Impairment of Hepatosplanchnic Oxygenation and Increase of Serum Hyaluronate During Normothermic and Mild Hypothermic Cardiopulmonary Bypass

Okano, Nobuhiro; Miyoshi, Sotaro; Owada, Ryoichi; Fujita, Nao; Kikuchi, Yuji; Saito, Shigeru; Goto, Fumio; Morita, Toshihiro

doi:10.1213/00000539-200208000-00004

Cited by 39 publications

(14 citation statements)

References 27 publications

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“…This could be due to the different number of patients; Haisjackl observed only 12 patients. Okano et al (1) observed a decrease of the splanchnic oxygen delivery and maintained HBF during CPB. Lower hematocrit levels during normothermic CPB could have been responsible for the lower splanchnic oxygen supply during CPB in Okano's patients, because Okano's transfusion threshold was a hematocrit of 0.20 compared with 0.22 in our patients.…”

Section: Discussionmentioning

confidence: 99%

“…T he effects of the normothermic cardiopulmonary bypass CPB on the hepatosplanchnic area have been investigated in several recent studies. A preserved splanchnic oxygen supply was demonstrated in most of them (1–3). It still remains unclear if the maintained splanchnic (i.e.…”

mentioning

confidence: 94%

“…Liver dysfunction, with increased transaminase levels or decreased plasmatic coagulation parameters, rarely occurs after CPB. It is unknown if specific hepatocellular functions are impaired (1). Lidocaine is metabolized primarily by the liver cytochrome P450 system through sequential oxidative N ‐dealcylation.…”

mentioning

confidence: 99%

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Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass

Braun

Schroeder

Buehner

et al. 2004

Acta Anaesthesiol Scand

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Increased oxygen consumption during CPB may indicate an inflammatory reaction due to the pump beginning in the splanchnic area or a redistribution of the splanchinc blood flow during the CPB. Normothermic CPB does not lead to a significant or prolonged reduction of liver function. Normothermic CPB causes an increase of gastrointestinal permeability. The intestinal barrier function prior to surgery was accountable for the degree of loss of intestinal barrier function following surgery.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 94%

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Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass

Braun

Schroeder

Buehner

et al. 2004

Acta Anaesthesiol Scand

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“…It has been well documented that CPB triggers production and release of numerous vasoactive substances and cytotoxic mediators which affect coagulopathy, immune system, vascular resistance, vascular permeability, fluid balance, and major organ functions [17] . Other contributing factors, such as hypothermia, hemodilution, and hypoperfusion during the CPB, also may be responsible for morbidity and mortality after surgery [18] . Previous reports have shown that the higher mortality was not attributable to impaired cardiac function, but to an increased susceptibility to infections, gastrointestinal complications, and bleeding [8] .…”

Section: Discussionmentioning

confidence: 99%

Open-Heart Surgery in Patients with Liver Cirrhosis: Indications, Risk Factors, and Clinical Outcomes

Zhong³

2007

Eur Surg Res

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Background: Because of recent advances in cardiopulmonary bypass (CPB) surgery, there are broadened indications to approach patients with a high operative risk. Meanwhile, there is an increasing number of patients with severe liver dysfunction subjected to open-heart surgery. This retrospective study was designed to evaluate the operative indications and clinical outcomes in patients with liver cirrhosis (LC) undergoing open-heart surgery. In addition, determinants influencing their prognosis were assessed. Patients and Methods: Between May 1996 and June 2005, 24 patients with LC underwent CPB open-heart surgery in our institution. The preoperative severity of the LC was determined according to the Child-Pugh classification. Their perioperative data were analyzed. Several perioperative factors were compared by multivariate logistic regression analysis between survivors and nonsurvivors to determine possible risk factors contributing to mortality. Results:There were 14 females and 10 males. Their age ranged from 36 to 72 (mean 53 ± 13) years. Seventeen cases were classified as having Child-Pugh class A LC, 6 as having Child-Pugh class B, and 1 as having Child-Pugh class C LC. All patients underwent CPB surgery. The mean operation time and the cross-clamp time were 160 ± 53 and 90 ± 42 min, respectively. During the first 24 h after the operation, the mean chest tube output was 1,080 ± 320 ml. The mean duration of mechanical ventilation was 32 ± 22 h, and the mean intensive care unit stay was 11 ± 8 days. Sixty-six percent of the patients experienced significant morbidity. Fifty-three percent of the patients with Child-Pugh class A LC and 100% of those with Child-Pugh class B and C LC suffered postoperative complications. The overall mortality rate was 25%. The postoperative mortality rates of the patients with Child-Pugh class A, B, and C LC were 6, 67, and 100%, respectively. Preoperative serum total bilirubin and cholinesterase levels and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values along with CPB time were identified as the important predictors to differentiate between survivors and nonsurvivors by multivariate logistic regression analysis. Conclusions: The Child-Pugh class is associated with hepatic decompensation and mortality after open-heart CPB surgery in patients with LC. Such surgery can be performed safely in patients with a Child-Pugh class A LC. But cardiac interventions using CPB in patients with more advanced LC are associated with high mortality and morbidity rates. The preoperative total plasma bilirubin and cholinesterase concentrations as well as the EuroSCORE along with the CPB time are identified as statistically significant predictors of mortality after open-heart surgery in patients with LC. Our findings indicate that patients with chronic liver disease scheduled for open-heart surgery should be carefully evaluated before the operation and that the CPB duration should be as short as possible.

