Effect of ultrafiltration on extravascular lung water assessed by lung ultrasound in children undergoing cardiac surgery: A randomized prospective study

- lung water assessed by lung ultrasound in children undergoing cardiac surgery: a.
- Background: Increased lung water and the resultant atelectasis are significant pulmonary complications after cardiopulmonary bypass (CPB) in children undergoing cardiac surgery.
- This study investigated whether conventional ultrafiltration during CPB in paediatric heart surgeries influences post-bypass extravascular lung water (EVLW) assessed by lung ultrasound (LUS)..
- Conventional ultrafiltration targeting a haematocrit (HCT) level of 28% was performed on the ultrafiltration group, while the control group did not receive ultrafiltration.
- LUS scores were recorded at baseline and at the end of surgery.
- The PaO2/FiO2 ratio (arterial oxygen tension divided by the fraction of inspired oxygen), urine output, and haemodynamic parameters were also recorded..
- Results: LUS scores were comparable between the two groups both at baseline ( p = 0.92) and at the end of surgery ( p = 0.95).
- however, within the same group, the scores at the end of surgery significantly differed from their baseline values in both the ultrafiltration ( p = 0.01) and non-ultrafiltration groups ( p = 0.02)..
- The baseline PaO2/FiO2 ratio was comparable between both groups.
- at the end of surgery, The PaO2/FiO2 ratio increased in the ultrafiltration group compared to that in the non-ultrafiltration group, albeit insignificant ( p = 0.16)..
- no correlation between the PaO2/FiO2 ratio and LUS score was found at baseline (r.
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- In children, increased lung water and the resultant atel- ectasis are significant pulmonary complications after car- diac surgery with cardiopulmonary bypass (CPB).
- interstitial oedema may lead to changes in the intrinsic elastic properties of the lung parenchyma during CPB.
- In combination with the action of constrictor mediators, oedema produces an obstruct- ive process in the bronchi leading to both atelectasis and bronchospasm [2].
- Paediatric patients are more sensitive to factors like anticoagulation, haemodilution, hypothermia and the ex- posure of blood to non-endothelialised surfaces.
- Which initiate a systemic inflammatory response that increases the total body water and extravascular lung water (EVLW) [5]..
- In the current research we studied the effect of ultrafiltration during CPB on post-bypass EVLW using LUS and its effect on oxygenation.
- To the best of our knowledge, no previous study has assessed the effect of conventional ultrafiltration during CPB on EVLW by using bedside LUS in children undergoing cardiac surgery..
- Included in the study were 60 patients with congenital heart disease (ASA II-III), age ranged from 1 to 48 months, and with body weight >.
- Anaesthesia was maintained by expired sevoflurane 0.3–2% in the oxygen-air mixture (1:1 flow ratio) to obtain an FiO2 of 60%.
- The tidal volume was maintained at 8 to 10 mL/kg, and the positive end-expiratory pressure (PEEP) was 4 cmH2O.
- A small inci- sion at the interatrial septum facilitated the insertion of the left atrial vent to vent the left heart.
- Blood was added to the priming solution to achieve a haematocrit (HCT) of 28% at the start of CPB.
- Furosemide 1 mg//kg was given after initiation of the bypass.
- Conventional ultrafiltration was performed after placement of the haemoconcentrator D575 with DHF02 (Sorin Group Italia, s.r.l., LIVANOVA) with its inlet connected to the arterial line and outlet to the cardiotomy or to the venous reservoir.
- After the initiation of CPB and stabilization of the haemo- dynamics according to the standardized parameters, hemofiltration was started and continued for up to 10 min before weaning from CPB to maintain the HCT value at 28%..
- After surgical repair, de-airing, rewarming and aor- tic declamping were performed, and the lungs were recruited with a continuous positive airway pressure (C-PAP) of 30 cmH2O for 40 s.
- Dobutamine 5–10 μg/kg/min, nitroglycerin 1–4 μg/kg/min, adrenaline 0.01–0.05 μg/kg/min or milrinone 0.2–0.5 μg/kg/min were used according to the pathophysiology and the intraoperative state of the patient.
- The final LUS score of the patient was the sum of each regional ultrasound score ranging from 0 to 36.
