RESUMEN
OBJECTIVE: This study was carried out to: (a) compare complement and granulocyte activation during cardiac operations in patients operated with cardiopulmonary bypass coated with heparin by the Duraflo II method, with activation in patients operated with uncoated circuits; and (b) relate complement, and granulocyte activation to selected adverse effects. METHODS: In a multicentre study among Rikshospitalet, Ullevaal Hospital in Norway and Uppsala University Hospital in Sweden, plasma concentrations of the complement activation products C4b/iC4b/C4c (C4bc), C3b/iC3b/C3c (C3bc), the terminal SC5b-9 complement complex (TCC), and the granulocyte proteins myeloperoxidase and lactoferrin were assessed in two groups of patients undergoing aortocoronary bypass. Seventy-six patients underwent surgery operated with circuits coated by the Duraflo II heparin coating and 75 uncoated circuits. The same amount of systemic heparin was administered to all patients. RESULTS: In both groups a significant increase in C4bc was first seen by the end of operation, from 86.7 +/- 12.5 to 273.0 +/- 277.4 nM in controls and from 86.9 +/- 18.5 to 320.2 +/- 190.5 nM in the control group, confirming previous documentation that the classical pathway is not activated during CPB, but as a consequence of protamin administration. The formation of C4bc did not differ significantly between the two groups. In the uncoated group the C3bc concentration increased from 124.0 +/- 15.3 to a maximum of 1176.1 +/- 64.7 nM (P < 0.01) and in the coated group it increased from 129.8 +/- 16.1 to a maximum of 1019.4 +/- 54.9 nM (P < 0.01) during CPB. Summary values but not peak values differed significantly between the groups. In the uncoated group the TCC concentration increased from 0.52 +/- 0.03 to a maximum value of 8.09 +/- 0.57 AU/ml (P < 0.01) while in the coated group the TCC concentration increased from a baseline of 0.53 +/- 0.03 to a peak value of 5.2 +/- 0.24 AU/ml (P <0.01). The difference between the peak values was statistically significant (P = 0.00002). In both groups a significant increase in myeloperoxidase and lactoferrin release was observed by the end of operation. There was no difference in myeloperoxidase or lactoferrin release between the two groups. TCC levels were compared to the occurrence of perioperative infarction, development of lung or renal failure, postoperative bleeding, time on ventilator and days in hospital. Three patients developed perioperative infarction; the peak levels of TCC were significantly higher in these patients than in the 148 patients that did not develop infarction. The reduction in TCC formation in the heparin-coated group was not associated with differences in any of the other clinical parameters. Few adverse effects occurred in the study. The peak values of C3bc were higher in the patients needing inotropic support that in those who did not, the relevance of this finding remains uncertain. CONCLUSION: It is concluded that the Duraflo II heparin coating reduces complement activation, particularly TCC formation, during CPB, but not the release of specific neutrophil granule enzymes. No certain correlation was established between complement and granulocyte activation and clinical outcome.
Asunto(s)
Puente Cardiopulmonar/instrumentación , Activación de Complemento/inmunología , Puente de Arteria Coronaria , Granulocitos/inmunología , Heparina , Complicaciones Intraoperatorias/inmunología , Lactoferrina/sangre , Peroxidasa/sangre , Anciano , Complejo de Ataque a Membrana del Sistema Complemento/metabolismo , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/inmunología , Factores de Riesgo , Propiedades de SuperficieRESUMEN
BACKGROUND: The inflammatory response induced by cardiopulmonary bypass can result in severe organ dysfunction in some patients. This postperfusion response is caused mainly by contact between blood and the foreign surface of the cardiopulmonary bypass equipment and includes adhesion of leukocytes to vascular endothelium, which precedes a series of events that mediate inflammatory damage to tissues. METHODS: Low-risk patients accepted for coronary artery bypass grafting were randomized to operation with the cardiopulmonary bypass surface either completely heparin coated (Duraflo II) or uncoated. There were 12 patients in each group. Blood plasma sampled during cardiopulmonary bypass was analyzed for complement activation (C3bc and terminal SC5b-9 complement complex) and neutrophil activation (lactoferrin and myeloperoxidase). In addition, neutrophils, monocytes, and platelets were counted, and the expression of surface markers on the neutrophils and monocytes (complement receptor [CR] 1, CR3, CR4, and L-selectin) and on the platelets (P-selectin and CD41) was quantified with flow cytometry. RESULTS: Clinical and surgical results were similar in both groups. In the group with the heparin-coated surface, the formation of the terminal SC5b-9 complement complex was significantly reduced, and the counts of circulating leukocytes and platelets were significantly less reduced initially but were higher at the end of cardiopulmonary bypass compared with baseline. Also, the expression of CR1, CR3, and CR4 was significantly less upregulated and the L-selectin, significantly less downregulated on monocytes and neutrophils. CONCLUSIONS: We conclude that heparin coating reduces complement activation and attenuates the leukocyte integrin and selectin response that occurs when uncoated circuits are used.