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“…On the other hand, we cannot assume that the effects of CPB on liver and renal function were the essential mechanisms involved in the changes observed in the pharmacokinetics of propranolol, since the total body clearance was unchanged. Despite the absence of alteration in total body clearance, it is well known that CPB and hypothermia induce a 30% reduction in hepatic blood flow and influence the metabolism and elimination of the drug by the liver and kidney (28)(29)(30). Interindividual factors not taken into account in the present study might interfere with drug clearance after CPB, contributing to the wide variation observed pre-and postoperatively and possibly to the absence of difference.…”

Section: Kinetics Of Propranolol Distribution and Coronary Artery Bypmentioning

confidence: 65%

Cardiopulmonary bypass alters the pharmacokinetics of propranolol in patients undergoing cardiac surgery

Carmona

Malbouisson

Pereira

et al. 2005

Braz J Med Biol Res

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The pharmacokinetics of propranolol may be altered by hypothermic cardiopulmonary bypass (CPB), resulting in unpredictable postoperative hemodynamic responses to usual doses. The objective of the present study was to investigate the pharmacokinetics of propranolol in patients undergoing coronary artery bypass grafting (CABG) by CPB under moderate hypothermia. We evaluated 11 patients, 4 women and 7 men (mean age 57 ± 8 years, mean weight 75.4 ± 11.9 kg and mean body surface area 1.83 ± 0.19 m 2 ), receiving propranolol before surgery (80-240 mg a day) and postoperatively (10 mg a day). Plasma propranolol levels were measured before and after CPB by highperformance liquid chromatography. Pharmacokinetic Solutions 2.0 software was used to estimate the pharmacokinetic parameters after administration of the drug pre-and postoperatively. There was an increase of biological half-life from 4.5 (95% CI = 3.9-6.9) to 10.6 h (95% CI = 8.2-14.7; P < 0.01) and an increase in volume of distribution from 4.9 (95% CI = 3.2-14.3) to 8.3 l/kg (95% CI = 6.5-32.1; P < 0.05), while total clearance remained unchanged 9.2 (95% CI = 7.7-24.6) vs 10.7 ml min -1 kg -1 (95% CI = 7.7-26.6; NS) after surgery. In conclusion, increases in drug distribution could be explained in part by hemodilution during CPB. On the other hand, the increase of biological half-life can be attributed to changes in hepatic metabolism induced by CPB under moderate hypothermia. These alterations in the pharmacokinetics of propranolol after CABG with hypothermic CPB might induce a greater myocardial depression in response to propranolol than would be expected with an equivalent dose during the postoperative period.

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Impairment of Hepatosplanchnic Oxygenation and Increase of Serum Hyaluronate During Normothermic and Mild Hypothermic Cardiopulmonary Bypass

Cited by 39 publications

References 27 publications

Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass

Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass

Open-Heart Surgery in Patients with Liver Cirrhosis: Indications, Risk Factors, and Clinical Outcomes

Cardiopulmonary bypass alters the pharmacokinetics of propranolol in patients undergoing cardiac surgery

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