Effects of combined conventional ultrafiltration and a simplified modified ultrafiltration in adult cardiac surgery

Background Today’s practice of cardiac surgery encounters an increasing number of older and/or sicker patients, who are expected to have higher morbidity and mortality. Ultrafiltration during cardiac surgery is one of the strategies to prevent major vital organ dysfunction associated with cardiopulmonary bypass (CPB) and therefore might reduce the morbidity and mortality in these patients. This study aims to evaluate the effects of combined conventional ultrafiltration (CUF) and a simplified modified ultrafiltration (S-MUF) on clinical outcome in sick adult patients undergoing cardiac surgery. Methods In this prospective, randomized controlled study fifty adult patients with > 3 Euro SCORE who underwent open heart surgery were enrolled. In this study group (n=25), both CUF and S-MUF was performed, using a simplified circuit. The control group of patients (n=25) were treated identically to the study group except no ultrafiltration was performed. Effects of ultrafiltration on hemodynamics, hematocrit, pulmonary function, postoperative blood loss and homologous blood and blood component usage were recorded. Results During the immediate S-MUF period there was a significant increase in MAP (mean arterial pressure) and haematocrit (54.3 ± 11.6 to 74.3 ± 9.1 mmHg; p < 0.001) and (28.6 ± 5.4% to 36.6 ± 4%; p < 0.001 respectively) in the study group, where as no such phenomenon was observed in the control group. This fact remains true for both the groups during the post operative period. In contrary to the control group, the oxygenation parameters were improved significantly (p < 0.05), immediately after S-MUF and remained at a higher level (p < 0.05) during the postoperative period in the study. The total postoperative blood loss was significantly less in the study group than the control group (402 ± 249 ml vs 603 ± 377 ml, p < 0.05) and (1.8 ± 1.3 U/patient vs 3.1 ± 1.1 U/patient, p < 0.001 respectively). The total duration of mechanical ventilation, ICU stay, inotropic/vasodilator support and hospital stay were similar in both the groups. Conclusion The use of combined CUF and S-MUF can effectively concentrate the blood, transiently improve pulmonary function and decrease postoperative blood loss as well as postoperative requirement of allogenic blood transfusion in sick adult patients. It did not have any major impact on clinical outcome.     

改良超滤联合常规超滤用于重症心脏瓣膜病患者瓣膜置换术的效果

目的 评价改良超滤联合常规超滤用于重症心脏瓣膜病患者瓣膜置换术的效果.方法 择期行瓣膜置换术的重症心脏瓣膜病患者108例,性别不限,年龄≥18岁,体重50～80kg,采用随机数字表法,将患者随机分为常规超滤绀(CUF组,n=56)和改良超滤联合常规超滤组(CMUF组,n=52).CMUF组于 CPB结束后行改良超滤,流世400 ml/min,超滤时间15～20 min.分别于诱导后(T1)、常规超滤开始(T2)、常规超滤结束(T3)、改良超滤开始(T4)、改良超滤结束(T5)、CPB结束后2 h(T6)、8h(T7)及24 h(T8)时采集动脉血样行血气分析,并测定血浆IL-6和IL-8浓度.计算T5-8时的氧合指数,并记录气道压.记录术中尿量、术后24 h尿量、胸腔引流量、术后呼吸机支持时间、术后血制品使用情况及ICU停留时间.结果 与CUF组比较,CMUF组T5,6时Hct升高,T7,8时氧合指数升高,术后呼吸机支持时间、术后24 h尿量、胸腔引流量和浓缩红细胞用量减少(P＜0.05)、血浆IL-6和IL-8浓度、气道压、术中尿量和ICU停留时间比较差异无统计学意义(P＞0.05).结论 改良超滤联合常规超滤可于重症心脏瓣膜病瓣膜置换术患者,改善术后脏器功能,减少异体输血.     