- The LUS score was recorded at baseline 5 min after induc- tion of anaesthesia and at the end surgery after skin closure..
- The primary endpoint of the current study was the LUS score at the end of surgery.
- The PaO2/FiO2 ratio (arterial oxygen tension divided by the fraction of in- spired oxygen) and haemodynamic parameters (heart rate, blood pressure) at baseline and at the end of sur- gery were also recorded.
- The volume of ultrafiltrate and urine output were also recorded at the end of surgery and day 1 (D1) postoperatively.
- Urea and creatinine were recorded at baseline and D1 in the intensive care unit (ICU).
- A general linear model was performed for between-group comparisons of lung scores and the PaO2/FiO2 ratio, and the same model with age adjustment as the covariate was applied for paired analysis of the same group variables.
- Corre- lations between the PaO2/FiO2 ratio and LUS score were determined using the Pearson moment correlation equation.
- Data for 10 pa- tients from our centre showed that the mean ± SD of the lung score of these patients subjected to non- ultrafiltration was 13.1 ± 5.
- Seventy participants aged four to 48 months were en- rolled in the study.
- The median and IQR of LUS scores in the ultrafiltra- tion and non-filtration groups were assessed at baseline vs and at the end of sur- gery vs .
- Relative to the base- line, the paired analysis revealed that lung scores at the end of the surgery were significantly lower, indicating an improvement of lung scores in both the ultrafiltration (p = 0.01) and non-ultrafiltration groups (p = 0.02).
- How- ever, the LUS scores were comparable between the two groups both at baseline (p = 0.92) and at the end of sur- gery (p = 0.95) (Fig.
- The baseline PaO2/FiO2 ratio was comparable be- tween the ultrafiltration and non-filtration groups at baseline vs and at the end of sur- gery vs 248 ± 125).
- The PaO2/FiO2 ratio.
- increased at the end of surgery in the ultrafiltration group compared to that in the non-ultrafiltration group, but there was no significant difference (p = 0.16) (Fig.
- There was no correlation between the PaO2/FiO2 ra- tio and LUS scores at baseline readings (r.
- At the end of surgery, a negative correl- ation was illustrated (r.
- Between groups, urea and creatinine were comparable at baseline (ultrafiltration vs non-filtration.
- 1 CONSORT flow diagram showing the number of patients at each phase of the study.
- Ultrafiltration group ( N = 30) Non-filtration group ( N = 30) P value.
- Intraoperatively, urine output was comparable between the ultrafiltration group mL) and the non- filtration group mL, p = 0.11) and remained so at D1, being 321 ± 175 mL in the ultrafiltration group and 400 ± 145 mL in the non-filtration group, with p = 0.06..
- Two patients in the non-filtration group developed mild lung congestion defined by increased bilateral basal crepitations with in- creased broncho-vascular markings on chest X-ray.
- Two patients in the ultrafiltration group developed mild chest infection diagnosed by increased chest secretions with a change in sputum colour and fever up to 38.5 °C.
- In the current study, the lung U/S score showed no sig- nificant difference between the ultrafiltration and non- filtration groups despite the improvement in the scores at the end of surgery compared to those at the beginning of surgery in both groups.
- Additionally, in the filtration group, the PaO2/FiO2 ratio insignificantly increased at the end of surgery compared to patients who did not undergo filtration on CPB..
- This reduction is significantly connected to the weight loss encountered during dialysis, emphasising a direct relationship be- tween pulmonary B-lines and fluid balance..
- [17] showed that in paediatric patients the combined use of balanced and modified ultrafiltra- tion could effectively increase the concentration of the blood, alter the increase in detrimental inflammatory mediators, attenuate the lung oedema and inflammatory pulmonary injury together with mitigation of the pul- monary function impairment.
- The Huang explanation was that conventional ultrafiltration is a useful mean for decreasing fluid accumulation in the lungs, but it is not a satisfactory method in the paediatric population be- cause of the lower volume in the venous reservoir.
- Ultrafiltration group (N = 30) Non-filtration group (N = 30) P value.
- Operations Ultrafiltration group ( N = 30) Non-filtration group ( N = 30).
