A systematic review of the evidence supporting post-operative diuretic use following cardiopulmonary bypass in children with Congenital Heart Disease

2021 ◽  
pp. 1-8
Author(s):  
Henry P. Foote ◽  
Christoph P. Hornik ◽  
Kevin D. Hill ◽  
Alexandre T. Rotta ◽  
Reid Chamberlain ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Urine Output ◽  
Ethacrynic Acid ◽  
Fluid Overload ◽  
Pragmatic Trial ◽  
Kidney Injury ◽  
Eligibility Criteria ◽  
Diuretic Resistance ◽  
Timing Of Initiation

Abstract Background: Paediatric cardiac surgery on cardiopulmonary bypass induces substantial physiologic changes that contribute to post-operative morbidity and mortality. Fluid overload and oedema are prevalent complications, routinely treated with diuretics. The optimal diuretic choice, timing of initiation, dose, and interval remain largely unknown. Methods: To guide clinical practice and future studies, we used PubMed and EMBASE to systematically review the existing literature of clinical trials involving diuretics following cardiac surgery from 2000 to 2020 in children aged 0–18 years. Studies were assessed by two reviewers to ensure that they met eligibility criteria. Results: We identified nine studies of 430 children across four medication classes. Five studies were retrospective, and four were prospective, two of which included randomisation. All were single centre. There were five primary endpoints – urine output, acute kidney injury, fluid balance, change in serum bicarbonate level, and required dose of diuretic. Included studies showed early post-operative diuretic resistance, suggesting higher initial doses. Two studies of ethacrynic acid showed increased urine output and lower diuretic requirement compared to furosemide. Children receiving peritoneal dialysis were less likely to develop fluid overload than those receiving furosemide. Chlorothiazide, acetazolamide, and tolvaptan demonstrated potential benefit as adjuncts to traditional diuretic regimens. Conclusions: Early diuretic resistance is seen in children following cardiopulmonary bypass. Ethacrynic acid appears superior to furosemide. Adjunct diuretic therapies may provide additional benefit. Study populations were heterogeneous and endpoints varied. Standardised, validated endpoints and pragmatic trial designs may allow investigators to determine the optimal diuretic, timing of initiation, dose, and interval to improve post-operative outcomes.

Fluid Management With Peritoneal Dialysis After Pediatric Cardiac Surgery

2018 ◽  
Vol 9 (6) ◽  
pp. 696-704 ◽  
Author(s):  
Matthew F. Barhight ◽  
Danielle Soranno ◽  
Sarah Faubel ◽  
Katja M. Gist
Keyword(s):  
Cardiac Surgery ◽  
Peritoneal Dialysis ◽  
Cardiopulmonary Bypass ◽  
Fluid Overload ◽  
Fluid Management ◽  
Kidney Injury ◽  
Clinical Markers ◽  
Fluid Removal ◽  
Vasoactive Medication ◽  
Potential Benefits

Children who undergo cardiac surgery with cardiopulmonary bypass are a unique population at high risk for postoperative acute kidney injury (AKI) and fluid overload. Fluid management is important in the postoperative care of these children as fluid overload is associated with increased morbidity and mortality. Peritoneal dialysis catheters are an important tool in the armamentarium of a cardiac intensivist and are used for passive drainage for fluid removal or dialysis for electrolyte and uremia control in AKI. Prophylactic placement of a peritoneal catheter is a safe method of fluid removal that is associated with few major complications. Early initiation of peritoneal dialysis has been associated with improved clinical markers and outcomes such as early achievement of a negative fluid balance, lower vasoactive medication needs, shorter duration of mechanical ventilation, and decreased mortality. In this review, we discuss the safety and potential benefits of peritoneal catheters for dialysis or passive drainage in children following cardiopulmonary bypass.