Effects of conventional ultrafiltration on renal performance during adult cardiopulmonary bypass procedures

Ultrafiltration has been used successfully in a variety of applications in the perioperative setting to assist in hemoconcentration and volume reduction. This study was designed to investigate the effects of aggressive conventional hemofiltration on bypass urine production, fluid balance, and renal performance in the 24 hours after bypass procedures in the adult population. A prospective, randomized study was designed to determine the effects of conventional ultrafiltration (CUF) during bypass while monitoring urine dynamics intraoperatively and in the 24-hour post-bypass period. Study group 1 (CUF, n = 49) was compared to control group 2 (non-CUF, n = 47) by monitoring urine values, volume additions, and packed red cell (PRC) use throughout the procedure. The mean total CUF volume removed from group 1 was 5781 +/- 2612. There were no differences in pre-bypass, total bypass, or total operating room (OR) urine between the two groups. The 24-hour urine totals were significantly higher in group 2 (2389 +/- 895) than in group 1 (2035 +/- 895). The ending bypass hematocrit was also lower in group 2 (26 +/- 2.0) than in group 1 (30 +/- 6.0). OR PRC additions were higher in group 2 (395 +/- 699) than group 1 (204 +/- 300). The non-CUF control group 2 experienced significantly greater ending fluid balance (3006 +/- 868) compared with group 1 (744 +/- 1271). No significant differences in pre- or postoperative creatinine values were observed. Aggressive CUF can be safely used during cardiopulmonary bypass in the adult population to reduce fluid accumulation and elevate bypass hematocrit without effecting bypass or intraoperative urine production.     

不同超滤法在小儿体外循环中的应用比较

目的 比较不同超滤法在小儿体外循环中的效果。方法 80例先天性心脏病病儿，随机分成4组，分别为对照（CUF）组，平衡超滤（BUF）组，改良超滤（MUF）组和平衡超滤＋改良超滤（B＋M）组。在围术期检测肿瘤坏死因子（TNF）、白细胞介素－8（IL－8）和E-selectin的浓度。结果 CUF组各类炎症因子的浓度随转流时间的延长不断上升，BUF和B＋M组停转流时炎症因子的浓度明显低于对照组和MUF组（P＜0．05）。MUF组进行超滤时，炎症因子浓度上升，红细胞压积不断升高，B＋M组在停体外循环时炎症介质浓度较低，但在改良超滤时上升，上升幅度较MUF组低。结论 平衡超滤法能降低体内炎症介质，改良超滤法可以在术后迅速浓缩血液，但不能降低炎症介质的浓度。平衡超滤和改良超滤结合起来应用，可兼有二者的作用，但仍不能在转流后将炎症介质的浓度保持在相当低的水平。     

Balanced ultrafiltration, modified ultrafiltration, and balanced ultrafiltration with modified ultrafiltration in pediatric cardiopulmonary bypass.

This study evaluates the effect of balanced ultrafiltration, modified ultrafiltration, and balanced ultrafiltration with modified ultrafiltration on inflammatory mediators in children's open-heart surgery. Eighty children with congenital heart disease were randomly divided into four groups: control group (C group); balanced ultrafiltration group (BUF group); modified ultrafiltration group (MUF group); and balanced ultrafiltration with modified ultrafiltration group (B+M group). Clinical data of these groups were similar. Tumor necrosis factor (TNF), interleukin-8(IL-8), and E-selectin were measured at the beginning of cardiopulmonary bypass (CPB), 30 min later, at the cessation of CPB, at the cessation of MUF (MUF group and B+M group), and 2 hours postoperatively. During CPB, the concentrations of TNF, IL-8, and E-selectin increased significantly in C and MUF groups and did not change significantly in BUF and B+M groups. In the period of MUF, TNF and IL-8 increased; whereas, E-selectin did not change. The study shows that ultrafiltration can filter out the inflammatory mediators, but only BUF can decrease the concentrations of them. Moreover, MUF only can concentrate blood. Combining both techniques has both effects, but the effect of BUF was offset by MUF.     

