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  • 1.
    Axelsson, Birger
    et al.
    Örebro University, Örebro, Sweden .
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Gupta, Anil
    Örebro University, Örebro, Sweden .
    Tyden, Hans
    Örebro University, Örebro, Sweden .
    Wouters, Patrick
    Ghent, Belgium.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Effects of Combined Milrinone and Levosimendan Treatment on Systolic and Diastolic Function During Postischemic Myocardial Dysfunction in a Porcine Model2016In: Journal of Cardiovascular Pharmacology and Therapeutics, ISSN 1074-2484, E-ISSN 1940-4034, Vol. 21, no 5, p. 495-503Article in journal (Refereed)
    Abstract [en]

    It is not known whether there are positive or negative interactions on ventricular function when a calcium-sensitizing inotrope is added to a phosphodiesterase inhibitor in the clinical setting of acute left ventricular (LV) dysfunction. We hypothesized that when levosimendan is added to milrinone treatment, there will be synergetic inotropic and lusitropic effects. This was tested in an anesthetized porcine postischemic global LV injury model, where ventricular pressures and volumes (conductance volumetry) were measured. A global ischemic injury was induced by repetitive left main stem coronary artery occlusions. Load-independent indices of LV function were assessed before and after ventricular injury, after milrinone treatment, and finally after addition of levosimendan to the milrinone treatment. Nonparametric, within-group comparisons were made. The protocol was completed in 12 pigs, 7 of which received the inotrope treatment and 5 of which served as controls. Milrinone led to positive lusitropic effects seen by improvement in tau after myocardial stunning. The addition of levosimendan to milrinone further increased lusitropic state. The latter effect could however not be attributed solely to levosimendan, since lusitropic state also improved spontaneously in time-matched controls at the same rate during the corresponding period. When levosimendan was added to milrinone infusion, there was no increase in systolic function (preload recruitable stroke work) compared to milrinone treatment alone. We conclude that in this model of postischemic LV dysfunction, there appears to be no clear improvement in systolic or diastolic function after addition of levosimendan to established milrinone treatment but also no negative effects of levosimendan in this context.

  • 2.
    Axelsson, Birger
    et al.
    Dept of Cardiovascular and Thoracic Surgery and Anesthesiology and Intensive Care, Örebro University Hospital.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Gupta, Anil
    Dept of Clinical Medicine, School of Health and Medical Sciences, Örebro University.
    Tydén, Hans
    Dept of Clinical Medicine, School of Health and Medical Sciences, Örebro University.
    Wouters, Patrick
    Dept of Anesthesiology, University Hospital Ghent, Ghent, Belgium.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Systolic and diastolic effects of milrinone and levosimendan in porcine post-ischemic myocardial dysfunctionManuscript (preprint) (Other academic)
  • 3.
    Hällgren, Oskar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Implementing a Statistical Model for Protamine Titration: Effects on Coagulation in Cardiac Surgical Patients2017In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 31, no 2, p. 516-521Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To implement a statistical model for protamine titration. DESIGN: Prospective randomized trial. SETTING: University hospital. PARTICIPANTS: Sixty (n = 30+30) patients scheduled for elective coronary artery bypass surgery were randomly assigned to 2 groups. INTERVENTIONS: Protamine dose calculated according to an algorithm established from a statistical model or to a fixed protamine-heparin dose ratio (1:1). MEASUREMENTS AND MAIN RESULTS: Both groups demonstrated comparable patient demographics and intraoperative data. Coagulation effects were evaluated using rotational thromboelastometry. Using the statistical model reduced (p<0.01) the protamine dose from 426±43 mg to 251±66 mg, followed by significantly (p<0.01) shorter intrinsic clotting time (208±29 seconds versus 244±52 seconds) and stronger clot firmness (p = 0.01), and effects on indices of extrinsic or fibrinogen coagulation pathways were insignificant. Test of residual heparin was negative in all patients after protamine administration, aligned with insignificant (p = 0.27) intergroup heparinase-verified clotting time differences. CONCLUSIONS: The statistical model for protamine titration is clinically feasible and protects the patient from exposure to excessive doses of protamine, with advantageous effects on coagulation as measured using rotational thromboelastometry. Significance regarding clinical outcome is yet to be defined.

