Effect of ulinastatin on post-operative blood loss and allogeneic transfusion in patients receiving cardiac surgery with cardiopulmonary bypass: a prospective randomized controlled study with 10-year follow-up

Effects of different doses of ulinastatin on organ protection of deep hypothermic circulatory arrest in rats

BACKGROUND

Deep hypothermic circulatory arrest (DHCA) can cause systemic inflammatory response (SIR) and ischemia-reperfusion (I/R) injury, potentially exacerbating organ failure. Ulinastatin (UTI) is a frequently employed anti-inflammatory medication in clinical practice, but different timing and dosage may influence its protective efficacy.

METHODS

24 rats were randomly divided into four groups. Three different doses of UTI (3/10/30 × 104 U/kg; low/medium/high dose) were administered in the DHCA rat model, with a control group that underwent DHCA without UTI administration. Inflammatory markers and routine clinical indicators of myocardial, hepatic, and renal tissue injury were evaluated. All rats underwent the standard DHCA procedure.

RESULTS

Interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α) and neutrophil elastase (ELA-2) levels in rats exposed to DHCA gradually increased after rewarming. Compared with the DHCA-only group, both the low dose of UTI (UTI-L) and the medium dose of UTI (UTI-M) significantly reduced IL-6 (p = 0.017, p = 0.022 ), TNF-α (p = 0.003, p < 0.001), ELA-2 levels ( p = 0.018, p = 0.001), and elevated IL-10 levels ( p < 0.001, p < 0.001) 4 h post-weaning from cardiopulmonary bypass (CPB). In addition, compared with the DHCA group, both the UTI-L and UTI-M group showed significantly lower levels of cardiac troponin I (p = 0.001, p = 0.001), creatine kinase muscle and brain isoenzyme (CK-MB) (p < 0.001, p < 0.001), creatinine (p < 0.001, p < 0.001), blood urea nitrogen (p = 0.002, p = 0.021), aspartate transaminase (p < 0.001, p < 0.001) and alanine aminotransferase (p < 0.001, p < 0.001) at the end of the experiment. The hematoxylin-eosin staining results of kidney and liver tissue damage were alleviated in the UTI-L and UTI-M groups. The high dose of UTI (UTI-H) group did not exhibit dose-dependent anti-inflammatory effects and was associated with aggravated injury to the heart, liver, and kidney.

CONCLUSION

This study demonstrated that the administration of low to medium doses of UTI during DHCA significantly attenuated the levels of IL-6, TNF-α, and ELA-2, elevated the level of the anti-inflammatory factor IL-10, and provided protective effects on myocardial, hepatic, and renal tissues.

Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted.

METHODS

An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE).

RESULTS

Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE.

CONCLUSION

This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.

Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults

BACKGROUND

Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness.

OBJECTIVES

The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies.

SELECTION CRITERIA

RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported.

DATA COLLECTION AND ANALYSIS

Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2.

MAIN RESULTS

A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low.

AUTHORS' CONCLUSIONS

A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.

Inflammatory risk stratification individualizes anti-inflammatory pharmacotherapy for acute type A aortic dissection

The systemic benefits of anti-inflammatory pharmacotherapy vary across cardiovascular diseases in clinical practice. We aimed to evaluate the application of artificial intelligence to acute type A aortic dissection (ATAAD) patients to determine the optimal target population who would benefit from urinary trypsin inhibitor use (ulinastatin). Patient characteristics at admission in the Chinese multicenter 5A study database (2016-2022) were used to develop an inflammatory risk model to predict multiple organ dysfunction syndrome (MODS). The population (5,126 patients from 15 hospitals) was divided into a 60% sample for model derivation, with the remaining 40% used for model validation. Next, we trained an extreme gradient-boosting algorithm (XGBoost) to develop a parsimonious patient-level inflammatory risk model for predicting MODS. Finally, a top-six-feature tool consisting of estimated glomerular filtration rate, leukocyte count, platelet count, De Ritis ratio, hemoglobin, and albumin was built and showed adequate predictive performance regarding its discrimination, calibration, and clinical utility in derivation and validation cohorts. By individual risk probability and treatment effect, our analysis identified individuals with differential benefit from ulinastatin use (risk ratio [RR] for MODS of RR 0.802 [95% confidence interval (CI) 0.656, 0.981] for the predicted risk of 23.5%-41.6%; RR 1.196 [0.698-2.049] for the predicted risk of <23.5%; RR 0.922 [95% CI 0.816-1.042] for the predicted risk of >41.6%). By using artificial intelligence to define an individual's benefit based on the risk probability and treatment effect prediction, we found that individual differences in risk probability likely have important effects on ulinastatin treatment and outcome, which highlights the need for individualizing the selection of optimal anti-inflammatory treatment goals for ATAAD patients.

