.3%), hepatitis B in 10
(16.7%), and undetermined conditions in 3
(5%).
Results
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
CUF CUF + MUF(n=30) (n=30)
Age (years) 27.3±7.8 28.4±8.3Sex (M/F) 21 / 30 (70%) 18 / 30 (60%)Weight(Kg) 67.5±11.6 73.4±9.2Height(cm) 166.5±3.7 167.2±4.3Child-Pugh
Grade A 14 (46.7%) 11 (36.7%)Grade B 13 (43.3%) 15 (50%)Grade C 3 (10%) 4 (13.3%)
MELD score 20 [21] 19 [23]EuroSCORE 3.7 [6] 3.2 [6]Height(cm) 166.5±3.7 167.2±4.3Types of surgery
Aortic valve replacement 9 (30%) 12 (40%)Mitral valve replacement 14 (46.7%) 10 (33.4%)Double valve replacement 5 (16.6%) 4 (13.3%)Triple valve Surgery 2 (6.7%) 4 (13.3%)
CPB time (min) 102.4±20.5 110.1±27.3Aortic clamping time (min) 57.5±25.1 60.2±28.8
Table (1): Patients data.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
CUF CUF + MUF P value(n=30) (n=30)
NTG dose (µg kg-1 min-1) 1.7±0.67 1.9±2.1 0.770
Epinephrine dose (ng.kg-1.min-1) 97±40.01 102±27.3 0.814
Volume of CUF (mL) 1687.5±278.4 1908.4±202.4 0.671
Volume of MUF (mL) 1541.4±239.23
Time to extubation (hrs) 10.3±5.61 6.3±2.61 0.006
Ventilation time (hrs) 8.6±6.21 5.5±2.41 0.007
Perioperative bleeding (mL) 1064±337.13 808±137.42 0.02
PRBCs transfusion (n) 4.4±1.32 2.8±0.82 0.004
ICU length of stay (days) 7.6±3.91 4.1±1.61 0.02
Hospital length of stay (days) 18.7±10.6 10.4±2.11 0.03
Mortality (n(%)) 2 (6.7%) 1 (3.3%) 0.481
Table (2): Clinical data.
Data are mean ± SD and number (%). * P< 0.05 significant compared with CUF group.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Baseline 15 min 30 min 1 h 6 h 12 h 24 h0
5
10
15
20
25
30
35
40
45CUF CUF + MUF
Time
Hae
mat
ocrit
(%)
*
Figure (1): Haematocrit (%) changes.
Data are mean ± SD. * P< 0.05 significant compared with CUF group.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Baseline 15 min 30 min 1 h 6 h 12 h 24 h0
5
10
15
20
25
CUF CUF + MUF
Time
Plat
elet
s (1
04/µ
mL)
Data are mean ± SD. * P< 0.05 significant compared with CUF group.
Figure (2): Platelets (104/µmL) changes.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Group Postoperative
Baseline 12 h Day 1 Day 3 Day 7
AST (IU/L) CUF 47.2±22.63 101.1±27.83 137.7±51.42 124.9±26.54 88.9±27.94
CUF + MUF
39.9±19.17 50.5±25.64 * 84.1±29.14 * 90.7±14.74 * 53.6±18.92 *
ALT (IU/L) CUF 46.7±22.43 112.4±31.23 152.1±31.44 134.8±31.23 98.9±37.81
CUF + MUF
38.5±18.93 55.7±21.54 * 82.1±14.91 * 96.6±13.64 * 59.2±16.50 *
ALP (IU/L) CUF 154.9±101.6 211.1±114.62 255.8±120.63 283.2±122.60 222.5±128.90
CUF + MUF
161.3±79.30 176.4±74.42* 186.4±74.42* 166.1±60.53* 127.7±54.80 *
GGTP (IU/L) CUF 112.9±67.13 196.0±80.34 224.0±85.41 208.4±80.24 189.1±78.61
CUF + MUF
115.8±65.94 136.0±61.80* 176.6±56.40* 139.8±49.21* 121.7±42.84 *
Table (3): Liver enzymes changes.
Data are mean ± SD. * P< 0.05 significant compared with CUF group.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Baseline 12 h Day 1 Day 3 Day 70
0.5
1
1.5
2
2.5
3
3.5
4
4.5CUF CUF + MUF
Time
Bilir
ubin
(mg
dL-1
)Figure (3): Bilirubin (mg dL-1) changes.
Data are mean ± SD. * P< 0.05 significant compared with CUF group.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Baseline 12 h Day 1 Day 3 Day 70
0.5
1
1.5
2
2.5
3
3.5
4
4.5CUF CUF + MUF
Time
Albu
min
(gm
dL-
1)Figure (4): Albumin (gm dL-1) changes.
Data are mean ± SD. * P< 0.05 significant compared with CUF group.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Baseline 12 h Day 1 Day 3 Day 70
5
10
15
20
25
30
35CUF CUF + MUF
Time
Prot
hrom
bin
time
(sec
)Figure (5): Prothrombin time (sec) changes.
Data are mean ± SD. * P< 0.05 significant compared with CUF group.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
CUF CUF + MUFP value
(n=30) (n=30)
Coagulopathy 4 (13.3%) 2 (6.7%) 0.770
Pulmonary 1 (3.3%) 0 (0%) 0.814
Renal 1 (3.3%) 0 (0%) 0.556
New onset or worsening of ascites 5 (16.7%) 3 (10%) 0.477
Encephalopathy 3 (10%) 1 (3.3%) 0.442
Wound dehiscence or infection 1 (3.3%) 2 (6.7%) 0.544
Mortality 2 (6.7%) 1 (3.3%) 0.544
Table (4): Perioperative Complications.
Data are number (%). * P< 0.05 significant compared with CUF group.
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Limitations
The studied population is quite different from
other institutions with the extreme youth of
the studied patients (30 years).
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
The small BMI (24-26 kg/m2) of the studied
population would have a significant
hemodilutional effect from CPB & the use of
CUF+MUF might have a greater effect than
with a larger size population.
Limitations
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
We concluded that CUF + MUF reduced
postoperative bleeding and transfusions,
improved liver function and shortened the
hospital stay in cirrhotic patients after valvular
heart surgery.
Conclusion
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Introduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF
MUF CUF DUF UF & Cirrhosis Our Study
Summary
Thank You