  • 4.
    Johagen, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Svenmarker, Pontus
    Umeå University, Faculty of Science and Technology, Department of Physics.
    Jonsson, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine. Department of Biomedical Engineering and Informatics, Umeå University, Umeå, Sweden.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    A microscopic view of gaseous microbubbles passing a filter screen2017In: International Journal of Artificial Organs, ISSN 0391-3988, E-ISSN 1724-6040, Vol. 40, no 9, p. 498-502Article in journal (Refereed)
    Abstract [en]

    Purpose: The aim of this study was to investigate the filtration efficacy of a 38-µm 1-layer screen filter based on Doppler registrations and video recordings of gaseous microbubbles (GME) observed in a microscope.

    Methods: The relative filtration efficacy (RFE) was calculated from 20 (n = 20) sequential bursts of air introduced into the Plasmodex® primed test circuit.

    Results: The main findings indicate that the RFE decreased (p = 0.00), with increasing flow rates (100-300 mL/min) through the filter screen. This reaction was most accentuated for GME below the size of 100 µm, where counts of GME paradoxically increased after filtration, indicating GME fragmentation. For GME sized between 100-250 µm, the RFE was constantly >60%, independently of the flow rate level. The video recording documenting the GME interactions with the screen filter confirmed the experimental findings.

    Conslusions: The 38-µm 1-layer screen filter investigated in this experimental setup was unable to trap gaseous microbubbles effectively, especially for GME below 100 µm in size and in conjunction with high flow rates.

  • 5.
    Johagen, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    The scientific evidence of arterial line filtration in cardiopulmonary bypass2016In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 31, no 6, p. 446-457Article in journal (Refereed)
    Abstract [en]

    Background: The indication for arterial line filtration (ALF) is to inhibit embolisation during cardiopulmonary bypass. Filtration methods have developed from depth filters to screen filters and from a stand-alone component to an integral part of the oxygenator. For many years, ALF has been a standard adopted by a majority of cardiac centres worldwide. The following review aims to summarize the available evidence in support for ALF and report on its current practice in Europe. Method: The principles and application of ALF in Europe was investigated using a survey conducted in 2014. The scientific evidence for ALF was examined by performing a systematic literature search in six different databases, using the following search terms: Cardiopulmonary bypass AND filters AND arterial. The primary endpoint was protection against cerebral injury verified by the degree of cerebral embolisation or cognitive tests. The secondary endpoint was improvement of the clinical outcome verified elsewise. Only randomised clinical trials were considered. Results: The response rate was 31% (n=112). The great majority (88.5%) of respondents were using ALF, following more than 10 years of experience. Integrated arterial filtration was used by 55%. Of respondents not using ALF, fifty-four percent considered starting using integrated arterial filtration. The systematic literature database search returned 180 unique publications where 82 were specifically addressing ALF in cardiopulmonary bypass. Only four out of the 82 identified publications fulfilled our inclusion criteria. Of these, three were more than 20 years old and based on the use of bubble oxygenation. Conclusion: ALF is a standard implemented in a majority of cardiopulmonary bypass procedures in Europe. The level of scientific evidence available in support of current arterial line filtration methods in cardiopulmonary bypass is, however, poor. Large, well-designed, randomised trials are warranted.

  • 6.
    Karlsson, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hannuksela, Matias
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hällgren, Oskar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Johagen, Daniel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wahba, Alexander
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Cardiopulmonary bypass and dual antiplatelet therapy: a strategy to minimise transfusions and blood loss2019In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111XArticle in journal (Refereed)
    Abstract [en]

    Background: Patients with preoperative dual antiplatelet therapy prior to coronary artery bypass surgery are at risk of bleeding and blood component transfusion. We hypothesise that an optimised cardiopulmonary bypass strategy reduces postoperative blood loss and transfusions.