Effects of Ulinastatin on Postoperative Renal Function in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Cohort Study with 10-Year Follow-Up

INTRODUCTION

The present study aimed to explore the potential effect of ulinastatin on renal function and long-term survival in patients receiving cardiac surgery with cardiopulmonary bypass (CPB).

METHODS

This prospective cohort study was conducted at Fuwai Hospital, Beijing, China. Ulinastatin was applied after induction anesthesia. The primary outcome was the rate of new-onset postoperative acute kidney injury (AKI). Moreover, a 10-year follow-up was conducted until January 2021.

RESULTS

The rate of new-onset AKI was significantly lower in the ulinastatin group than in the control group (20.00 vs. 32.40%, p = 0.009). There was no significant difference in renal replacement therapy between the two groups (0.00 vs. 2.16%, p = 0.09). The postoperative plasma neutrophil gelatinase-associated lipocalin (pNGAL) and IL-6 levels were significantly lower in the ulinastatin group compared with the control group (pNGAL: p = 0.007; IL-6: p = 0.001). A significantly lower incidence of respiratory failure in the ulinastatin group compared with the control group (0.76 vs. 5.40%, p = 0.02). The nearly 10-year follow-up (median: 9.37, 95% confidence interval: 9.17-9.57) survival rates did not differ significantly between the two groups (p = 0.076).

CONCLUSIONS

Ulinastatin significantly reduced postoperative AKI and respiratory failure in patients receiving cardiac surgery with CPB. However, ulinastatin did not reduce intensive care unit and hospital stays, mortality, and long-term survival rate.

The efficacy and safety of intravenous administration of tranexamic acid in patients undergoing cardiac surgery: Evidence from a single cardiovascular center

BACKGROUND

The current study was performed to systemically review the efficacy and safety of tranexamic acid (TXA) in patients undergoing cardiac surgery at a single large-volume cardiovascular center.

METHODS

A computerized search of electronic databases was performed to identify all relevant studies using search terms till December 31st, 2021. The primary outcomes were postoperative blood loss and the composite incidence of mortality and morbidities during hospitalization. Secondary outcomes included postoperative massive bleeding and transfusion, postoperative recovery profiles, coagulation functions, inflammatory variables, and biomarkers of vital organ injury.

RESULTS

Database search yielded 23 qualified studies including 27,729 patients in total. Among them, 14,136 were allocated into TXA group and 13,593 into Control group. The current study indicated that intravenous TXA significantly reduced total volume of postoperative bleeding in both adult and pediatric patients, and that medium- and high-dose TXA were more effective than low-dose TXA in adult patients (P < .05). The current study also demonstrated that intravenous TXA, as compared to Control, remarkably reduced postoperative transfusion incidences and volume of red blood cell and fresh frozen plasma, and reduced postoperative transfusion incidence of platelet concentrates (PC) (P < .05) without obvious dose-effects (P > .05), but TXA did not reduce PC transfusion volume postoperatively in adult patients (P > .05). For pediatrics, TXA did not significantly reduce postoperative transfusion incidence and volume of allogenic red blood cell, fresh frozen plasma and PC (P > .05). Additionally, the current study demonstrated that intravenous TXA did not influence the composite incidence of postoperative mortality and morbidities in either adults or pediatrics during hospitalization (P > .05), and that there was no obvious dose-effect of TXA in adult patients (P > .05).

