Bando K, Turrentine M W, Vijay P, Sharp T G, Sekine Y, Lalone B J, Szekely L, Brown J W
Section of Cardiothoracic Surgery, James W. Riley Hospital for Children and Indiana University Medical Center, Indianapolis 46202-5123, USA.
Ann Thorac Surg. 1998 Sep;66(3):821-7; discussion 828. doi: 10.1016/s0003-4975(98)00606-7.
Modified ultrafiltration (MUF) after cardiopulmonary bypass (CPB) in children decreases body water, removes inflammatory mediators, improves hemodynamics, and decreases transfusion requirements. The optimal target population for MUF needs to be defined. This prospective, randomized study attempted to identify the best candidates for MUF during operations for congenital heart disease.
Informed consent was obtained from 100 consecutive patients with complex congenital heart disease undergoing operations with CPB. They were randomized into a control group (n = 50) of conventional ultrafiltration during bypass and an experimental group using dilutional ultrafiltration during bypass and venovenous modified ultrafiltration after bypass (MUF group, n = 50). Postoperative arterial oxygenation, duration of ventilatory support, transfusion requirements, hematocrit, chest tube output, and time to chest tube removal were compared between the groups stratified by age and weight, CPB technique, existence of preoperative pulmonary hypertension, and diagnosis.
There were no MUF-related complications. In patients with preoperative pulmonary hypertension, MUF significantly improved postoperative oxygenation (445 +/- 129 mm Hg versus control: 307 +/- 113 mm Hg, p = 0.002), shortened ventilatory support (42.9 +/- 29.5 hours versus control: 162.4 +/- 131.2 hours, p = 0.0005), decreased blood transfusion (red blood cells: 16.2 +/- 18.2 mL/kg versus control: 41.4 +/- 27.8 mL/kg, p = 0.01; coagulation factors: 5.3. +/- 6.9 mL/kg versus control: 32.3 +/- 15.5 mL/kg, p = 0.01), and led to earlier chest tube removal. In neonates (< or =30 days), MUF significantly reduced transfusion of coagulation factors (5.4 +/- 5.0 mL/kg versus control: 39.9 +/- 25.8 mL/kg, p = 0.007), and duration of ventilatory support (59.3 +/- 36.2 hours versus 242.1 +/- 143.1 hours, p = 0.0009). In patients with prolonged CPB (>120 minutes), MUF significantly reduced the duration of ventilatory support (44.7 +/- 37.0 hours versus 128.7 +/- 133.4 hours, p = 0.002). No significant differences were observed between MUF and control patients for any parameter in the presence of ventricular septal defect without pulmonary hypertension, tetralogy of Fallot, or aortic stenosis.
Modified ultrafiltration after CPB is safe and decreases the need for homologous blood transfusion, the duration of ventilatory support, and chest tube placement in selected patients with complex congenital heart disease. The optimal use of MUF includes patients with preoperative pulmonary hypertension, neonates, and patients who require prolonged CPB.
小儿体外循环（CPB）后改良超滤（MUF）可减少机体水分，清除炎症介质，改善血流动力学，并减少输血需求。需要确定MUF的最佳目标人群。这项前瞻性随机研究试图确定先天性心脏病手术期间MUF的最佳适用对象。
连续100例接受CPB手术的复杂先天性心脏病患者均获得知情同意。他们被随机分为对照组（n = 50），在体外循环期间进行常规超滤；以及实验组，在体外循环期间进行稀释超滤，并在体外循环后进行静脉-静脉改良超滤（MUF组，n = 50）。比较两组按年龄和体重、CPB技术、术前是否存在肺动脉高压及诊断分层后的术后动脉氧合、通气支持时间、输血需求、血细胞比容、胸管引流量及胸管拔除时间。
未出现与MUF相关的并发症。在术前有肺动脉高压的患者中，MUF显著改善了术后氧合（445±129mmHg，对照组：307±113mmHg，p = 0.002），缩短了通气支持时间（42.9±29.5小时，对照组：162.4±131.2小时，p = 0.0005），减少了输血（红细胞：16.2±18.2ml/kg，对照组：41.4±27.8ml/kg，p = 0.01；凝血因子：5.3±6.9ml/kg，对照组：32.3±15.5ml/kg，p = 0.01），并使胸管拔除时间提前。在新生儿（≤30天）中，MUF显著减少了凝血因子的输注量（5.4±5.0ml/kg，对照组：39.9±25.8ml/kg，p = 0.007）以及通气支持时间（59.3±36.2小时对242.1±143.1小时，p = 0.0009）。在体外循环时间延长（>120分钟）的患者中，MUF显著缩短了通气支持时间（44.7±37.0小时对128.7±133.4小时，p = 0.002）。在无肺动脉高压的室间隔缺损、法洛四联症或主动脉狭窄患者中，MUF与对照组患者在任何参数上均未观察到显著差异。
CPB后改良超滤是安全的，可减少特定复杂先天性心脏病患者的同种异体输血需求、通气支持时间及胸管留置时间。MUF的最佳应用对象包括术前有肺动脉高压的患者、新生儿以及需要长时间CPB的患者。
