CASE SERIES IN POSTOPERATIVE CARDIAC SURGERY PATIENTS

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1 2 nd International User Meeting October 2, 2015 Berlin Prof. Dr. Karl Träger Cardiosurgical ICU Dept. of Cardiac Anesthesiology University Hospital Ulm Albert-Einstein-Allee 23, Ulm GERMANY CASE SERIES IN POSTOPERATIVE CARDIAC SURGERY PATIENTS

2 Cardio-Pulmonary-Bypass (CPB) as a paradigm of an inflammatory insult Cytokine storm Pro-Inflammation Anti-Inflammation TOXIC death Organ failure recovery Time (days / weeks) 17

3 Overwhelming SIRS post CPB SIRS - the systemic inflammatory response syndrome after cardiac operations Taylor KM, Ann Thorac Surg 1996, 61:1607 Pathophysiology Inflammatory stimuli Surface contact Inflammatory cytokine release DAMPs Clinical symptoms Hypotension Vasoplegia Capillary leakage Pulmonary Dysfunction Renal Dysfunction Therapeutic approaches MECC (minimalized extracorporeal circulation) Hemofiltration during CPB Steroids Catecholamines Vasopressin MODS Hemoadsorption

4 Strategies to manage overwhelming SIRS post CPB Prophylaxis Preemptive treatment Treatment (ICU) Catecholamines Steroids Fluids Organ support therapy Cytokine elimination Cytokines in the systemic inflammatory response syndrome: a review Jaffer U et al: HSR Proc Intensive Care Cardiovasc Anesth 2010, 2:161

5 Controlling cytokine storm during SIRS and SEPSIS by ADSORPTION () EFFICACY Reducing increased cytokine levels Reduced cytokine production REGISTERED CYTOKINE ADSORBER (EUROPE) SAFETY High biocompatibility (ISO 10993) FAST SETUP AND EASY HANDLING Use with conventional CRRT devices Whole blood hemoperfusion REIMBURSEMENT

6 Controlling cytokine storm in the cardiosurgical patient Preemptive approach Therapeutic approach During CPB Adjunctive therapy postoperative / ICU

7 treatments: different indications During during CPB 20% septic shock 18% VA ECMO 22% What are the effects on Cytokine levels Clinical parameters SIRS post CPB 40%

8 Behandlungen bei SIRS post CPB DURATION [MIN] mean max 50 0 CPB duration CPB Zeit Cross clamp min min mean max Cross clamp Mean 207 min Range min Mean 119 min Range min

9 Treatment in SIRS post CPB SURVIVORS (n=10) und NON-SURVIVORS (n=6) Mean Minimum Maximum Treatment time [h] Time per adsorber [h] 30 1,5 50 Treatment time SURVIVORS Treatment time NON-SURVIVORS

10 treatment in SIRS post CPB Effects on cytokine levels? Effects on inflammatory parameters? Effects on clinical parameters?

11 IL6 after treatment in SIRS post CPB

12 IL6 after treatment in SIRS post CPB

13 IL8 after treatment in SIRS post CPB

14 IL8 after treatment in SIRS post CPB

15 CRP after treatment in SIRS post CPB

16 treatment in SIRS post CPB Effects on cytokine levels? Effects on inflammatory parameters? Effects on clinical parameters?

17 Hemodynamic parameters during treatment in SIRS post CPB

18 Hemodynamic parameters during treatment in SIRS post CPB

19 Hemodynamic parameters during treatment in SIRS post CPB

20 Noradrenaline dose during treatment in SIRS post CPB

21 Noradrenaline dose during treatment in SIRS post CPB

22 Adrenaline dose during treatment in SIRS post CPB

23 Lactate during treatment in SIRS post CPB

24 SAPS II before and after treatment in SIRS post CPB

25 APACHE II before and after treatment in SIRS post CPB

26 Other effects of treatment Elimination of Free hemoglobin, 35 KD Myoglobin, 17 kd Bilirubin, 8 KD

27 Elimination of free hemoglobin during treatment Case 14: m, 76 free hemoglobin during treatment 1800 free hemoglobin [mg/l] FHB_BASE 12H 24H 36H 48H Treatment time

28 Future perspective: treatment in cardiac surgery

29 Registry Coordination: ZKS, Centre for Clinical Studies, University Hospital Jena (Prof. Dr. F.M. Brunkhorst)

30 POTENTIAL EFFECTS? Decreased capillary leak? Better organ recovery? Outcome CYTOSORB THERAPY ACHIEVABLE EFFECTS WITH THERAPEUTIC AND PREEMPTIVE USE Reduction of cytokine levels Mitigation of cytokine storm Maintained immune response Faster stabilization of clinical parameters hemodynamic metabolic

31 treatment in cardiac surgery SIRS post CPB Septic schock Severe reperfusion Severe hemolysis Acute endocarditis Local infections Complex and long lasting surgery Long CPB and X-clamp time Re-do

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