PREVENTION OF SYSTEMIC INFLAMMATORY RESPONSE DURING LONG-STANDING CAR DIOPULMONARY BYPASS IN PATIENTS WITH COMORBIDITIES
DOI:
https://doi.org/10.31379/2411.2616.14.2.3Keywords:
Cardiopulmonary bypass, hemodiafiltration, sorption, polyorganic insufficiency syndromeAbstract
Objectives. To evaluate the effectiveness of preventive strategies of systemic inflammatory response during long-standing cardiopulmonary bypass (CPB) in patients with comorbidities. Materials and methods. Prospective randomized clinical trial including 60 male patients with expected duration of CPB >120 min due to comorbidities. Inclusion criteria: patients with coronary artery disease and/or heart valve disease with the history of atrial fibrillation and comorbidities (chronic pyelonephritis, chronic obstructive pulmonary disease, diabetes mellitus), requiring CABG surgery and/or valve surgery and “Maze” procedure. Patients who underwent urgent surgery were excluded from the trial. Standard anesthesia protocol was carried out, cardioplegia was obtained by Custodiol © solution. Study includes 3 groups: 1st group (controlled, n=20) included standard CPB, 2nd group (analyzed №1, n=20) included perfusion with high-volume hemofiltration using polyionic buffered solution during all CPB time, 3rd group (analyzed №2, n=20) – CPB with polymethyl methacrylate (PMMA) hemodiafilter. Envelope randomization was carried out. Target analytes’ concentration was examined 1 hour and 1 day after the procedure (WBC, Hb, Plt, IL-6, IL-10, lactate, procalcotonin, C-RP). Clinical data, such as respiratory and renal complications, drainage blood loss, hemostasis disorders, requiring hemostatics and blood transfusion, ICU and in-hospital were evaluated. Results. Filtrative and sorptive methods can reduce the level of inflammatory cytokines, as well as the trigger components and markers of systemic inflammatory response. 1 hour after the sorption IL-6 levels was significantly lower, that in control group. There also was a tendency to the lower concentrations of IL-6 1 day after the procedure. Levels of anti-inflammatory IL-10 one hour after the procedure was insignificantly higher comparing to those in patients, who did not undergo a PMMA-sorption procedure, which leads to the increase in adaptive anti-inflammatory reaction of the body. IL-10 level rises briefly (first hours after the trigger), that’s why its level 1 day after the procedure was low and did not vary in different groups significantly. Median value of sTREM-1 concentration in blood after 1 hour was 4 times less than in control group, however, a wide range of sTREM-1 levels and small amount of patients did not lead to any statistically significant difference. Nevertheless, sorption effect on sTREM-1 (molecular weight ~17 kDa) can be considered relevant. Median value of sTREM-1 concentration in blood 1 day after in analyzed groups was 2 times less than in control group, but it was not statistically relevant. Transfusion rate were the same in both groups, but patients from analyzed group did not require any hemostatic therapy. There was no need in inotropic and vasopressor medications in the analyzed group by the end of the first postoperative day, all patients were extubated in first postoperative hours. Complicated postoperative period occurred in 2 (10%) cases in analyzed groups vs 5(25%) in controlled group; renal dysfunction, requiring dialysis, was diagnosed in 6 (30%) patients from controlled group vs. 2 patients (10%) from analyzed group №2; respiratory insufficiency has developed in 3 patients (15%) only in controlled group. In-hospital stay was comparable in both groups, but lower ICU-stay was significantly lower in analyzed groups. Polyorganic insufficiency syndrome (POIS) occurred in 3 patients (15%) from the controlled group. Conclusion. High-volume hemofiltration using polyionic buffered solution or the use polymethyl methacrylate hemodiafilter for longstanding CPB reduces risks of organic dysfunction in postoperative period.
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