CPB and Systemic Inflammation: Are We Doing It Right?

Jefferson, MD.,Saeful, NsIntegrated Cardiovascular servicesCipto Mangunkusumo HospitalJakarta

Outline

•Introduction

•Mechanism and Patophysiology

•Therapeutic effort

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

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

Humoral Component

ComplementCPB

Mackay and Rosen. The Immune System. NEJM 2000

The Late Phase :Ischemia-Reperfusion

injuryIschemic phase

Endothelial injury

Neutrophyl activationROSHydrogen peroxideHydroxyl radicalsSuperoxide Anions

Cell Damage

Reperfusion phase

Reintroduction to oxygen

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

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

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

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

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

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

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

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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