- the patients’ blood content 2 to 3 times due to their small circulating volume, whereas it only equals 1/3 to 1/4 of the total blood volume in the adult population..
- This dilution can be reduced by decreasing the number of crystalloids and adding blood to the priming fluid, by using diuretics or by using ultrafiltration.
- Two recent studies [19, 20] showed that the advantages of modified ultrafiltration over conventional ultrafiltration are only applicable to the immediate post- bypass period but not to the postoperative outcome pa- rameters.
- In the last decade, very few studies have re- vealed the benefits of ultrafiltration in paediatrics because priming with blood increases the HCT and the ultrafiltration rate is inversely proportional to HCT.
- In the early 1990s, the protocol was an HCT of 24% for CPB, but now, perfusionists employ an HCT of 28% or even more for CPB.
- This difference in the HCT makes the use of ultrafiltration less efficient [21].
- 2 LUS score at baseline and at the end of surgery.
- 3 PaO2/FiO2 ratio at baseline and at the end of surgery.
- The improvement of the lung score at the end of the operation compared to the beginning of the operation could be attributed to the manual ventilation with high inspiratory pressure at the end of the bypass to recruit collapsed lungs.
- Another main factor for improvement may be CHD repair and the elimination of pulmonary circulation overload and lung congestion.
- The use of di- uretics after bypass may have also decreased plasma water in the alveolar interstitial space, thereby increasing pulmonary compliance and improving gas exchange across the respiratory membrane, which in turn might have been responsible for the improved PaO2/FiO2 ratio and the lung score at the end of operation compared to those at baseline..
- [22], the actual level in the reservoir remains very close to the alarm level, and thus, any filtration during bypass decreases the volume of the total circuit (patient and prime), resulting in the reduction of the actual fluid level in the venous reservoir already close to the alarm level.
- This means that more fluid must be added to the circuit, thereby negating the potential effects of ultrafil- tration.
- Although no pulmonary data were measured in their study, this theory could explain the comparable lung scores at the end of the operation in the current study groups..
- LUS can also predict the volume and severity of EVLW, as there is a linear rela- tionship between lung water and the number of B-lines..
- 4 Correlation between the PaO2/FiO2 ratio and LUS score at baseline.
- 5 Correlation between the PaO2/FiO2 ratio and LUS score at the end of surgery.
- Increased urea and creatinine levels at D1 compared to baseline values in both groups might be explained by the combined ef- fect of fluid administration and diuretic use postopera- tively in the ICU..
- In the current study, the PaO2/FiO2 ratio was nega- tively correlated with LUS scores, which agrees with the findings of Konstantinos Stefanidis et al.
- The non-ventilated regions in the dependent lung areas were significantly reduced when the PEEP increased from 5 to 10 to 15 cmH 2 O..
- No significant difference in haemodynamics was ob- served in either group due to the deliberate use of ino- tropes and vasoactive drugs to maintain haemodynamic stability throughout the study period..
- ideally, lung scores and PaO2/FiO2 ratios should have been recorded just before the start and at the end of bypass, but in the op- erating theatre environment, it would be impractical to.
- Conventional ultrafiltration did not alter EVLW when assessed by LUS and the oxygenation state.
- EVLW: Extravascular lung water.
- Pao2/Fio2 Ratio: Arterial oxygen tension divided by the fraction of inspired oxygen.
- ME conceived of the study and participated in its design.
- MAM participated in the design of the study and drafted the manuscript.
- AAAM participated in the data collection and helped draft the manuscript.
- AH, AN, AL, HMH, and PH participated in the data collection.
- MW and AKM participated in the design of the study.
- They did not have any influence on study design, data collection, analysis and interpretation of study data, or writing of the manuscript..
- Table 4 Mean (SD) of the haemodynamic parameters Ultrafiltration group.
- At the end.
- Modified and conventional ultrafiltration during pediatric cardiac surgery, clinical outcomes compared.
- Ultrasound examination of the lungs in the intensive care unit.
- Prognostic value of extravascular lung water assessed with lung ultrasound score by chest sonography in patients with acute respiratory distress syndrome.
- Accuracy of lung ultrasonography versus chest radiography for the diagnosis of adult community-acquired pneumonia: review of the literature and meta-analysis

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