    Methods: In total, 60 patients admitted for coronary artery bypass grafting with ticagrelor and aspirin medication withdrawn <96 hours before surgery were prospectively randomised into two equal sized groups. Cardiopulmonary bypass combined a closed Cortiva (R) heparin-coated circuit with low systemic heparinisation (activated clotting time < 250 seconds) and intraoperative cell salvage in the study group, whereas the control group used a Balance (R) coated open circuit, full systemic heparinisation (activated clotting time > 480 seconds) and conventional cardiotomy suction. This perfusion strategy was evaluated by the chest drain volume after 24 hours, perioperative haemoglobin and platelet loss accompanied by global coagulation assessments.

    Results: Patients in the study group demonstrated significantly better outcomes signified by lower blood loss 554 +/- 224 versus 1,100 +/- 989 mL (p < 0.001), reduced packed red cell transfusion 7% versus 53% (p < 0.001), reduced haemoglobin -28 +/- 15 versus -40 +/- 14 g/L (p = 0.004) and platelet loss -35 +/- 36 versus -82 +/- 67 x 10(9)/L (p = 0.001). Indices of rotational thromboelastometry indicated shorter clotting times within the internal and external pathways. Adenosine diphosphate activated platelet function was within normal range based on Multiplate (R) aggregometry, while ROTEM (R) platelet analyses indicated inhibited function both preoperatively and post-bypass. Platelet inhibition by aspirin was verified throughout the perioperative period. Platelet function showed no intergroup differences.

    Conclusion: A stringent perfusion strategy reduced blood loss and transfusions in dual antiplatelet therapy patients requiring urgent surgery.

  • 7.
    Malmqvist, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Claesson Lingehall, Helena
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Cardiopulmonary bypass prime composition: beyond crystalloids versus colloids2019In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 34, no 2, p. 130-135Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: In the literature addressing cardiopulmonary bypass (CPB) prime composition, there is a considerable lack of discussion concerning plasma osmolality changes induced by using a hyperosmolar prime. With this study, we try to determine the magnitude and temporal relationship of plasma osmolality changes related to the use of a hyperosmolar CPB prime.

    METHOD: In this prospective observational study performed in a university hospital setting, we enrolled thirty patients scheduled for elective coronary bypass surgery. Plasma osmolality was analysed on eight occasions. A hyperosmolar CPB prime was used.

    RESULTS: Analyses of the perioperative plasma osmolality on eight occasions gave the following results: the preoperative osmolality level was normal (297±4 mOsm/kg); a significant increase to 322±17 mOsm/kg (p<0.001) was observed at the commencement of CPB and remained elevated after 30 minutes (310±4 mOsm/kg) and throughout the procedure (309±4 mOsm/kg); the osmolality level returned to 291±5 mOsm/kg on day 1 postoperatively and remained normal the following day (291±6 mOsm/kg).

    CONCLUSIONS: Use of hyperosmolar CPB prime resulted in a dramatic and instant elevation of the plasma osmolality. Rapid changes in plasma osmolality are associated with organ dysfunction (e.g. osmotic demyelination syndrome), therefore, effects on plasma osmolality related to the CPB prime composition should be recognised. Influence on organ function and clinical outcome warrants further investigations. - Clinical Trials.gov (NCT03060824). Changes in Plasma Osmolality Related to the Use of Cardiopulmonary Bypass With Hyperosmolar Prime. URL: https://clinicaltrials.gov/ct2/show/NCT03060824?term=cpb&cond=osmolality&rank=1.

  • 8.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Cardiothoracic Surgery Division, Heart Center.
    Lingehall, Helena Claesson
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium2018In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 32, no 2, p. 684-690Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to determine risk factors for postoperative delirium after cardiac surgery, specifically associated with the conduct of cardiopulmonary bypass (CPB).