A prospective randomized study comparing volume-standardized modified and conventional ultrafiltration in pediatric cardiac surgery

BACKGROUND: Modified ultrafiltration has been touted as superior to conventional ultrafiltration for attenuating the consequences of hemodilution after cardiac surgery with cardiopulmonary bypass in children. We conducted a prospective randomized study to test the hypothesis that modified and conventional ultrafiltration have similar clinical effects when a standardized volume of fluid is removed. METHODS: From October 1998 to September 1999, 110 children weighing 15 kg or less (median weight 6.1 kg, median age 6.3 months) undergoing surgery with cardiopulmonary bypass for functionally biventricular congenital heart disease were randomized to conventional (n = 67) or arteriovenous modified ultrafiltration (n = 43) for hemoconcentration. The volume of fluid removed with both methods was standardized as a percentage of effective fluid balance (the sum of prime volume and volume added during cardiopulmonary bypass minus urine output): in patients weighing less than 10 kg, 50% of effective fluid balance was removed, whereas 60% was removed in patients weighing 10 to 15 kg. Hematocrit, hemodynamics, ventricular function, transfusion of blood products, and postoperative resource use were compared between groups. RESULTS: There were no significant differences between groups in age, weight, or duration of cardiopulmonary bypass. The total volume of fluid added in the prime and during bypass was greater in patients undergoing conventional ultrafiltration than in those receiving modified ultrafiltration (205 +/- 123 vs 162 +/- 74 mL/kg; P =.05), although the difference was due primarily to a greater indexed priming volume in patients having conventional ultrafiltration. There was no difference in the percentage of effective fluid balance that was removed in the 2 groups. Accordingly, the volume of ultrafiltrate was greater in patients receiving conventional than modified ultrafiltration (95 +/- 63 vs 68 +/- 28 mL/kg; P =.01). Preoperative and postoperative hematocrit levels were 35.6% +/- 6.6% and 36.3% +/- 5.6% in patients having conventional ultrafiltration and 34.4% +/- 6.7% and 38.7% +/- 7.5% in those having modified ultrafiltration. By repeated-measures analysis of variance, patients receiving modified and conventional ultrafiltration did not differ with respect to hematocrit value (P =.87), mean arterial pressure (P =.85), heart rate (P =.43), or left ventricular shortening fraction (P =.21) from baseline to the postbypass measurements. There were no differences between groups in duration of mechanical ventilation, stay in the intensive care unit, or hospitalization. CONCLUSIONS: When a standardized volume of fluid is removed, hematocrit, hemodynamics, ventricular function, requirement for blood products, and postoperative resource use do not differ between pediatric patients receiving conventional and modified ultrafiltration for hemoconcentration after cardiac surgery.     

Conventional and conventional plus modified ultrafiltration during cardiac surgery in high-risk congenital heart disease.

BACKGROUND: This prospective nonrandomized study is the critical assessment of conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) techniques and their efficiency in congenital heart disease surgeries. Use of cardiopulmonary bypass (CPB) in children is associated with body water retention as a consequence of prime volume and systemic inflammatory reaction. The CUF during CPB has reduced body water excess and the MUF after CPB, removes inflammatory mediators, improves hemodynamic performance, and decreases transfusion requirements. METHODS: Forty-one patients, aged 9 to 36 months, submitted to surgical correction for cardiac defects, using CPB, were divided into 2 similar groups: CUF (21 patients) operated between 1996-1997 were ultrafiltered during CPB, and CUF+MUF, (20 patients) operated between 1997-1998 and ultrafiltered during and after CPB. Postoperative duration of ventilator support, pediatric intensive care unit stay (PICU), hospital stay of the groups with and without preoperative pulmonary hypertension (PH), as well as transfusion requirement, hematocrit and platelet counts were compared. RESULTS: There were no technical complications and a significant ultrafiltrate in the CUF+MUF group was observed as compared to the CUF group. No significant differences were observed between the CUF and CUF+MUF groups regarding ventilatory support, PICU stay and hospital stay. Requirements for red cell transfusion, Ht and platelet counts were not statistically different. CONCLUSIONS: CUF and CUF+MUF were safe and efficient methods for patient stabilization independent of diagnosis and complexity of surgery. Future clinical evaluation should address a larger population of patients to research the different variables.     

