scholarly journals Optimal perfusion: Review based on recent scientific evidence

2019 ◽  
pp. 13-27
Author(s):  
Alexis Martin ◽  
Carlos Albendea ◽  
Jimmy Franklin Alemán ◽  
Victor Gómez ◽  
Laura Ciuró
Keyword(s):  
Cardiac Surgery ◽  
Extracorporeal Circulation ◽  
Scientific Evidence ◽  
Kidney Injury ◽  
Physiological Variables ◽  
Analysis And Synthesis ◽  
Pubmed Search ◽  
Bibliographic Search ◽  
Risk Patients ◽  
History Of

Introduction: Throughout the history of extracorporeal circulation there have been several controversial aspects regarding the management of the different physiological, hemodynamic and technical variables. In this review we will synthesize recent scientific evidence of what we call "optimal perfusion". Method: The bibliographic search was carried out in the Cochrane and MEDLINE databases using the PubMed search engine, where the main term was “optimal perfusion” combining it with MeHS terms such as “cardiopulmonary bypass”, “cardiac surgery”, “acute kidney injury” and “goal directed perfusion”. Results: 168 references were obtained, of which 61 were selected for later analysis and synthesis. The main blood pressure remains one of the parameters with less consensus, especially in high-risk patients. The incidence of acute renal failure after cardiac surgery associated with extracorporeal circulation has undergone a notable change thanks to the management of physiological variables or the so-called goal directed perfusion. With these strategies it has been possible to update and review the critical hematocrit in order to ensure a constant and optimal oxygen supply at all times and avoid tissue hypoperfusion and its incidence in global morbidity. Conclusions: The parameters referred to as "optimal" are under continuous review and analysis and, together with the advances in active and real-time monitoring of the delivery and consumption parameters, have changed management in our daily clinical practice.

scholarly journals Goal Directed Perfusion: Bibliographical Review

2019 ◽  
pp. 5-11 ◽  
Author(s):  
Juan Carlos Santos ◽  
Jose Maria Jaime ◽  
Jose Maria Gonzalez
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Extracorporeal Circulation ◽  
Kidney Injury ◽  
Carbon Dioxide Production ◽  
Search Term ◽  
Initial Term ◽  
Venous Oxygen Saturation ◽  
Pubmed Search ◽  
Made In

Objective: The aim of this study is to synthesize the existing evidence on Goal Directed Perfusion Methods: The search for the existing evidence was made in the MEDLINE databases, using the PubMed search engine. The initial search term was “goal directed perfusion.” In order to narrow the search, MeHS terms such as “cardiac surgery” and “cardiopulmonary bypass” were used together with the initial term and the Boolean operator AND. Results: At first, 238 references were obtained, combined whit “cardiac surgery” there were 49 references and finally whit “cardiopulmonary bypass” 21. We read 23 articles. Levels of oxygen delivery (DO2i) > 272 ml/min/m2, minimize hemodilution an maintain hematocrit values > 26% decrease acute kidney injury. A carbon dioxide production VCO2 i > of 60 ml/min/m2 and DO2i/VCO2i < 5 are predictors of hyperlactatemia. The mixed venous oxygen saturation (SvO2) and the oxygen extraction rate (ERO2) are better predictors of transfusion during extracorporeal circulation than hemoglobin value. The majority of the bibliography refers to adult surgery, but the application of GDP to the pediatric perfusion is beginning. Conclusion: The improvement of “optimal” perfusion, considered the gold standard, towards goal directed perfusion is already in use. Many hospitals are incorporating online monitoring of the new perfusion parameters in order to apply a specific perfusion to each patient as well as his metabolic needs during extracorporeal circulation.

scholarly journals Effect of Remote Ischemic Preconditioning on Kidney Injury Among High-Risk Patients Undergoing Cardiac Surgery

JAMA ◽  
2015 ◽  
Vol 313 (21) ◽  
pp. 2133 ◽  
Author(s):  
Alexander Zarbock ◽  
Christoph Schmidt ◽  
Hugo Van Aken ◽  
Carola Wempe ◽  
Sven Martens ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
High Risk ◽  
Ischemic Preconditioning ◽  
Kidney Injury ◽  
Remote Ischemic Preconditioning ◽  
High Risk Patients ◽  
Risk Patients

scholarly journals Risk factors for acute kidney injury and mortality in high risk patients undergoing cardiac surgery

PLoS ONE ◽  
2021 ◽  
Vol 16 (5) ◽  
pp. e0252209
Author(s):  
Giuseppe Filiberto Serraino ◽  
Michele Provenzano ◽  
Federica Jiritano ◽  
Ashour Michael ◽  
Nicola Ielapi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Acute Kidney Injury ◽  
Logistic Regression ◽  
Regression Analysis ◽  
Cardiac Surgery ◽  
Blood Glucose ◽  
Kidney Injury ◽  
Glucose Levels ◽  
Blood Glucose Levels ◽  
Risk Patients