    Design: Prospective observational study.

    Setting: Heart Centre, University Hospital.

    Participants: The study included 142 patients aged 70 years and older scheduled for elective cardiac surgery with CPB.

    Interventions: Risk factor analysis comprised information collected from the hospital clinical and CPB dedicated databases in addition to the medical chart. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criterion using the Mini Mental State Examination and the Organic Brain Syndrome scale.

    Measurements and Main Results: Assessments of delirium diagnosis were executed preoperatively and on the following first and fourth postoperative days. Delirium occurred in 55% (78/142) of the patients. Patients with delirium were identified with significantly higher body weight and body surface area preoperatively, accompanied with longer CPB time, higher positive fluid balance per CPB, and lower systemic pump flow related to body surface area. Furthermore, the duration of the mixed venous oxygen saturation (SvO2) below 75% was significantly longer during CPB. The result from the multivariable logistic regression analysis included the duration of SvO2 below 75%, fluid balance per CPB and patient age as independent risk factors for postoperative delirium.

    Conclusions: The influence of the SvO2 level during CPB, fluid balance, and patient age should be recognized as risk factors for postoperative delirium after cardiac surgery in patients 70 years and older.

  • 9.
    Svenmarker, S.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandström, E.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Karlsson, T.
    Häggmark, S.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Jansson, E.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Appelblad, M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lindholm, R.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Åberg, T.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Neurological and general outcome in low-risk coronary artery bypass patients using heparin coated circuits2001In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 19, no 1, p. 47-53Article in journal (Refereed)
    Abstract [en]

    Objective: The clinical significance of heparin coating in cardiopulmonary bypass has previously been investigated. However, few studies have addressed the possible influence on brain function and memory disturbances.

    Methods: Three hundred low-risk patients exposed to coronary bypass surgery were randomised into three groups according to type of heparin coating: Carmeda Bioactive Surface, Baxter Duraflo II and a control group. Outcome was determined from a number of clinically oriented parameters, including a detailed registry of postoperative deviations from the normal postoperative course. Brain damage was assessed through S100 release and memory tests, including a questionnaire follow-up.

    Results: Clinical outcome was similar for all groups. Blood loss (Duraflo only), transfusion requirements and postoperative creatinine elevation were reduced in the heparin-coated groups. A lower incidence of atrial fibrillation was noted in the Duraflo group. Heparin coating did not uniformly attenuate the release of S100 or the degree of memory impairment.

    Conclusions: Cardiopulmonary bypass (CPB) with heparin coating and a reduced dose of heparin seems to be safe. Clinical outcome and neurological injury seem not to be associated with type of heparin coating used for CPB. However, blood loss and transfusion requirements may be reduced.

  • 10.
    Svenmarker, Staffan
    Umeå University, Faculty of Arts, Archaeology and Sami Studies.
    Heparin coating and cardiotomy suction in cardiopulmonary bypass2003Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The present thesis addresses various means of reducing inflammatory responses associated with cardiopulmonary bypass (CPB) and retransfusion of pericardial suction blood (PSB) during cardiac surgery.

    Four (I-IV) prospective randomised controlled clinical trials comprising 475 patients were performed in the following areas: effects of heparin coating on measures of clinical outcome and memory function (I, II), inflammatory reactions in PSB and its systemic effects after retransfusion using cardiotomy suction or cell salvage (III) and effects of retransfusion of PSB on memory function and release patterns of protein S100B (IV).

    The use of heparin coated CPB-circuits was associated with a decrease of postoperative blood loss (I, II), transfusion requirements (II), shorter stay in hospital (I) decreased postoperative ventilator time (I), lower incidences of atrial fibrillation (II) and neurological deviations (I), reduction in releases of protein S100B (I, II) and lower postoperative creatinine elevation (I, II).