Sodium modelling and profiled ultrafiltration in conventional haemodialysis

Summary: Previous controlled studies have shown that sodium modelling may reduce intradialytic hypotension and symptoms (particularly cramp, headache and nausea) in patients on maintenance haemodialysis, and it has been proposed that decremental profiled ultrafiltration may improve haemodynamic stability. Those controlled studies of sodium modelling were flawed because sodium modelling programmes were compared to a constant sodium dialysate concentration lower than the overall mean sodium concentration during sodium modelling (the ‘true mean’). to compare sodium modelling to its true mean constant dialysate concentration and also to compare profiled ultrafiltration with constant ultrafiltration, 12 patients on conventional haemodialysis were dialysed by four regimens in random order each for 3 weeks: (i) sodium modelling (exponential decline from 150 to 140 mmol/L) and conventional (linear) ultrafiltration; (ii) sodium modelling and profiled (65% of target loss in first 2 h) ultrafiltration; (iii) constant sodium (143 mmol/L, the true mean) and conventional ultrafiltration; and (iv) constant sodium and profiled ultrafiltration. Weight gain and pre-dialysis blood pressure were no different between the four regimens. Sodium modelling had no effect on the frequency of intradialytic hypotension or need for saline administration when compared to a constant sodium dialysate of 143 mmol/L, nor improved frequency or severity of thirst, cramp, nausea and lethargy. Interdialytic headache was less severe (P<0.05) but no less frequent with sodium modelling. Profiled ultrafiltration increased the frequency of intradialytic hypotension (odds ratio 2.44, P<0.05) and did not improve symptoms except interdialytic thirst, which occurred less frequently than with linear ultrafiltration (odds ratio 0.55, P<0.05). the haemodynamics and symptoms were no better with sodium modelling and profiled ultrafiltration than with constant sodium dialysis and linear ultrafiltration, respectively. Thus, there is no justification for the routine use of sodium modelling or profiled ultrafiltration in conventional haemodialysis on the grounds of haemodynamic stability or symptom control.     

Influence of modified ultrafiltration on coagulation, fibrinolysis and blood loss in adult cardiac surgery.

OBJECTIVES: Modified ultrafiltration (MUF) significantly reduce blood loss and transfusion requirements in pediatric cardiac surgery presumably by a reduction in inflammatory mediators which decrease the inflammatory axes and decrease the cross-activation of fibrinolysis and thrombosis. The influence of MUF on blood loss and homologous blood transfusion in adult cardiac surgery has not yet been determined. Furthermore, data about the influence on routine coagulation tests, platelet activation as well as the coagulation and fibrinolytic systems are limited. METHODS: In a prospective randomized study 48 patients scheduled for elective myocardial revascularization were randomized into a control group (n=16), a conventional ultrafiltration (CUF) group (n=16) and a MUF group (n=16). Perioperatively, serial blood samples were drawn at specific intervals to evaluate coagulation, fibrinolysis, and platelet function. RESULTS: Neither the coagulation nor the fibrinolytic system was positively influenced by MUF or CUF. The routine clotting tests were comparable except for a significantly higher antithrombin III activity after MUF compared to the CUF control group persisting 24 h postoperatively. Platelet factor 4 activity and platelet counts showed no differences among the groups. MUF considerably reduced the postoperative blood loss (MUF, 6.4+/-1.7 ml/kg bw per 24 h vs. CUF, 9.2+/-2.5 ml/kg bw per 24 h (P=0.003) vs. control, 8.9+/-2.2 ml/kg bw per 24 h (P=0.008)) and allogeneic blood transfusion (MUF, 2.0+/-3.4 ml/kg bw per 24 h vs. CUF, 6.9+/-5.1 ml/kg bw per 24 h (P=0.034) vs. control, 7.0+/-6.3 ml/kg bw per 24 h (P=0.029)). CONCLUSIONS: MUF in adult cardiac surgery significantly reduces postoperative blood loss and transfusion requirements. The mechanism for reduced blood loss could not be elucidated in this study.     

