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

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

The hill of

schistosomiasis in

the Nile Delta,

Lower and Upper

Egypt is the Gift of the Nile

Egypt has possibly the highest HCV

prevalence worldwide (10%–20%)

and is the leading cause of chronic

liver disease and hepatocellular

carcinoma.

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% 100%

100%Complications Mortality

Chest-tube output

Propensity-score pair-matched control group Cirrhosis

Re-exploration rate Postcardiotomy syndrome and pleurisy

0%1%2%3%4%5%6%7%8%9%

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%

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.

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.

Unfortunately, the first clinical applications of

ultrafiltration in patients with renal failure did

not occur until the 1952.

During the 1970s, Lee West Henderson was the

first who used the UF during open heart

surgery.

Ultrafiltration is the selective separation of

plasma water and LMW solutes from the

intravascular cellular components and plasma

proteins, using a semipermeable membrane

filter.

UF is being categorized by the timing and

technique used in the UF process:

Conventional ultrafiltration is performed during

CPB (usually during the rewarming phase) and

the volume removed is based on the volume

within the CPB circuit.

Modified ultrafiltration refers to the use of

ultrafiltration after the stabilization of the

patient’s hemodynamics after CPB.

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.

The MUF removed volume after CPB is 20 to 30

mL/kg.

TRAPtest ASPItest ADPtest0

10203040506070

Control N-MUF

Chest tube output 24 hrs Chest tube output 48 hrs0

200400600800

100012001400 1075

890 900

Control N-MUF

Continuous ultrafiltration (CUF+MUF) is a

technique that using both CUF and MUF during

and after the cessation of CPB, respectively.

CUF attenuates the inflammatory response,

increases hemoglobin conc. and platelets,

improves hemodynamics, decreases the need

for transfusion, postoperative ventilation and

ICU stay.

Extubation time ICU stay0

10203040506070

CUF MUF Both

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.

Adding small aliquots of crystalloid < 20 mL/kg

as necessary to maintain a safe blood level in

the venous reservoir.

Contributing factors for adverse outcome in cirrhotic

patients after CPB include:

no pulsatile flow,

hemodilution,

hemolysis,

activation of the inflammatory cascade,

anticoagulation,

hypothermia,

and reduced end-organ perfusion.

The Royal Hall Harrogate International Centre, King’s Road, Harrogate, 2008.

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

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

Sixty cirrhotic ASA II – IV patients (Child-Pugh

Grade A–C) scheduled for valvular heart

surgery using CPB were studied.

Methods

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

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

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

The target volume for UF removal was:

(priming solution + any additional fluid during

CPB) – (CUF fluid + UOP during bypass).

Methods

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

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

The main causes of hepatic cirrhosis were

hepatitis C in 47 (78.3%), hepatitis B in 10

(16.7%), and undetermined conditions in 3

Results

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.

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.

Baseline 15 min 30 min 1 h 6 h 12 h 24 h0

45CUF CUF + MUF

Figure (1): Haematocrit (%) changes.

Data are mean ± SD. * P< 0.05 significant compared with CUF group.

Baseline 15 min 30 min 1 h 6 h 12 h 24 h0

CUF CUF + MUF

Figure (2): Platelets (104/µmL) changes.

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.

4.5CUF CUF + MUF

)Figure (3): Bilirubin (mg dL-1) changes.

4.5CUF CUF + MUF

1)Figure (4): Albumin (gm dL-1) changes.

35CUF CUF + MUF

)Figure (5): Prothrombin time (sec) changes.

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.

Limitations

The studied population is quite different from

other institutions with the extreme youth of

the studied patients (30 years).

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

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

Summary

Thank You

Ultrafiltration for Cirrhotic Patients during Cardiopulmonary Bypass: Egyptian Experience. Dr....

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