    PSB contained high concentrations of cytokines, complements, myeloperoxidase, free plasma haemoglobin and protein S100B (III, IV). Retransfusion using cardiotomy suction increased the systemic concentrations of free plasma haemoglobin and protein S100B, whereas retransfusion using cell salvage caused no detectable systemic effects (III, IV). CPB was associated with a small but significant release of protein S100B, despite elimination of PSB-contained protein S100B using cell salvage (IV).

    Subtle signs of impaired memory function were identified that were not associated with the use of heparin coated CPB-circuits (I, II) or retransfusion of PSB (IV).

    Key words: cardiopulmonary bypass, oxygenators, heparin, S100 proteins, blood loss, haemostasis, memory, outcome and process assessment.

  • 11.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Hannuksela, Matias
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    A retrospective analysis of the mixed venous oxygen saturation as the target for systemic blood flow control during cardiopulmonary bypass2018In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 33, no 6, p. 453-462Article in journal (Refereed)
    Abstract [en]

    Objectives: The patient's body surface area serves as the traditional reference for the determination of systemic blood flow during cardiopulmonary bypass (CPB). New strategies refer to different algorithms of oxygen delivery. This study reports on the mixed venous oxygen saturation (SvO2) as the target for systemic blood flow control. We hypothesise that an SvO2>75% (S(v)O(2)75) is associated with better preservation of renal function and improved short-term survival.

    Methods: This retrospective, 10-year, observational study analysed 6945 consecutive cardiac surgical cases requiring CPB. Endpoints included rates of acute kidney injury (AKI) and short-term survival, also the estimated glomerular filtration rate ((e)GFR), lactate levels and blood transfusions.

    Results: Seventy-seven percent of the patients attained the S(v)O(2)75 target. For this group, the median SvO2 was 78.1 (5.8) %, with a mean oxygen delivery of 331 (78) ml/min per m(2) body surface area. Overall incidence of AKI levels (I-III): 7.5% - 2.6% - 0.6%. Incidence of (e)GFR (<50%): 3.9%, increasing to 6% for haemoglobin levels <80 g/L (p<0.001). Red cell transfusion was more frequent (p<0.001) within this group (30.6%) compared to levels >100 g/L (0.3%). Further, women (52.8%) were transfused more often than men (14.6%). Lactate level at weaning from CPB was 1.3 (0.7) mmol/L. The S(v)O(2)75 target demonstrated a relative risk reduction of 22.5% (p=0.032) for AKI (I), increasing to 32.3% (p=0.026) for procedures extending >90 minutes. In addition, the risk for death 90-days postop was lower (p=0.039).

    Conclusion: The S(v)O(2)75 target showed a decreased risk for postoperative AKI and prolonged short-term survival. Good clinical outcomes were also linked to measures of lactate and the (e)GFR. However, anaemia remains a risk factor for AKI.

  • 12.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Holmgren, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Serum markers are not reliable measures of renal function in conjunction with cardiopulmonary bypass2011In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 12, no 5, p. 713-717Article in journal (Refereed)
    Abstract [en]

    The present study explored the influence of haemodilution on estimates of the glomerular filtration rate (GFR) in conjunction with cardiopulmonary bypass (CPB) and cardiac surgery. Ninety-eight patients (n = 98) undergoing coronary artery bypass grafting with the aid of CPB were examined. The serum concentration of cystatin C and creatinine was analysed prior to surgery, after completion of CPB and in the intensive care the day after surgery. The estimated GFR was calculated using standard equations based on the serum concentration of cystatin C and creatinine. It was found that haemodilution induced by CPB had significant effects on the estimated GFR. For cystatin C, the GFR increased by 50.5 ± 2.5 ml/min (P = 0.000) and for creatinine based GFR with 22.5 ± 0.9 ml/min (P = 0.000) using the 4-variable modification of diet renal disease formula and with 22.1 ± 0.93 ml/min (P = 0.000) for the Cockcroft-Gault formula, respectively. Similar effects of haemodilution on GFR were also detected postoperatively. Haemodilution induced by CPB may therefore significantly overestimate the renal function as indicated by GFR based on serum markers.

