Use of intraoperative haemoadsorption in patients undergoing heart transplantation: a proof-of-concept randomized trial.

AIMS: The aim of this trial was to compare the clinical effects of intraoperative haemoadsorption versus standard care in patients undergoing orthotopic heart transplantation (OHT). METHODS AND RESULTS: In a randomized, controlled trial, OHT recipients were randomized to receive intraoperative haemoadsorption or standard care. Outcomes were vasoactive-inotropic score (VIS), frequency of vasoplegic syndrome (VS) in the first 24 h; post-operative change in procalcitonin (PCT) and C-reactive protein (CRP) levels; intraoperative change in mycophenolic acid (MPA) concentration; frequency of post-operative organ dysfunction, major complications, adverse immunological events and length of in-hospital stay and 1-year survival. Sixty patients were randomized (haemoadsorption group N = 30, control group N = 25 plus 5 exclusions). Patients in the haemoadsorption group had a lower median VIS and rate of VS (VIS: 27.2 [14.6-47.7] vs. 41.9 [22.4-63.2], P = 0.046, and VS: 20.0% vs. 48.0%, P = 0.028, respectively), a 6.4-fold decrease in the odds of early VS (OR: 0.156, CI: 0.029-0.830, P = 0.029), lower PCT levels, shorter median mechanical ventilation (MV: 25 [19-68.8] hours vs. 65 [23-287] hours, P = 0.025, respectively) and intensive care unit stay (ICU stay: 8.5 [8.0-10.3] days vs. 12 [8.5-18.0] days, P = 0.022, respectively) than patients in the control group. Patients in the haemoadsorption versus control group experienced lower rates of acute kidney injury (AKI: 36.7% vs. 76.0%, P = 0.004, respectively), renal replacement therapy (RRT: 0% vs. 16.0%, P = 0.037, respectively) and lower median per cent change in bilirubin level (PCB: 2.5 [-24.6 to 71.1] % vs. 72.1 [11.2-191.4] %, P = 0.009, respectively) during the post-operative period. MPA concentrations measured at pre-defined time points were comparable in the haemoadsorption compared to control groups (MPA pre-cardiopulmonary bypass: 2.4 [1.15-3.60] µg/mL vs. 1.6 [1.20-3.20] µg/mL, P = 0.780, and MPA 120 min after cardiopulmonary bypass start: 1.1 [0.58-2.32] µg/mL vs. 0.9 [0.45-2.10] µg/mL, P = 0.786). The rates of cardiac allograft rejection, 30-day mortality and 1-year survival were similar between the groups. CONCLUSIONS: Intraoperative haemoadsorption was associated with better haemodynamic stability, mitigated PCT response, lower rates of post-operative AKI and RRT, more stable hepatic bilirubin excretion, and shorter durations of MV and ICU stay. Intraoperative haemoadsorption did not show any relevant adsorption effect on MPA. There was no increase in the frequency of early cardiac allograft rejection related to intraoperative haemoadsorption use.

Perioperative Gelatin Use Is Associated With Increased Complication Rates and Does Not Prevent Postoperative Fluid Overload in Patients Undergoing Elective Cardiac Surgery.

OBJECTIVES: The benefit of using gelatin solution in cardiac surgery is still controversial. Previous data suggested adverse interactions of gelatin infusion with acute kidney injury (AKI) or coagulopathy. The purpose of this study was to evaluate the association between perioperative gelatin use and fluid overload (FO), hemodynamic stability, and outcomes compared to crystalloid-based fluid management. DESIGN: A retrospective study design. SETTING: At a single-center tertiary university setting. PARTICIPANTS: Propensity score-matched cohort study of 191 pairs of patients scheduled for cardiac surgery. INTERVENTIONS: Patients received either gelatin + crystalloid or pure crystalloid-based perioperative fluid management. The primary outcomes were the frequency of FO and hemodynamic stability defined by the vasoactive-inotropic score. Postoperative complications and 3-year survival were analyzed also. MEASUREMENTS AND MAIN RESULTS: Patients who received gelatin experienced more frequent postoperative FO than controls (11.0% v 3.1%, p = 0.006) despite comparable hemodynamic stability in both groups. Gelatin administration was linked with a higher rate of postoperative complications, including blood loss, AKI, and new-onset postoperative atrial fibrillation. Use of gelatin infusion resulted in an adjusted odds ratio of 1.982 (95% CI 1.051-3.736, p = 0.035) for developing early postoperative AKI. This study confirmed a dose-dependent relationship between gelatin infusion and AKI. Thirty-day mortality and 3-year survival were similar in the groups. CONCLUSIONS: Gelatin administration versus crystalloid fluid management showed a significant association with a higher rate of FO and an increased risk for early postoperative AKI in a dose-dependent manner.

