Interactive Cardiovascular and Thoracic Surgery 2:420-423(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiopulmonary bypass |
Is prophylactic haemofiltration during cardiopulmonary bypass of benefit during cardiac surgery?
Satish Das and
Joel Dunning*
Department of Cardiothoracic Surgery, Wythenshawe Hospital, South Moor Road, Manchester M23 9LT, UK
* Corresponding author. Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Tel.: +44-7801548122
joeldunning{at}doctors.org.uk
Received August 26, 2003;
accepted August 28, 2003
 |
Abstract
|
|---|
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic haemofiltration during cardiopulmonary bypass is of benefit during cardiac surgery? Altogether 273 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that haemofiltration will increase the haematocrit, reduce some inflammatory markers and may increase the variability of heparin levels. It may also reduce post-operative blood transfusion and possibly increase BP and cardiac index immediately after haemofiltration, although no differences in morbidity or mortality has ever been shown.
Key Words: Haemofiltration; Preoperative care; Evidence-based medicine; Thoracic surgery
|
1. Clinical scenario
|
|---|
You are performing a difficult aortic valve replacement in an 80-year-old patient that also requires three coronary grafts and has an ejection fraction of only 35%. You know that the bypass time is going to be long. The perfusionist informs you that in the last institution he worked at, every patient was prophylactically haemofiltered if bypass was used and that this reduced inflammatory mediators and improved outcome. You decide to use a haemofilter in this high-risk case but resolve to look up the evidence for this after the case.
|
2. Three-part question
|
|---|
In [Patients undergoing elective Cardiac Surgery] does [prophylactic haemofiltration] improve [survival or time to discharge or days in CSU].
2.1. Search strategy
Medline 1966–July 2003 using the OVID interface [(exp haemofiltration/OR hemofiltration.mp OR haemofiltration.mp OR ultrafiltration.mp) AND (exp thoracic surgery/or thoracic surgery.mp or cardiac surgery.mp or CABG.mp OR exp Cardiopulmonary Bypass/OR Cardiopulmonary bypass.mp] LIMIT to Human and English.
2.2. Search outcome
Two hundred and seventy-three papers were found of which nine were deemed to be relevant [1–9]. These are tabulated in Table 1.
2.3. Comment(s)
It is noted that modified haemofiltration (MUF) is the technique of performing haemofiltration for 10–20 min at the end of bypass, during rewarming and in contrast to conventional haemofiltration, which is performed throughout cardiopulmonary bypass. To perform modified haemofiltration, the patient is first weaned off bypass and then the haemofilter pressure is maintained by the difference in pressure between the arterial inflow and the right atrial outflow.
Three studies showed a reduction in inflammatory markers including IL-8 and IL-6 with haemofiltration, although one study found no difference. Two studies showed a reduction in post-operative bleeding, although one study found there to be no difference. Three studies report improved haemodynamics after haemofiltration including improved cardiac index and BP. Five studies report an improved haematocrit or reduced patient weight post haemofiltration. Individual studies also found an increased variability in heparin concentration but no change in aprotinin levels.
All studies were small and therefore there is no reliable data on the effect of haemofiltration on mortality or morbidity.
2.4. Clinical bottom line
Haemofiltration will increase the haematocrit, reduce some inflammatory markers and may increase the variability of heparin levels. It may also reduce post-operative blood transfusion and possibly increase BP and cardiac index immediately after haemofiltration, although no differences in morbidity or mortality have ever been shown.
doi:10.1016/S1569-9293(03)00205-6
|
References
|
|---|
- Leyh RG, Bartels C, Joubert-Hubner E, Bechtel JF, Sievers HH. Influence of modified ultrafiltration on coagulation, fibrinolysis and blood loss in adult cardiac surgery. Eur J Cardiothorac Surg. 2001;19:145–151[Abstract/Free Full Text]
- Onoe M, Magara T, Yamamoto Y, Nojima T. Modified ultrafiltration removes serum interleukin-8 in adult cardiac surgery. Perfusion. 2001;16:37–42[Abstract/Free Full Text]
- Blanchard N, Toque Y, Trojette F, Quintard JM, Benammar A, Montravers P. Hemodynamic and echocardiographic effects of hemofiltration performed during cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2000;14:393–398[CrossRef][Medline]
- Boga M, Islamoglu, Badak I, Cikirikcioglu M, Bakalim T, Yagdi T, Buket S, Hamulu A. The effects of modified hemofiltration on inflammatory mediators and cardiac performance in coronary artery bypass grafting. Perfusion 2000;15:143–150.
- Grunenfelder J, Zund G, Schoeberlein A, Maly FE, Schurr U, Guntli S, Fischer K, Turina M. Modified ultrafiltration lowers adhesion molecule and cytokine levels after cardiopulmonary bypass without clinical relevance in adults. Eur J Cardiothorac Surg. 2000;17:77–83[Abstract/Free Full Text]
- Van Norman GA, Patel MA, Chandler W, Vocelka C. Effects of hemofiltration on serum aprotinin levels in patients undergoing cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2000;14:253–256[CrossRef][Medline]
- Tassani P, Richter JA, Eising GP, Barankay A, Braun SL, Haehnel CH, Spaeth P, Schad H, Meisner H. Influence of combined zero-balanced and modified ultrafiltration on the systemic inflammatory response during coronary artery bypass grafting. J Cardiothorac Vasc Anesth. 1999;13:285–291[CrossRef][Medline]
- Babka RM, Petress J, Briggs R, Helsal R, Mack J. Conventional haemofiltration during routine coronary bypass surgery [erratum appears in Perfusion Nov;12(6):347.]. Perfusion. 1997;12:187–192[Abstract/Free Full Text]
- Despotis GJ, Levine V, Filos KS, Joiner-Maier D, Joist JH. Hemofiltration during cardiopulmonary bypass: the effect on anti-Xa and anti-IIa heparin activity. Anesth Analg. 1997;84:479–483[Abstract]
|
|
Top
Abstract
1. Clinical scenario