  • 13.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Hultin, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Holmgren, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Static blood-flow control during cardiopulmonary bypass is a compromise of oxygen delivery2009In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 37, no 1, p. 218-222Article in journal (Refereed)
    Abstract [en]

    Background: Blood-flow control during cardiopulmonary bypass (CPB) is by tradition based on the patient's body surface area. Emergence of new techniques enables dynamic blood-flow control based on online measurement of venous oxygen saturation and oxygen consumption. Present investigation aimed to compare static versus dynamic blood-flow control with respect to use of oxygen and effects upon organ function. Methods: In this study, 100 coronary-artery-bypass surgical patients were prospectively randomised to static or dynamic hypothermic blood-flow control during CPB. In the static group, pump flow was set to 2.4 (litres per minute) times the patient's body surface area (m(2)) throughout the procedure. Pump flow in the dynamic group was varied according to the reading of the venous oxygen saturation and maintained at >75%. CPB-specific information was collected online. Blood samples were collected for analysis of haemoglobin, lactate, amylase, creatinine and C-reactive protein: pre-CPB, at weaning from CPB and on day 1 postoperatively. Results: Randomisation formed two uniform groups. Choice of static or dynamic blood-flow control during CPB had no significant effects on organ function as judged by lactate, amylase or creatinine levels. On increasing oxygen demand, oxygen balance was maintained by increasing venous oxygen extraction rates in the static flow mode and by increasing the pump flow rate in the dynamic group. Conclusions: Independent of the blood-flow control mode, oxygen balance remained preserved. However, the dynamic mode provided higher oxygen delivery, which may increase margins of safety and protection of organ function.

  • 14.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Axelsson, B.
    Wiklund, Urban
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Regional changes in cerebral blood flow oxygenation can indicate global changes in cerebral blood flow during coronary artery occlusion in juvenile pigs2014In: Physiological Measurement, ISSN 0967-3334, E-ISSN 1361-6579, Vol. 35, no 7, p. 1439-1450Article in journal (Refereed)
    Abstract [en]

    Near infrared spectroscopy (NIRS) is a widely employed method for assessment of regional cerebral oxygenation (R(c)StO(2)). RcStO(2) values are expected to vary with changes in the relative amount of oxyhaemoglobin. The present experimental study aimed to assess the response of RcStO(2) to controlled alterations of carotid blood flow (CQ). Landrace pigs were anesthetized followed by surgical preparation. Cyclic variations in cardiac output were accomplished by intermittently occluding the main stem of the left coronary artery. A flow measurement probe for assessing CQ was placed around the left carotid artery. One NIRS probe was placed on the left ipsilateral forehead to assess regional cerebral oximetry. Simultaneous registration of CQ and RcStO(2) was conducted. There was a strong correlation for variation in CQ and RcStO(2) signal values. Based on coherence analysis the fraction of power of the RcStO(2) that was coherent with the CQ signal reached 0.84 - 0.12 (P < 0.05) for frequencies lower than 0.1 Hz. The agreement of the sampleto- sample co-variation, as assessed by the Pearson correlation coefficient, was 0.83 +/- 0.08 (P < 0.05). One explanatory component for variations in cerebral oxygenation verified by NIRS should be attributed to variations in the cerebral blood flow.

  • 15.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Häggmark, Sören
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Östman, Margareta
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Holmgren, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Central venous oxygen saturation during cardiopulmonary bypass predicts 3-year survival2013In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 16, no 1, p. 21-26Article in journal (Refereed)
    Abstract [en]