婴幼儿心脏手术后两种改良超滤方法对血流动力学的影响

目的 评估先天性心脏患儿体外循环术后静脉-动脉改良超滤(V-A MUF)和动脉-静脉改良超滤(A-V MUF)两种方法对血流动力学的影响.方法 40例患儿随机均分为两组,分别在体外循环术后行10 min改良超滤.分别在体外循环前、体外循环后、体外循环后10、30 min,记录心率、血压和中心静脉压血流动力学参数和血细胞压积.经食管超声心动图测定左心室后壁收缩期(LVPWs)和舒张期厚度(LVPWd)、舒张末期容积(EDV)、收缩术期容积(ESV)和射血分数(EF)并进行两组比较.结果 V-A MUF患儿在体外循环术后10 min和30 min比术后即刻能维持更好的动脉收缩压.体外循环术后两组患儿EF均显著下降(P<0.05).V-A MUF组EF值在CPB术后10 min(60%)和30 min(46%)较CPB术后即刻显著升高(P<0.001).A-V MUF组EF值无上升.V-A MUF组左心室后壁厚度较A-VMUF有显著改善(P<0.05).两组在围术期血细胞压积差异无统计学意义.结论 静脉-动脉改良超滤是一种安全有效改善患儿心脏术后血流动力学的方法.

Abstract：

Objective Evaluate the effects of venous-arterial modified ultrafiltration on hemodynamics compared to arterial-venous in children undergoing cardiopulmonary bypass (CPB) for repair of congenital heart defects. Methods Forty patients underwent MUF randomly divided into two groups,group V-A MUF (n =20) and group A-V MUF (n =20) for 10 min after CPB. They were studied before CPB, after CPB, 10 min after CPB, and 30 min after CPB. Haemodynamic data including heart rate, blood pressure, central venous pressure and hematocrit were recorded. Transoesophaegeal echocardiography determined left ventricular posterior wall thickness in end-systole ( LVPWs) and end-diastole (LVPWd) , end diastolic volume (EDV) , end systolic volume (ESV) and ejection fraction (EF) were measured and compared in two groups. Results Patients in V-A MUF maintained better systolic arterial blood pressure at 10 min and 30 min compared with 0 min values after CPB. A significant decrease in EF were observed in both groups immediately after CPB ( P < 0.05 ). Significant increase in EF was observed at 10 min (60% ) and 30 min (46% ) after CPB compared with 0 min value after bypass in V-A MUF (P <0.001 ). In A-V MUF, no such increase in EF was observed. EF were significantly higher at 10 min and 30 min in V-A MUF as compared with A-V MUF (P < 0. 001). There was also significant improvement in posterior wall thickness in V-A MUF (P <0.05). Haematocrit values were not different in duration of postoperative between two groups. Conclusion Veno-arterial modified ultrafiltration is a safe and effective method of improving hemodynamics in children following cardiac surgery.     

Pitfall of modified ultrafiltration in pediatric cardiac surgery

Since June, 1998, modified ultrafiltration (MUF) was performed for 92 consecutive children who underwent cardiac surgery using cardiopulmonary bypass, except those with atrial septal defect. Among 92 cases, MUF could not be completed in two cases because of the accident that many air bubbles were found in the arterial line of the CPB circuit. The causes of such trouble were discussed.     

