ICU outcomes in adult cardiac surgery patients in relation to ultrafiltration type

Abstract

Ultrafiltration (UF) is used to ameliorate the deleterious effects of cardiopulmonary bypass (CPB) in cardiac surgery patients. There are two different methods; conventional ultrafiltration (CUF), performed during CPB, and modified ultrafiltration (MUF), performed after CPB is finished. It has not been established which is better, and controversy remains regarding the optimal UF strategy. The objective of this study was to evaluate if MUF alone, or combined with CUF, could achieve greater fluid removal and contribute to better postoperative clinical outcomes. Also, the potential technique complications were studied. This was a prospective study which enrolled 125 consecutive adult patients receiving elective cardiac surgery with CPB. We analysed three treatment groups: MUF, CUF and both. Ultrafiltration was performed using a non-pulsatile CPB with a non-occlusive roller pump, Sarns 9000®, and a polysulfone ultrafilter, Minntech®. We studied pre- and intraoperative data and immediate postoperative clinical outcomes: total amount of drainage, transfusion needs, respiratory outcome, cardiac, renal and neurologic complications. Statistical analysis was performed using SPSS 11.0. All three groups were homogeneous and did not have differences in terms of demographic factors, previous history, risk scores, intervention and operative data. Volume of filtrate removal in the group which applied both techniques was larger than in the CUF or MUF groups alone (2569±823 vs 1679±651 vs 1398±353 ml, respectively, p=0.0001); however, despite this difference, there was no difference in the immediate postoperative fluid balances between the groups (596±1244 vs 880±1054 vs 986±1190 ml, p=0.30). Respiratory parameters and postoperative morbidity data analysed (total amount of drainage, transfusion needs, haemoglobin, acute lung injury, time with inotropes, ventricular failure, cardiogenic shock, neurologic complications and renal failure) were similar in all three groups, without statistical differences. Extubation time (10±7 vs 8.9±3 vs 9.4±7.9 hours, p=0.72) and ICU stay (56.6±72 vs 66.5±109 vs 44.2±25 hours, p=0.43) also were similar between the groups. We did not find any technique complication associated with any patient. In the present study, with adult patients receiving elective cardiac surgery, the combined ultrafiltration group had a larger fluid removal. However, neither type of ultrafiltration nor amount of filtered volume was accompanied by different postoperative ICU clinical outcomes. Ultrafiltration was considered a safe and reliable technique, with no related complications.

Get full access to this article

View all access options for this article.

References

1 Westaby S . Organ dysfunction after cardiopulmonary bypass: a systemic inflammatory reaction induced by the extracorporeal circuit. Intensive Care Med 1987; 13: 89–95.

2 Rubens FD Mesana T . The inflammatory response to cardiopulmonary bypass: a therapeutic overview. Perfusion 2004; 19(Suppl I): S5–S12.

3 Seghaye MC Grabitz RG Duchateau J . Inflammatory reaction and capillary leak syndrome related to cardiopulmonary bypass in neonates undergoing cardiac operations. J Thorac Cardiovasc Surg 1996; 112: 687–697.

4 Chew MS . Does modified ultrafiltration reduce the systemic inflammatory response to cardiac surgery with cardiopulmonary bypass. Perfusion 2004; 19: S57–S60.

5 Groom RC Froebe S Martin J . Update on pediatric perfusion practice in North America: 2005 survey. J Extra Corpor Technol 2005; 37: 343–350.

6 Naik SK Knight A Elliot MJ . A successful modification of ultrafiltration for cardiopulmonary bypass. Perfusion 1991; 6: 41–50.

7 Naik SK Knight A Elliot MJ . A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery. Circulation 1991; 84: 422–431.

8 Luciani GB Menon T Vecchi B Auriemma S Mazzucco A . Modified ultrafiltration reduces morbidity after adult cardiac operations. A prospective, randomized trial. Circulation 2001; 104(suppl I): 253–259.