    Long-term survival after cardiac surgery is determined by a number of different risk factors. Central venous oxygen saturation (SvO2) measures the balance between oxygen delivery and demand. SvO2 levels in the intensive care situation are reported to be associated with patient outcome. The present report explores the connection between SvO2 during cardiopulmonary bypass (CPB) and survival after cardiac surgery. Retrospective analysis of one thousand consecutive cardiac surgical patients was undertaken. SvO2 during CPB was monitored online. Registry data combining specific risk factors with SvO2 were selected for Kaplan-Meier and Cox regression analysis to examine the influence on 30-day and 3-year survivals. Nine-hundred and thirty-two patient records were eligible for analysis. SvO2 below 75% during CPB was associated with significantly shorter 30-day and 3-year survivals. Based on Kaplan-Meier statistics, the survival rate decreased by 3.1% (98.1-95.0), P = 0.011 and 6.1% (92.7-86.6), P = 0.003, respectively. The influence of SvO2 on 3-year survival remained statistically significant after controlling for a series of risk factors in the Cox regression analysis. Patients with SvO2 < 75% carried a 2-fold (odds ratio 2.1) increased relative risk of shortened 3-year survival (P = 0.003). Other risk factors statistically significantly associated with 3-year survival were age, gender, duration of CPB, blood temperature, hypertension, haematocrit and type of surgical procedure. We report decreased 30-day and 3-year survival expectancy for patients experiencing SvO2 lower than 75% during CPB.

  • 16.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Sandström, Erik
    Karlsson, Thomas
    Jansson, Erica
    Lindholm, Ronny
    Appelblad, Micael
    Åberg, Torkel
    Clinical effects of the heparin coated surface in cardiopulmonary bypass1997In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 11, no 5, p. 957-964Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: In a randomised study of 120 patients, undergoing primary operation for coronary heart decease, two groups were investigated as regards to the effects of heparin coated cardiopulmonary bypass on brainfunction parameters and general clinical outcome. The study group (n = 56) was perfused using an extra-corporeal circuit treated with covalent bonded heparin; the control group (n = 59) used an identical set-up without heparin treatment. Systemic heparin doses were calculated to achieve ACT levels of 250 and 500 s, respectively. Postoperative course was evaluatedby examining a set of clinically relevant parameters including a detailed registry of postoperative deviations. Brain function was assessed by the biochemical marker S-100 and tests of memory performance.

    RESULTS: There were several signs of reduced operative trauma in the study group. Hospital stay was reduced by nearly 1 day (P < 0.05). Time on postoperative ventilatory support was approximately 4 h shorter (P = 0.009). Chest drain blood loss was decreased both at 8 (P = 0.01) and 24 h (P = 0.007) postoperatively. Body temperature was lower after surgery and especially on days 2 (P = 0.03) and 3 (P = 0.01). Perioperative creatinine elevation was significantly reduced (P = 0.03). Neurological deviations were fewer (P =0.01). Brain function assessment revealed reduced plasma levels of S- 100 both at termination of cardiopulmonary bypass (P = 0.008) and 7 h later (P= 0.04). However, no remediation of memory impairment could be demonstrated.

    CONCLUSIONS: Cardiopulmonary bypass with covalent bonded heparin attached to the extra-corporeal circuit in combination with a reduced systemic heparin dose seems to reduce safely and effectively the operative stress to the patient. There were also signs of improved cerebral protection.

  • 17.
    Ödling Davidsson, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Johagen, Daniel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Reversal of Heparin After Cardiac Surgery: Protamine Titration Using a Statistical Model2015In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 29, no 3, p. 710-714Article in journal (Refereed)
    Abstract [en]

    Objective: To establish a statistical model for determination of protamine dose in conjunction with cardiopulmonary bypass. Design: Prospective.

    Setting: University hospital.

    Participants: Ninety consecutive cardiac surgical patients.

    Interventions: None.

    Measurements and Main Results: A series of clinically oriented variables were introduced into a statistical model for projection of the protamine dose after cardiopulmonary bypass. The following significant predictors were identified using multivariable regression analysis: The patient's body surface area, the administered dose of heparin, heparin clearance, and the preoperative platelet count. The statistical model projected the protamine dose within 3 +/- 23 mg of the point-of-care test used as reference.

    Conclusion: Protamine dosing based on statistical modeling represents an alternative to point-of-care tests.

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