Asunto(s)
Antígenos de Superficie/metabolismo , Puente Cardiopulmonar/instrumentación , Activación de Complemento , Puente de Arteria Coronaria , Heparina , Materiales Biocompatibles , Puente Cardiopulmonar/efectos adversos , Femenino , Humanos , Recuento de Leucocitos , Activación de Linfocitos , Masculino , Recuento de PlaquetasRESUMEN
BACKGROUND: Centrifugal pumps are being used increasingly for short-term extracorporeal circulation purposes such as during heart operations. Whether the centrifugal pump improves the cardiopulmonary bypass biocompatibility has not been fully documented. METHODS: A roller pump (n = 20) was compared in vivo with a centrifugal pump (n = 20) in groups of patients in which cardiopulmonary bypass circuits that were either totally heparin coated (Carmeda BioActive Surface; n = 20) or uncoated (n = 20) were used. We expected the heparin coating to attenuate blood activation, thus possibly making the comparison of the two pumps easier with respect to their different blood activation potentials. Samples of blood plasma, obtained during cardiopulmonary bypass from low-risk coronary artery bypass grafting patients, were analyzed for hemolysis (plasma haemoglobin), complement activation (C3bc and the terminal complement complex), a complement lytic inhibitor (vitronectin), coagulation activation (fibrinopeptide A), granulocyte activation (lactoferrin), and platelet activation (beta-thromboglobulin). RESULTS: The concentrations of terminal complement complex, lactoferrin, and beta-thromboglobulin were significantly lower in association with heparin-coated surfaces. The concentration of plasma hemoglobin was significantly lower in association with the centrifugal pump. In uncoated circuits, the beta-thromboglobulin level was significantly higher in association with the roller pump than with the centrifugal pump, but this significant reduction in the beta-thromboglobulin level did not hold true for the heparin-coated circuit group. CONCLUSIONS: A heparin-coated cardiopulmonary bypass surface reduces the blood activation potential during cardiopulmonary bypass, and the centrifugal pump causes less hemolysis than the roller pump.
Asunto(s)
Materiales Biocompatibles , Puente Cardiopulmonar , Heparina/administración & dosificación , Adulto , Anciano , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/instrumentación , Puente Cardiopulmonar/métodos , Complemento C3b/análisis , Complejo de Ataque a Membrana del Sistema Complemento/análisis , Puente de Arteria Coronaria , Femenino , Fibrinopéptido A/análisis , Hemoglobinas/análisis , Hemólisis , Humanos , Lactoferrina/sangre , Masculino , Persona de Mediana Edad , Vitronectina/sangre , beta-Tromboglobulina/análisisRESUMEN
BACKGROUND: Several studies have indicated reduced "blood activation" in heparin-coated cardiopulmonary bypass systems. The present study compares the effect of two different heparin coatings on different blood activation indices. METHODS: Low-risk patients (n = 40) were randomized to coronary artery bypass grafting using cardiopulmonary bypass with surfaces coated entirely by either the Duraflo II heparin coat or the Carmeda Biological Active Surface, or with identical uncoated equipment. In all cases, a standard systemic heparin dosage was used. Complement activation (C3 activation products C3bc and C3a and formation of fluid phase terminal SC5b-9 complement complex), neutrophil activation (lactoferrin and myeloperoxidase), and lytic inhibitors (vitronectin and clusterin) were quantified during cardiopulmonary bypass and 6 hours postoperatively. RESULTS: Heparin coating by either method reduced the formation of terminal SC5b-9 complement complex and the release of lactoferrin and myeloperoxidase compared with uncoated systems. Lactoferrin and myeloperoxidase levels increased significantly during cardiopulmonary bypass in the Duraflo II group, whereas no significant increase was observed in the Carmeda Biological Active Surface group. The least formation of terminal SC5b-9 complement complex and neutrophil activation was observed with the Maxima Carmeda Biological Active Surface-coated equipment. The vitronectin and clusterin concentrations were significantly less reduced in the Duraflo II compared with the control group. This study underlines the importance of terminal SC5b-9 complement complex as a suitable marker in the evaluation of complement activation during cardiopulmonary bypass. CONCLUSIONS: Both heparin coatings reduce blood activation, probably more so with Carmeda Biological Active Surface than with Duraflo II.
