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CPB and Systemic Inflammation: Are We Doing It Right?
Jefferson, MD.,Saeful, NsIntegrated Cardiovascular servicesCipto Mangunkusumo HospitalJakarta
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Outline
•Introduction
•Mechanism and Patophysiology
•Therapeutic effort
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Cardiopulmonary Bypass (ECC)
Contact Activation of Complement system
Bowel Ischaemia
EndotoxinemiaBacterial
Translocation
Reperfusion Injury
Macrophage Activation and Secretion of
TNF∝
Neutrophil/Endothelial adhesion + Migration
Cytokines MOFMOFAndropoulos. Anesthesia for Congenital Heart. Dis. 2nd edition. 2010
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The Early Phase :Contact Activation
5 Cellular Components 5 Humoral Components
Endothelial CellsNeutrophilsMonocytes
LymphocytesPlatelets
Contact systemIntrinsic coagulationExtrinsic coagulation
ComplementFibrinolysis
Journal of Cardiothoracic and Vasc Anesth 2009. 23:(2)223-231
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Humoral Component
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ComplementCPB
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Mackay and Rosen. The Immune System. NEJM 2000
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The Late Phase :Ischemia-Reperfusion
injuryIschemic phase
Endothelial injury
Neutrophyl activationROSHydrogen peroxideHydroxyl radicalsSuperoxide Anions
Cell Damage
Reperfusion phase
Reintroduction to oxygen
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The Late Phase :Endotoxin
Gut ischemia
Mucosal barrier injury
Translocation of bacterial and or endotoxin
Endotoxin
Complement activationpro inflammatory cytokines releaseActivation of macrophages and other pro inflammatory cellsNO release
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Interventions designed to limit inflammatory response
• Preoperative
• Intestinal Decontamination (SDD)
• Preoperative inotropes
• Modification of circuit
• heparin-coating
• pulsatile flow
• ultrafiltration
• leukocyte filtration
• Pharmacological interventions
• Steroids
• Aprotinin
• Antioxidants
• Complement inhibitor
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Our little simple data
•30 patient tetralogy of fallot underwent total corrections are studied retrospectively between october 2011 to february 2012
•15 pts were given single dose gentamycin for gut prophylaxis
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Group Characteristic
Genta (+) n=15 Genta (-) n=15
Age 4.87 ± 2.97 6.81 ± 2.85Weight 11.84 ± 4.94 16.78 ± 15.08Height 102.77 ± 13.58 102.67 ± 34.65
McGoon 1.96 ± 0.60 1.95 ± 0.60
Nakata309.29 ± 140.12
310.89 ± 207.93
Xclamptime 37.53 ±19.96 33.93 ± 7.57Bypasstime 87.33 ± 28.64 87.40 ± 25.51
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Comparison of patient in both group with fever (1st day)
fever (24 hrs)total
y n
Gentamycin
y 3 12 15
n 9 6 15
total 12 18
p = 0.06 using Chi square
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Length of Stay, Time to Extubation, and mortality
Gentamycin
y n p
Time to extubation 24 ± 14 45.92 ±16 0.203
LOS ICU40.69 ±
2768.31 ± 74 0.219
Mortality 2 2 1.000
Time to extubation and LOS ICU using t test and Mortality using chi square
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Renal Function data
Gentamycinp
y n
Ureum18.43 ± 2.524
22.4 ±1.701 0.099
Creatinine 0.4 ±0.160.5133 ±0.05
0.119
Oliguria (+)6 / (-)9 (+)8 / (-)7 0.358Furosemid
e(+)11 / (-)4 (+)10 / (-)5 0.500
Ureum Creatinine using t test, oliguria and frusemide using chi square
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Things to emphasize
• Treatment modalities shows potency in terms of reducing inflammatory mediators
• Treatment modalities should be used in concert to treat multifaceted inflammatory response to bypass
• Outcome parameters in open heart surgery are multifactorial. Well management of cpb related systemic inflammation is only one factor. Probably this is the cause why it is difficult to correlate modification of inflammation and outcome.
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THANK YOU