Evaluating real-patient learning in medical education - Hungarian validation of the Manchester Clinical Placement Index.

Introduction: The Manchester Clinical Placement Index (MCPI) is an instrument to measure medical undergraduates' real-patient learning in communities of practice both in hospital and in GP placements. Its suitability to evaluate the quality of placement learning environments has been validated in an English-language context; however, there is a lack of evidence for its applicability in other languages. Our aim was to thoroughly explore the factor structure and the key psychometric properties of the Hungarian language version. Methods: MCPI is an 8-item, mixed-method instrument which evaluates the quality of clinical placements as represented by the leadership, reception, supportiveness, facilities and organization of the placement (learning environment) as well as instruction, observation and feedback (training) on 7-point Likert scales with options for free-text comments on the strengths and weaknesses of the given placement on any of the items. We collected data online from medical students in their preclinical (1st, 2nd) as well as clinical years (4th, 5th) in a cross-sectional design in the academic years 2019-2020 and 2021-2022, by the end of their clinical placements. Our sample comprises data from 748 medical students. Exploratory and confirmatory factor analyses were performed, and higher-order factors were tested. Results: Although a bifactor model gave the best model fit (RMSEA = 0.024, CFI = 0.999, and TLI = 0.998), a high explained common variance (ECV = 0.82) and reliability coefficients (ωH = 0.87) for the general factor suggested that the Hungarian version of the MCPI could be considered unidimensional. Individual application of either of the subscales was not supported statistically due to their low reliabilities. Discussion: The Hungarian language version of MCPI proved to be a valid unidimensional instrument to measure the quality of undergraduate medical placements. The previously reported subscales were not robust enough, in the Hungarian context, to distinguish, statistically, the quality of learning environments from the training provided within those environments. This does not, however, preclude formative use of the subscales for quality improvement purposes.

Influence of Venoarterial Extracorporeal Membrane Oxygenation Integrated Hemoadsorption on the Early Reversal of Multiorgan and Microcirculatory Dysfunction and Outcome of Refractory Cardiogenic Shock.

Background: The purpose of this investigation was to evaluate the impact of venoarterial extracorporeal membrane oxygenation (VA−ECMO) integrated hemoadsorption on the reversal of multiorgan and microcirculatory dysfunction, and early mortality of refractory cardiogenic shock patients. Methods: Propensity score−matched cohort study of 29 pairs of patients. Subjects received either VA−ECMO supplemented with hemoadsorption or standard VA−ECMO management. Results: There was a lower mean sequential organ failure assessment score (p = 0.04), lactate concentration (p = 0.015), P(v−a)CO2 gap (p < 0.001), vasoactive inotropic score (p = 0.007), and reduced delta C−reactive protein level (p = 0.005) in the hemoadsorption compared to control groups after 72 h. In−hospital mortality was similar to the predictions in the control group (62.1%) and was much lower than the predicted value in the hemoadsorption group (44.8%). There were less ECMO-associated bleeding complications in the hemoadsorption group compared to controls (p = 0.049). Overall, 90-day survival was better in the hemoadsorption group than in controls without statistical significance. Conclusion: VA−ECMO integrated hemoadsorption treatment was associated with accelerated recovery of multiorgan and microcirculatory dysfunction, mitigated inflammatory response, less bleeding complications, and lower risk for early mortality in comparison with controls.

Impact of intraoperative cytokine adsorption on outcome of patients undergoing orthotopic heart transplantation-an observational study.

AIM: The aim of this study was to assess the influence of intraoperative cytokine adsorption on the perioperative vasoplegia, inflammatory response and outcome during orthotopic heart transplantation (OHT). METHODS: Eighty-four OHT patients were separated into the cytokine adsorption (CA)-treated group or controls. Vasopressor demand, inflammatory response described by procalcitonin and C-reactive protein, and postoperative outcome were assessed performing propensity score matching. RESULTS: In the 16 matched pairs, the median noradrenaline requirement was significantly less in the CA-treated patients than in the controls on the first and second postoperative days (0.14 vs 0.3 µg*kg-1 *min-1 , P = .039 and 0.06 vs 0.32 µg*kg-1 *min-1 , P = .047). The inflammatory responses were similar in the two groups. There was a trend toward shorter length of mechanical ventilation and intensive care unit (ICU) stay in the CA-treated group compared to the controls. No difference in adverse events was observed between the two groups. The frequency of renal replacement therapy was less in the CA­treated patients than in the controls. CONCLUSIONS: Intraoperative CA treatment was associated with reduced vasopressor demand with a favorable tendency in length of mechanical ventilation, ICU stay and renal replacement therapy. CA treatment was not linked to higher rates of adverse events.