CONCLUSIONS

This current study suggested that intravenous TXA significantly reduced total volume of postoperative bleeding in both adult and pediatric patients undergoing cardiac surgery at the single cardiovascular center without increasing the composite incidence of mortality and morbidities.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

The effect of Ulinastatin on postoperative course in cardiopulmonary bypass patients in Asia: a meta-analysis of randomized controlled trials

OBJECTIVES

To evaluate the effect of urinary trypsin inhibitor (UTI) or Ulinastatin on postoperative course and clinical outcomes in patients with cardiopulmonary bypass.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library for the keywords UTI and Cardiopulmonary bypass (CPB). The primary outcome measure was the intensive care unit length of stay (ICU LOS), and results were stratified for relevant subgroups (dosage of UTI). The effects of UTI on mechanical ventilation duration (MVD), hospital LOS, renal failure incidence (RFI), and all-cause mortality were studied as secondary outcomes.

RESULTS

Twelve randomized controlled trials (enrolling 1620 patients) were evaluated. Eleven studies pooled for subgroup analysis showed that using UTI persistently or with a considerable amount would lead to a shorter ICU LOS (95% CI, - 0.69 to - 0.06; P = 0.0001). Ten studies showed that UTI could shorten MVD in patients (95% CI, - 1.505 to - 0.473; P < 0.0001). RFI generally showed a more favourable outcome with UTI treatment (95%CI, 0.18-1.17; P = 0.10). And the current evidence was insufficient to prove that UTI could reduce the hospital LOS (95% CI, - 0.22 to 0.16; P = 0.75) and the all-cause mortality rate (95% CI, 0.24-2.30; P = 0.60).

CONCLUSIONS

Various subsets of UTI treatment suggested that UTI could shorten ICU LOS, and it is associated with the dosage of UTI. Considering the substantial heterogeneity and lack of criteria for UTI dosage, more evidence is needed to establish a standard dosing guideline.

Evaluation of the Safety and Efficacy of a Novel Thrombin Containing Combination Hemostatic Powder Using a Historical Control

This clinical study compares 2 hemostatic agents, a novel combination powder (CP) (HEMOBLAST^™ Bellows) and an established polysaccharide starch powder (PP) (Arista^™ AH) to assess the usefulness of CP. Retrospective comparative analysis of CP (July 2018 to July 2019, 68 patients) to PP (January 2011 to January 2013, 94 patients) in cardiothoracic patients was performed using linear regression models adjusting for age, sex, and procedure type for the endpoints: blood loss; protamine to skin closure time (hemostasis time); chest tube output and blood products required 48 hours postoperatively; ICU stay; postoperative comorbidities; and 30 day mortality. 162 patients (108 M: 54 F) underwent 162 cardiothoracic surgical procedures including: transplantation (n = 44), placement of ventricular assist device (n = 87), and others (n = 31). Use of CP compared to PP (Estimated Mean Difference [95% CI], P-value) produced significant reductions: blood loss (mL) (-886.51 [-1457.76, -312.26], P = 0.003); protamine to skin closure time (min) (-16.81 [-28.03, -5.59], P = 0.004); chest tube output (48 hrs, mL) (-445.76 [-669.38, -222.14], P < 0.001); packed red blood cell transfusions (units) (-0.98 [-1.56, -0.4], P = 0.001); and postoperative comorbidities (-0.31 [-0.55, -0.07], P = 0.012). There were no differences in the ICU stay (4.07 [-2.01, 10.15], P = 0.188) or 30-day mortality (0.57 [0.20, 1.63], P = 0.291). The use of CP in complex cardiothoracic operations resulted in improved hemostasis and significant clinical benefits in blood loss, transfusion requirements, morbidity, and time in operating room.