Prevention of remote organ injury in cardiopulmonary bypass: the impact of flow generation technique.

The purpose of this study was to investigate the effects of 3 different types of flow generation for cardiopulmonary bypass on gastrointestinal permeability and on neutrophil expression of CD11b, a surface marker of neutrophil activation. Fourteen patients undergoing elective coronary revascularization were selected randomly to receive 1 of the 3 flow generation techniques (roller, pulsatile, or centrifugal). Intestinal permeability was assessed by the fraction of an oral dose of 51chromium-ethylenediaminetetraacetate (51Cr-EDTA) recovered in the urine over 24 h. Neutrophil activation was determined by expression of CD11b markers at 6 time points. Overall, the 14 patients showed significant increases in intestinal permeability. It was not possible to demonstrate statistically significant differences among the flow generation groups; however, when compared to both roller pump groups, the centrifugal pump group showed a 3.2% reduction in intestinal permeability. There was no change in the expression of CD11b receptors throughout the time points, nor was there a relationship of CD11b markers to the flow generation technique.

Intestinal permeability, gastric intramucosal pH, and systemic endotoxemia in patients undergoing cardiopulmonary bypass.

OBJECTIVE: To examine the relationship between gastric intramucosal pH, intestinal permeability, endotoxemia, and oxygen delivery in patients undergoing cardiopulmonary bypass (CPB). DESIGN: Prospective, observational study. SETTING: Tertiary care center. PATIENTS: Fifty patients undergoing elective cardiac surgery and 10 patients awaiting elective cardiac surgery. INTERVENTIONS: Patients received chromium 51-labeled ethylenediaminetetraacetic acid (51Cr-EDTA) as a marker of intestinal permeability; insertion of a nasogastric tonometer to measure intramucosal pH (pHi); insertion of a pulmonary artery catheter to measure systemic oxygen delivery and consumption variables; arterial blood sampling for plasma endotoxin by the Limulus amebocyte lysate assay; and blood and urine sampling for measurement of 51Cr-EDTA. MAIN OUTCOME MEASURES: Systemic oxygen delivery, duration of gastric mucosal acidosis, absorption of 51Cr-EDTA, appearance of systemic endotoxemia, renal dysfunction, and duration of hospital stay. RESULTS: Median (range) 24-hour urinary recovery of 51Cr-EDTA in patients was 10.6% (2.1% to 40.2%) while that in controls was 1.2% (0.7% to 2.0%, P<.001). Intestinal permeability increased during CPB. The median (range) for the lowest pHi after bypass was 6.98 (6.74 to 7.17). The pHi did not decline until CPB was discontinued and the heart took over the load of the circulation. Endotoxin was detectable (>0.2 endotoxin unit per milliliter) in the plasma of 21 patients (42%) during the study, most of whom were endotoxemic by the end of CPB. There was no evident relationship between the degree of gut permeability, endotoxemia, gut ischemia, or systemic oxygen dynamics. CONCLUSIONS: Cardiopulmonary bypass is associated with increases in gut permeability, which precede gut mucosal ischemia. In cardiac surgical patients, a low pHi is not necessarily indicative of an adverse clinical outcome. Endotoxemia as measured by the Limulus amebocyte lysate assay is common. The increased intestinal absorption of 51Cr-EDTA and gastric mucosal acidosis occur as independent phenomena and are not related in severity or time of onset.

Measuring carbon dioxide tension in saline and alternative solutions: quantification of bias and precision in two blood gas analyzers.

OBJECTIVE: To quantify the precision and bias for two standard blood gas analyzers when measuring PCO2 in five different test solutions (blood, normal saline, human albumin solution, succinylated gelatin 4%, and Hartmann's solution). DESIGN: A comparative laboratory study of two blood gas analyzers measuring known PCO2 in test solutions prepared with a thin film tonometer. MEASUREMENTS: The PCO2 was determined simultaneously in both blood gas analyzers. The precision and bias for both machines were calculated from the measured PCO2. RESULTS: Analyzer 1 showed a negative bias of between 66.4% and 39.2% when measuring PCO2 in saline. Under the same conditions, analyzer 2 showed a negative bias of between 17.7% and 17.9% for PCO2 in the mid- and high ranges of PCO2, but a positive bias in the low range. Both machines measured PCO2 with satisfactory bias and precision in blood. The use of succinylated gelatin 4% as a test solution improved the bias and precision of both machines. CONCLUSIONS: Because of the large bias and precision, neither of these machines is suitable for measuring PCO2 in saline solution. The use of succinylated gelatin 4% as a test solution improves the bias and precision of both machines and we favor this solution for nasogastric tonometry. Even with succinylated gelatin 4%, there is a large negative bias with analyzer 1 and our preference is to use analyzer 2. We recommend that other workers review critically the performance of blood gas electrode systems when measuring PCO2 in saline solution. Because of varying performance of "standard" machines, we also recommend that each institution determine its own reference range for intramucosal pH.