The effect of modified ultrafiltration on the postoperative course in patients with congenital heart disease

Improvements in the technology of cardiopulmonary bypass have significantly reduced morbidity following repair of congenital cardiac defects. However, the use of cardiopulmonary bypass exposes infants to extremes of hemodilution and hyperthermia, often in association with tissue ischemia. Exposure of the blood to surfaces of the bypass circuit initiates a systemic inflammatory response that may result in organ dysfunction after cardiopulmonary bypass, especially the heart, lungs, and brain. The technique of modified ultrafiltration (MUF) was introduced by Naik and colleagues at the Hospital for Sick Children in London over 10 years ago. Since that time, multiple studies have evaluated the effects of MUF on organ function and postoperative morbidity following repair of congenital heart defects. Use of MUF after cardiopulmonary bypass reverses hemodilution and decreases tissue edema resulting in improved pulmonary function with decreased duration of postoperative ventilation, improved left ventricular function, decreased postoperative bleeding, and a decrease in the incidence and duration of pleural effusions following the Fontan procedure. Despite the increasing evidence that the use of MUF reduces postoperative morbidity, many important questions remain unresolved. The mechanisms by which MUF results in these beneficial effects requires additional investigation. In addition, further studies are necessary to identify patients most likely to benefit from MUF and to define the optimal protocols for its use. In the future, prospective randomized studies incorporating recent advances in the technology of cardiopulmonary bypass will be necessary to define the optimal utilization of ultrafiltration during and after cardiopulmonary bypass. Copyright 2003 Elsevier, Inc. All rights reserved.     

Efficacy of modified ultrafiltration in reoperation for valvular disease

We evaluated the efficacy of modified ultrafiltration (MUF) in reoperation for valvular disease. Fourteen patients were divide into two groups consisting of a control group (n = 6) and a MUF group (n = 8). MUF was carried out for fifteen minutes immediately after the completion of cardiopulmonary bypass. The blood flow through the ultrafilter was 300 ml/min and about 1,200 ml of water was removed. The hematocrit elevated significantly from 25% to 31% in the MUF group (p < 0.05). The percentage of the increase in body weight after the operation in the MUF group was significantly less than that in the control group (3.3 +/- 3.1% vs 8.3 +/- 4.3%, p < 0.05). The PaO2/FIO2 after the operation in the MUF group was significantly higher than that in the control group (376 +/- 125 mmHg vs 242 +/- 79 mmHg, p < 0.05). The duration of mechanical ventilation in the MUF group was significantly less than that in the control group (1.1 +/- 1.1 days vs 5.3 +/- 3.3 days, p < 0.05). In conclusion, MUF is useful to hemoconcentrate, reduce postoperative body weight gain and promote early recovery of pulmonary function in reoperation for valvular disease.     

Effects of dilutional and modified ultrafiltration in plasma endothelin-1 and pulmonary vascular resistance after the Fontan procedure

BACKGROUND: Pulmonary vascular resistance (PVR) is closely related with patients' hemodynamics after the Fontan procedure and endothelin-1 (ET-1) may play an important role in pulmonary circulation. Modified ultrafiltration (MUF) is known to remove inflammatory mediators after cardiopulmonary bypass (CPB) surgery. The time courses of plasma ET-1 and PVR were examined before and after the Fontan procedure with MUF. METHODS: Twenty-two patients who underwent the Fontan procedure were divided into two groups: a dilutional ultrafiltration/modified ultrafiltration (DUF/MUF) group (n =11) and a control group (n = 11). Conventional ultrafiltration was performed during CPB in the control group. DUF was performed semicontinuously during CPB and MUF was continued until 15 to 20 minutes after the CPB with polyacrylonitonile membrane in the DUF/ MUF group. The plasma ET-1 concentration was measured before and after CPB, after MUF in the DUF/MUF group, and 6 and 24 hours after CPB. PVR was calculated simultaneously using a thermodilutional catheter. RESULTS: Plasma ET-1 levels increased significantly after CPB in the control group but they did not increase immediately after CPB in the DUF/MUF group. Similarly, PVR increased significantly after CPB in the control group but it did not increase after CPB in the DUF/MUF group and remained low at 6 and 24 hours after CPB. CONCLUSIONS: DUF and MUF suppress the increase in the plasma ET-1 concentration that occurs immediately after the completion of the Fontan procedure and may be an effective intervention for maintaining low PVR after the procedure.     