9 Bando K Turrentine MW Vijay P . Effect of modified ultrafiltration in high risk patients undergoing operations for congenital heart disease. Ann Thorac Surg 1998; 66: 821–828.

10.

10 Wang MJ Chiu IS Hsu CM . Efficacy of ultrafiltration in removing inflammatory mediators during pediatric cardiac operations. Ann Thorac Surg 1996; 61: 651–656.

11.

11 Thompson LD McElhinney DB Findlay P . A prospective randomized study comparing volume-standardized modified and conventional ultrafiltration in pediatric cardiac surgery. J Thorac Cardiovasc Surg 2001; 122: 220–228.

12.

12 Maluf MA . Modified ultrafiltration in surgical correction of congenital heart disease. Perfusion 2003; 18: 61–68.

13.

13 Sever K Tansel T Basaran M . The benefits of continuous ultrafiltration in pediatric cardiac surgery. Scand Cardiovasc J 2004; 38: 307–311.

14.

14 Williams GD Ramamoorthy C Chu L . Modified and conventional ultrafiltration during pediatric cardiac surgery: clinical outcomes compared. J Thorac Cardiovasc Surg 2006; 132: 1291–1298.

15.

15 Leyh RG Bartels C Joubert-Hübner E Bechtel JFM Sievers HH . Influence of modified ultrafiltration on coagulation, fibrinolysis and blood loss in adult cardiac surgery. Eur J Cardio-Thorac Surg 2001; 19: 145–151.

16.

16 Kiziltepe U Uysalel A Corapcioglu T Dalva K Akan H Akalin H . Effects of combined conventional and modified ultrafiltration in adult patients. Ann Thorac Surg 2001; 71: 684–693.

17.

17 Messent M Sullivan K Keogh BF Morgan CJ Evans TW . Adult respiratory distress syndrome following cardiopulmonary bypass. Anaesthesia 1992; 47: 267–268.

18.

18 Asimakopoulos G Smith PLC Ratnatunga CP Taylor KM . Lung injury and acute respiratory distress syndrome after cardiopulmonary bypass. Ann Thorac Surg 1999; 68: 1107–1115.

19.

19 Keenan HT Thiagarajan R Stephens KE Williams G Ramamoorthy C Lupinetti FM . Pulmonary function after modified venovenous ultrafiltration in infants: a prospective randomized trial. J Thorac Cardiovasc Surg 2000; 119: 501–505.

20.

20 Journois D Pouard P Greeley WJ Mauriat P Vouhe P Safran D . Hemofiltration during cardiopulmonary bypass in pediatric cardiac surgery. Effects on hemostasis cytokines and complement components. Anaesthesiology 1994; 81: 1181–1189.

21.

21 Huang H Yao T Wang W . Continuous ultrafiltration attenuates the pulmonary injury that follows open heart surgery with cardiopulmonary bypass. Ann Thorac Surg 2003; 76: 136–140.

22.

22 Draaisma AM Hazekamp MG Frank M Anes N Schoof PH Huysmans HA . Modified ultrafiltration after cardiopulmonary bypass in pediatric cardiac surgery. Ann Thorac Surg 1997; 64: 521–525.

23.

23 Wang W Huang H Zhu D Chen H Su ZK Ding WX . Modified ultrafiltration in paediatric cardiopulmonary bypass. Perfusion 1998; 13: 304–310.

24.

24 Chew MS Brix-Christensen V Ravn HB . Effect of modified ultrafiltration on the inflammatory response in pediatric open-heart surgery: a prospective randomized study. Perfusion 2002; 17: 327–333.

25.

25 Grünenfelder J Zünd G Schoeberlein A . Modified ultrafiltration lowers adhesion molecule and cytokine levels after cardiopulmonary bypass without clinical relevance in adults. Eur J Cardiothorac Surg 2000; 17: 77–83.