Background Acute Kidney Injury (AKI) represents a clinical condition with poor prognosis. The incidence of AKI in hospitalized patients was about 22–57%. Patients undergoing cardiac surgery (CS) are particularly exposed to AKI because of the related oxidative stress, inflammation and ischemia-reperfusion damage. Hence, the risk profile of patients undergoing CS who develop AKI and who are consequently at increased mortality risk deserves further investigation. Methods We designed a retrospective study examining consecutive patients undergoing any type of open-heart surgery from January to December 2018. Patients with a history of AKI were excluded. AKI was diagnosed according to KDIGO criteria. Univariate associations between clinical variables and AKI were tested using logistic regression analysis. Variable thresholds maximizing the association with AKI were measured with the Youden index. Multivariable logistic regression analysis was performed to assess predictors of AKI through backward selection. Mortality risk factors were assessed through the Cox proportional hazard model. Results We studied 158 patients (mean age 51.2±9.7 years) of which 74.7% were males. Types of procedures performed were: isolated coronary artery bypass (CABG, 50.6%), valve (28.5%), aortic (3.2%) and combined (17.7%) surgery. Overall, incidence of AKI was 34.2%. At multivariable analysis, young age (p = 0.016), low blood glucose levels (p = 0.028), estimated Glomerular Filtration Rate (p = 0.007), pH (p = 0.008), type of intervention (p = 0.031), prolonged extracorporeal circulation (ECC, p = 0.028) and cross-clamp (p = 0.021) times were associated with AKI. The threshold for detecting AKI were 91 and 51 minutes for ECC and cross-clamp times, respectively. At survival analysis, the presence of AKI, prolonged ECC and cross-clamp times, and low blood glucose levels forecasted mortality. Conclusions AKI is common among CS patients and associates with shortened life-expectancy. Several pre-operative and intra-operative predictors are associated with AKI and future mortality. Future studies, aiming at improving prognosis in high-risk patients, by a stricter control of these factors, are awaited.

‘Goal-directed extracorporeal circulation: transferring the knowledge and experience from daily cardiac surgery to extracorporeal membrane oxygenation’

Perfusion ◽  
2021 ◽  
pp. 026765912110638
Author(s):  
Ignazio Condello ◽  
Giuseppe Santarpino ◽  
Giuseppe Nasso ◽  
Marco Moscarelli ◽  
Giuseppe Speziale ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Extracorporeal Membrane Oxygenation ◽  
Oxygen Delivery ◽  
Life Support ◽  
Scientific Evidence ◽  
Kidney Injury ◽  
Form Of Life ◽  
Membrane Oxygenation ◽  
Metabolic Management ◽  
Vasopressor Use

Metabolism management plays an essential role in extracorporeal technologies. There are different metabolic management devices integrated to extracorporeal devices; the most commonly used and accepted metabolic target in adult patients is indexed oxygen delivery (280 mL/min/m2) and cardiac index (2.4 L/min/m2), which can be managed independently or according to other metabolic parameters. Extracorporeal membrane oxygenation (ECMO) is a temporary form of life support providing a prolonged biventricular circulatory and pulmonary support for patients experiencing both pulmonary and cardiac failure unresponsive to conventional therapy. The goal-directed perfusion initiative during cardiopulmonary bypass (CPB) reduced the incidence of acute kidney injury after cardiac surgery. On the basis of the available literature, the identified goals to achieve during CPB include maintenance of oxygen delivery > 300 mL O2/min/m2 and reduction in vasopressor use. ECMO and CPB are conceptually similar but differ in many aspects and finality; in particular, they differ in the scientific evidence for metabolic management nadirs. As for CPB, predictive target parameters have been found and consolidated, particularly in terms of acute renal injury and the prevention of anaerobic metabolism, while for ECMO management, a blurred path remains. In this context, we review the strategies for optimal goal-directed therapy during CPB and ECMO, trying to transfer the knowledge and experience from daily cardiac surgery to veno-arterial ECMO.

scholarly journals Renal protection in cardiovascular surgery

F1000Research ◽  
2016 ◽  
Vol 5 ◽  
pp. 331 ◽  
Author(s):  
Nora Di Tomasso ◽  
Fabrizio Monaco ◽  
Giovanni Landoni
Keyword(s):  
At Risk ◽  
Renal Damage ◽  
Scientific Evidence ◽  
Fluid Management ◽  
Kidney Injury ◽  
Hemodynamic Instability ◽  
Major Surgery ◽  
Renal Protection ◽  
Patients At Risk ◽  
Risk Patients

Acute kidney injury (AKI) is one of the most relevant complications after major surgery and is a predictor of mortality. In Western countries, patients at risk of developing AKI are mainly those undergoing cardiovascular surgical procedures. In this category of patients, AKI depends on a multifactorial etiology, including low ejection fraction, use of contrast media, hemodynamic instability, cardiopulmonary bypass, and bleeding. Despite a growing body of literature, the treatment of renal failure remains mainly supportive (e.g. hemodynamic stability, fluid management, and avoidance of further damage); therefore, the management of patients at risk of AKI should aim at prevention of renal damage. Thus, the present narrative review analyzes the pathophysiology underlying AKI (specifically in high-risk patients), the preoperative risk factors that predispose to renal damage, early biomarkers related to AKI, and the strategies employed for perioperative renal protection. The most recent scientific evidence has been considered, and whenever conflicting data were encountered possible suggestions are provided.

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