Influence of combined zero-balanced and modified ultrafiltration on the systemic inflammatory response during coronary artery bypass grafting.

OBJECTIVE: To evaluate whether combined zero-balanced and modified ultrafiltration affects the systemic inflammatory response in coronary artery bypass graft (CABG) patients. DESIGN: Randomized and controlled. SETTING: University-affiliated heart center. PARTICIPANTS: Forty-three patients scheduled for elective CABG. INTERVENTIONS: In the ultrafiltration group (UF group; n = 21), zero-balanced ultrafiltration was performed during rewarming and modified ultrafiltration immediately after the end of cardiopulmonary bypass (CPB). A control group of patients (n = 22) was treated identically to the treatment group except no ultrafiltration process was performed. MEASUREMENTS AND MAIN RESULTS: Immediately after CPB (ie, after zero-balanced ultrafiltration), and again after the modified ultrafiltration, the concentrations of interleukin-6 and interleukin-8 were significantly less (p < 0.05) in the UF group compared with the control group. Both proinflammatory cytokine levels peaked at 2 and 4 hours after CPB, at which time no difference between the two groups could be observed. The levels of measured anti-inflammatory mediators (interleukin-10 and interleukin-1 receptor antagonist) did not show any difference between the two groups. Intrapulmonary shunt fraction decreased in the course of the modified ultrafiltration from 31% +/- 1.2% to 25% +/- 1.3% (p < 0.01), whereas mean arterial pressure increased (69 +/- 1.8 to 80 +/- 2.8 mmHg; p < 0.01); neither parameter changed in the control group. Time to extubation was shorter in the UF group (6.1 +/- 0.5 v 8.6 +/- 0.7 hours; p < 0.05). CONCLUSION: It was concluded that the use of ultrafiltration diminished inflammatory response in a very limited time period immediately after CPB and, probably as a consequence, slightly improved clinical parameters.     

Veno-arterial modified ultrafiltration in children after cardiopulmonary bypass.

A method of performing veno-arterial modified ultrafiltration is described that utilizes conventional blood flow through the aortic and venous cannulae. A dual-pump blood cardioplegia console is adapted to aspirate blood from the cardiopulmonary bypass venous line. The blood is ultrafiltered, sent through the cardioplegia heat exchanger, and returned to the aorta via the cardioplegia needle. Veno-arterial modified ultrafiltration has produced no visual evidence of air entrainment in the cardiopulmonary arterial line. This method allows the immediate resumption of cardiopulmonary bypass without the need for the surgeon to recannulate or alter tubing. Thirty-five children underwent veno-arterial modified ultrafiltration; the results show significant increases in postoperative hematocrit, early extubation, and improved rheology.     

Application of modified ultrafiltration to cardiac surgery in adults]

Modified Ultrafiltration (MUF) was developed for blood concentration and reduction of postoperative edema in cardiac surgery in children. Its beneficial effects on postoperative hemodynamics have been reported. We applied MUF to cardiac surgery in adults and evaluated its usefulness. Between August, 1995 and April, 1997, MUF was performed in 41 adult patients. MUF was carried out immediately after the cessation of cardiopulmonary bypass. The mean fluid volume removed was 1,135.9 +/- 274.1 ml. The patient's haematocrit significantly increased from 23.2 +/- 2.6% to 26.9 +/- 3.2% (p < 0.0001). The dose of inotropes administered was maintained constant during MUF, and no changes were observed in CVP and the heart rate. However, the systolic blood pressure increased from 99.5 +/- 14.7 to 113.2 +/- 16.2 mmHg (p < 0.0001) and cardiac index from 4.2 +/- 0.9 to 4.9 +/- 1.3 l/min/m2 (p = 0.0006). It was suggested that MUF was an useful technique of haemoconcentration and appeared to have beneficial effects on postoperative hemodynamics in adult cardiac surgery.     