Asunto(s)
Anticoagulantes , Puente Cardiopulmonar/instrumentación , Activación de Complemento , Heparina , Chaperonas Moleculares , Puente Cardiopulmonar/efectos adversos , Clusterina , Proteínas Inactivadoras de Complemento/análisis , Puente de Arteria Coronaria , Femenino , Glicoproteínas/sangre , Humanos , Masculino , Activación Neutrófila , Propiedades de Superficie , Vitronectina/sangreRESUMEN
Plasma concentrations of the complement activation products C3b, iC3b, and C3c; the terminal C5b-9 complement complex; and the granulocyte proteins calprotectin, myeloperoxidase, and lactoferrin were assessed in two groups of patients undergoing aortocoronary bypass procedures. In 10 patients operated on, the bypass circuits were coated by the Carmeda Bio-Active Surface and systemic heparinization was reduced to 1.5 mg/kg; in another 10, the systems were uncoated and the dosage of systemic heparinization was 4 mg/kg. In both groups, significant complement activation was observed after the onset of cardiopulmonary bypass, but the maximum levels of C3b, iC3b, and C3c and the terminal C5b-9 complement complex were significantly lower in the heparin-coated group. In both groups, a significant increase in calprotectin, myeloperoxidase, and lactoferrin release was observed by the end of operation. The maximum myeloperoxidase levels were significantly lower in the heparin-coated group than those in the uncoated group (p = 0.03). There was a correlation of borderline significance between the formation of terminal C5b-9 complement complex and lactoferrin release, as well as between the formation of terminal C5b-9 complement complex and myeloperoxidase release (p = 0.05). The postoperative blood loss did not differ significantly between the two groups. We conclude that coating by end point-attached and functionally active heparin allows a significant reduction in the amount of systemic heparinization, and significantly reduces complement and granulocyte activation.
Asunto(s)
Puente Cardiopulmonar , Activación de Complemento , Granulocitos/metabolismo , Heparina/administración & dosificación , Anciano , Pérdida de Sangre Quirúrgica , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/instrumentación , Moléculas de Adhesión Celular Neuronal/sangre , Complemento C3/metabolismo , Complejo de Ataque a Membrana del Sistema Complemento/metabolismo , Femenino , Humanos , Lactoferrina/sangre , Complejo de Antígeno L1 de Leucocito , Masculino , Persona de Mediana Edad , Peroxidasa/sangre , Propiedades de SuperficieRESUMEN
The analgetic effect of bupivacaine given epidurally or interpleurally after thoracotomy was investigated in a randomized, double blind, placebo controlled study. 32 patients with both an epidural and an interpleural catheter, were randomized to receive either interpleural or epidural analgesia. The interpleural group was given bupivacaine 5 mg.ml-1 with 5 microgram epinephrine as a 30 ml interpleural bolus, followed by a continuous infusion starting at a rate of 7 ml per hour and epidurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The epidural group was given bupivacaine 3.75 mg.ml-1 with 5 microgram epinephrine as a 5 ml epidural bolus, followed by a continuous infusion starting at a rate of 5 ml per hour and interpleurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The draining tubes were clamped during the injection of the interpleural bolus and 15 min afterwards. Adequacy of pain relief was evaluated with the Prins-Henry pain scale. Morphine requirement was registered, there was no difference between the groups in pain scores or need for additional morphine.
Asunto(s)
Analgesia Epidural , Analgesia , Bupivacaína , Dolor Postoperatorio/prevención & control , Pleura , Toracotomía/efectos adversos , Adulto , Anciano , Analgesia Epidural/efectos adversos , Analgesia Epidural/instrumentación , Bupivacaína/administración & dosificación , Método Doble Ciego , Femenino , Hematoma/etiología , Humanos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Dimensión del Dolor , Placebos , Vértebras Torácicas , Factores de TiempoRESUMEN
Thoracoscopic pleurodesis for pneumothorax was performed on 23 patients (16 men, 7 women), including seven with chronic obstructive pulmonary disease, over a 12-month period. Single-lumen intubation with spontaneous ventilation were used making intrapleural insufflation unnecessary. Postoperatively the patients required chest drainage for 1-28 (mean 3) days and remained in hospital for 3-33 (mean 6) days. The 14 gainfully employed patients had 11-40 (mean 20) days' sick leave. Hydrothorax requiring pleurocentesis developed in one patient after thoracoscopy. Pneumothorax recurred in another immediately after removal of the chest drain, but resolved definitively after 2 more days of drainage. A patient with obstructive lung disease required ventilator management for a week after the operation, but otherwise no serious complications were observed.
Asunto(s)
Tubos Torácicos , Enfermedades Pulmonares Obstructivas/cirugía , Pleura/cirugía , Neumotórax/cirugía , Toracoscopía/métodos , Adolescente , Adulto , Anciano , Terapia Combinada , Femenino , Humanos , Intubación , Tiempo de Internación , Enfermedades Pulmonares Obstructivas/terapia , Masculino , Persona de Mediana Edad , Neumotórax/terapia , Cuidados Posoperatorios , Respiración Artificial , Cirugía Torácica/métodosRESUMEN
Propofol is approved by the Norwegian authorities (The Norwegian Medicine Control Authority) only for anaesthesia for less than three hours in adults. 54% of Norwegian hospitals had used propofol for anaesthesia in children and 33% for anaesthesia of more than three hours duration. In hospitals with an intensive care unit, 66% had used it for sedation in adults, 24% in children. It is not illegal to use a drug without the approval of the control authority, but the sedation of children had taken place without a basis in scientific documentation. The market for propofol fell by 40% shortly after the media focused on possible severe side effects in sedated children. Many of the anaesthesiologists found the media focus useful, but many thought that it was incorrect, and most of them that it was too general.