Abstract 13540: Peritoneal Dialysis vs. Furosemide for the Treatment of Oliguria in Infants After Cardiopulmonary Bypass

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
David M Kwiatkowski ◽  
Stuart L Goldstein ◽  
David S Cooper ◽  
David P Nelson ◽  
David L Morales ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Peritoneal Dialysis ◽  
Cardiopulmonary Bypass ◽  
Hospital Stay ◽  
Fluid Overload ◽  
Prolonged Mechanical Ventilation ◽  
Controlled Trial ◽  
Kidney Injury ◽  
Poor Response ◽  
Intention To Treat

Objectives: Acute kidney injury (AKI) is a frequent and serious complication in infants after cardiac surgery with cardiopulmonary bypass (CPB). Often the earliest sign is oliguria, which can lead to fluid overload, prolonged mechanical ventilation and ICU stay, abnormal electrolytes and increased mortality. We hypothesized that the use of peritoneal dialysis (PD) compared to furosemide use would mitigate these complications. Methods: This is a single-center, surgical complexity-stratified, randomized controlled trial performed within a cohort of patients younger than 6mo undergoing cardiac surgery with a preoperative plan of PD catheter placement due to risk of post-CPB kidney injury. If enrolled patients had urine output < 1mL/kg/hour for 4 hours during the first postoperative day, the patient was randomized to either a standardized regimen of furosemide or PD. If the patient demonstrated poor response to furosemide, PD could be initiated on postoperative day 2. Results: A total of 73 patients were randomized and completed the trial, including 2 patients who were randomized to furosemide and subsequently received PD. Using intention-to-treat analysis, the PD group was less likely to have fluid overload, had a lower delayed-extubation rate and fewer electrolyte replacements. There were no differences in mortality or ICU/hospital stay. No serious PD related complications were observed. PD was discontinued early in 9 patients due to pleural-peritoneal communication. Conclusions: Our study demonstrates that the use of PD in neonates with oliguria after CPB is associated with reduced morbidity but not differences in mortality or ICU/hospital stay. A multi-center study is necessary to further support these findings as well as determine association with mortality.

scholarly journals Urine Output During Cardiopulmonary Bypass Predicts Acute Kidney Injury After Cardiac Surgery

Medicine ◽  
2016 ◽  
Vol 95 (22) ◽  
pp. e3757 ◽  
Author(s):  
Young Song ◽  
Dong Wook Kim ◽  
Young Lan Kwak ◽  
Beom Seok Kim ◽  
Hyung Min Joo ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Urine Output ◽  
Kidney Injury

scholarly journals Urine microscopy as a biomarker of Acute Kidney Injury following cardiac surgery with cardiopulmonary bypass

2020 ◽  
Vol 42 (1) ◽  
pp. 18-23 ◽  
Author(s):  
João Carlos Goldani ◽  
José Antônio Poloni ◽  
Fabiano Klaus ◽  
Roger Kist ◽  
Larissa Sgaria Pacheco ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Serum Creatinine ◽  
Likelihood Ratio ◽  
Urine Sample ◽  
Urine Output ◽  
Kidney Injury ◽  
Urine Output Criterion ◽  
Output Criterion

Abstract Introduction: Acute kidney injury (AKI) occurs in about 22% of the patients undergoing cardiac surgery and 2.3% requires renal replacement therapy (RRT). The current diagnostic criteria for AKI by increased serum creatinine levels have limitations and new biomarkers are being tested. Urine sediment may be considered a biomarker and it can help to differentiate pre-renal (functional) from renal (intrinsic) AKI. Aims: To investigate the microscopic urinalysis in the AKI diagnosis in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: One hundred and fourteen patients, mean age 62.3 years, 67.5 % male, with creatinine 0.91 mg/dL (SD 0.22) had a urine sample examined in the first 24 h after the surgery. We looked for renal tubular epithelial cells (RTEC) and granular casts (GC) and associated the results with AKI development as defined by KDIGO criteria. Results: Twenty three patients (20.17 %) developed AKI according to the serum creatinine criterion and 76 (66.67 %) by the urine output criterion. Four patients required RRT. Mortality was 3.51 %. The use of urine creatinine criterion to predict AKI showed a sensitivity of 34.78 % and specificity of 86.81 %, positive likelihood ratio of 2.64 and negative likelihood ratio of 0.75, AUC-ROC of 0.584 (95%CI: 0.445-0.723). For the urine output criterion sensitivity was 23.68 % and specificity 92.11 %, AUC-ROC was 0.573 (95%CI: 0.465-0.680). Conclusion: RTEC and GC in urine sample detected by microscopy is a highly specific biomarker for early AKI diagnosis after cardiac surgery.