Efficacy of modified ultrafiltration in coronary artery bypass grafting]

We evaluated the efficacy of modified ultrafiltration (MUF) in coronary artery bypass grafting. Twenty patients were divide into two groups consisting of a control group (n = 11) and a MUF group (n = 9). MUF was carried out for fifteen minutes immediately after the completion of cardiopulmonary bypass. The blood flow through the ultrafilter was 300 ml/min and about 1,200 ml of water was removed. The hematocrit elevated significantly from 25% to 30% in the MUF group (p < 0.01). Postoperative blood loss in the first 24 hours in the MUF group was significantly less than that in the control group (8 +/- 2 ml/kg vs 12 +/- 4 ml/kg, p < 0.01). There was no statistical difference in the percentage of the increase in body weight after the operation, inflammatory reaction and pulmonary function (A-a DO2, PaO2/FIO2 and duration of intubation) between two groups. In conclusion, MUF is useful to hemoconcentrate and reduce postoperative blood loss in coronary artery bypass grafting.     

乳腺癌改良根治术联合化疗对患者并发症与生活质量的影响

目的探讨改良根治术联合化疗对乳腺癌患者术后并发症以及生活质量的影响。方法回顾性分析175例早期乳腺癌患者的临床资料,根据手术治疗方式的不同,分为对照组(n=100)和研究组(n=75),研究组行改良根治术,术前、术后联合化疗辅助治疗,对照组采用传统的标准根治手术,随访1~3年,比较两组复发、死亡情况以及术后并发症、生活质量的差异性。结果研究组3年随访局部及腋淋巴结复发率分别为6.7%、2.7%,远处转移率为10.7%,3年生存率为92%,与对照组比较(6%、3%、11%、91%),差异无统计学意义(P0.05);研究组术后并发症的发生率(6.7%)明显低于对照组(42%),差异有统计学意义(P0.05);并且术后生活质量大大提高,各项评分明显优于对照组(P0.05)。结论改良根治术联合化疗对于早期乳腺癌的临床治疗疗效与乳腺癌标准根治术相当,而在减少并发症、提高患者术后生活质量方面优势明显。     

Pharmacokinetic analysis of flomoxef in children undergoing cardiopulmonary bypass and modified ultrafiltration

Objective Cardiopulmonary bypass (CPB) induces changes in the pharmacokinetics of drugs. The purpose of this study was to model the pharmacokinetics of flomoxef, a cephalosporin antibiotic, in pediatric cardiac surgery. Methods Each patient received a flomoxef dose of 30 mg/kg as a bolus after the induction of anesthesia and an additional dose (1 g for a child weighing <10 kg, 2 g for ≥10 kg) was injected into the CPB prime. Modified ultrafiltration (MUF) was routinely performed. Blood samples, urine, and ultrafiltrate were collected. In seven patients (group I), serum flomoxef concentration-time courses were analyzed by a modified two-compartment model. Utilizing the estimated parameters, serum concentrations were simulated in another eight patients (group II). Results The initiation of CPB resulted in an abrupt increase in serum flomoxef concentrations in group I; however, concentrations declined biexponentially. The amount of excreted flomoxef in the urine and by MUF was 47% ± 8% of the total administered dose. In group II, an excellent fit was found between the values calculated by the program and the observed serum concentrations expressed; most of the performance errors were <1.0. There was no difference in any kinetic parameter between group I and groups I + II (n = 15). Conclusion The pharmacokinetics of flomoxef in children undergoing CPB and MUF were well fitted to a modified two-compartment model. Using the kinetic data from this study, the individualization of dosage regimens for prophylactic use of flomoxef might be possible.