A systematic review of the evidence supporting post-operative antithrombotic use following cardiopulmonary bypass in children with CHD

2022 ◽  
pp. 1-11
Author(s):  
Elizabeth J. Thompson ◽  
Henry P. Foote ◽  
Jennifer S. Li ◽  
Alexandre T. Rotta ◽  
Neil A. Goldenberg ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Vitamin K Antagonists ◽  
Pragmatic Trial ◽  
Thrombin Inhibitors ◽  
Cyclooxygenase Inhibitors ◽  
Clinical Endpoints ◽  
Optimal Drug ◽  
Timing Of Initiation

Abstract Objectives: To determine the optimal antithrombotic agent choice, timing of initiation, dosing and duration of therapy for paediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: We used PubMed and EMBASE to systematically review the existing literature of clinical trials involving antithrombotics following cardiac surgery from 2000 to 2020 in children 0–18 years. Studies were assessed by two reviewers to ensure they met eligibility criteria. Results: We identified 10 studies in 1929 children across three medications classes: vitamin K antagonists, cyclooxygenase inhibitors and indirect thrombin inhibitors. Four studies were retrospective, five were prospective observational cohorts (one of which used historical controls) and one was a prospective, randomised, placebo-controlled, double-blind trial. All included were single-centre studies. Eight studies used surrogate biomarkers and two used clinical endpoints as the primary endpoint. There was substantive variability in response to antithrombotics in the immediate post-operative period. Studies of warfarin and aspirin showed that laboratory monitoring levels were frequently out of therapeutic range (variably defined), and findings were mixed on the association of these derangements with bleeding or thrombotic events. Heparin was found to be safe at low doses, but breakthrough thromboembolic events were common. Conclusion: There are few paediatric prospective randomised clinical trials evaluating antithrombotic therapeutics post-cardiac surgery; most studies have been observational and seldom employed clinical endpoints. Standardised, validated endpoints and pragmatic trial designs may allow investigators to determine the optimal drug, timing of initiation, dosing and duration to improve outcomes by limiting post-operative morbidity and mortality related to bleeding or thrombotic events.

Urine Output during Cardiopulmonary Bypass Predicts Acute Kidney Injury after Coronary Artery Bypass Grafting

2016 ◽  
Vol 19 (6) ◽  
pp. 289 ◽  
Author(s):  
Mehmet Yilmaz ◽  
Rezan Aksoy ◽  
Vildan Kilic Yilmaz ◽  
Canan Balci ◽  
Cagri Duzyol ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiopulmonary Bypass ◽  
Coronary Artery ◽  
Coronary Artery Bypass Grafting ◽  
Coronary Artery Bypass ◽  
Urine Output ◽  
Artery Bypass ◽  
Kidney Injury ◽  
Urinary Output ◽  
Bypass Grafting

Objective: This study evaluated the relationship between the amount of urinary output during cardiopulmonary bypass and acute kidney injury in the postoperative period of coronary artery bypass grafting.Methods: Two hundred patients with normal preoperative serum creatinine levels, operated on with isolated CABG between 2012-2014 were investigated retrospectively. The RIFLE (Risk, injury, failure, loss of function, and end-stage renal disease) risk scores were calculated for each patient in the third postoperative day. Patients were distributed into two groups in relation to the presence of acute kidney injury or not and these two groups were compared.Results: The urinary output (mL/kg/hour) during cardiopulmonary bypass in the acute kidney injury negative group was significantly higher than in the acute kidney injury positive group (P = .022). In case of a urinary output value 3.70 and lower to predict acute kidney injury positivity, sensitivity was detected as 71.43%. Results of the analysis for urinary output predict positivity of acute kidney injury.Conclusion: We suggest that urine output during cardiopulmonary bypass is a significant criteria that could predict acute kidney injury following coronary artery bypass grafting with cardiopulmonary bypass. Attempts to increase the urine output during cardiopulmonary bypass could help to maintain the renal functions during and after surgery.

FC 051PREDICTIVE VALUE OF PLASMA NGAL:HEPCIDIN-25 FOR MAJOR ADVERSE KIDNEY EVENTS AFTER CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS: A PILOT STUDY

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Saban Elitok ◽  
Anja Haase-Fielitz ◽  
Martin Ernst ◽  
Michael Haase
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Roc Curve ◽  
Predictive Value ◽  
Kidney Injury ◽  
Urinary Output ◽  
Icu Admission ◽  
Plasma Ngal ◽  
Net Reclassification Improvement ◽  
Major Adverse Kidney Events

Abstract Background and Aims Neutrophil gelatinase-associated lipocalin (NGAL) and hepcidin-25 appear to be involved in catalytic iron-related kidney injury after cardiac surgery with cardiopulmonary bypass. We aimed to explore the predictive value of plasma NGAL, plasma hepcidin-25, and the plasma NGAL:hepcidin-25 ratio for major adverse kidney events after cardiac surgery. Method We compared the predictive value of plasma NGAL, hepcidin-25, and NGAL:hepcidin-25 with those of serum creatinine (Cr), and urinary output and urinary protein for primary endpoint major adverse kidney events (MAKE; acute kidney injury [AKI] stages 2 and 3, persistent AKI &gt; 48 hrs, acute dialysis, and in-hospital mortality) and secondary-endpoint AKI in 100 cardiac surgery patients at intensive care unit (ICU) admission. We performed ROC curve, logistic regression, and reclassification analyses. Results At ICU admission, plasma NGAL, plasma NGAL:hepcidin-25, and Cr predicted MAKE (area under the ROC curve [AUC]: 0.77 [95% confidence interval (CI) 0.60–0.94], 0.79 [0.63–0.95], 0.74 [0.51–0.97]) and AKI (0.73 [0.53–0.93], 0.89 [0.81–0.98], 0.70 [0.48–0.93]). For AKI prediction, NGAL:hepcidin-25 had a higher discriminatory power than Cr (AUC difference 0.26 [95% CI 0.00–0.53]). Urinary output and protein, plasma lactate, C-reactive protein, creatine kinase myocardial band, and brain natriuretic peptide did not predict MAKE or AKI (AUC &lt; 0.70). Only plasma NGAL:hepcidin-25 correctly reclassified patients for MAKE or AKI (category-free net reclassification improvement: 0.82 [95% CI 0.12–1.52], 1.03 [0.29–1.77]). After adjustment to the Cleveland risk score, plasma NGAL:hepcidin-25 ≥ 0.9 independently predicted MAKE (adjusted odds ratio 16.34 [95% CI 1.77–150.49], P = 0.014), whereas Cr did not. Conclusion NGAL:hepcidin-25 is a promising plasma marker for predicting postoperative MAKE.

CIRP Secretion during Cardiopulmonary Bypass Is Associated with Increased Risk of Postoperative Acute Kidney Injury

2021 ◽  
Author(s):  
Wenyan Liu ◽  
Yang Yan ◽  
Dan Han ◽  
Yongxin Li ◽  
Qian Wang ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Rna Binding ◽  
Multivariable Analysis ◽  
Kidney Injury ◽  
Proinflammatory Response ◽  
Increased Risk ◽  
Before And After ◽  
The Difference

Abstract Background Systemic inflammation contributes to cardiac surgery–associated acute kidney injury (AKI). Cardiomyocytes and other organs experience hypothermia and hypoxia during cardiopulmonary bypass (CPB), which induces the secretion of cold-inducible RNA-binding protein (CIRP). Extracellular CIRP may induce a proinflammatory response. Materials and Methods The serum CIRP levels in 76 patients before and after cardiac surgery were determined to analyze the correlation between CIRP levels and CPB time. The risk factors for AKI after cardiac surgery and the in-hospital outcomes were also analyzed. Results The difference in the levels of CIRP (ΔCIRP) after and before surgery in patients who experienced cardioplegic arrest (CA) was 26-fold higher than those who did not, and 2.7-fold of those who experienced CPB without CA. The ΔCIRP levels were positively correlated with CPB time (r = 0.574, p < 0.001) and cross-clamp time (r = 0.54, p < 0.001). Multivariable analysis indicated that ΔCIRP (odds ratio: 1.003; 95% confidence interval: 1.000–1.006; p = 0.027) was an independent risk factor for postoperative AKI. Patients who underwent aortic dissection surgery had higher levels of CIRP and higher incidence of AKI than other patients. The incidence of AKI and duration of mechanical ventilation in patients whose serum CIRP levels more than 405 pg/mL were significantly higher than those less than 405 pg/mL (65.8 vs. 42.1%, p = 0.038; 23.1 ± 18.2 vs. 13.8 ± 9.2 hours, p = 0.007). Conclusion A large amount of CIRP was released during cardiac surgery. The secreted CIRP was associated with the increased risk of AKI after cardiac surgery.

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