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Clinical Investigations: Cardiopulmonary BypassRelationship Between Preoperative Endotoxin Immune Status, Gut Perfusion, and Outcome From Cardiac Valve Replacement Surgery
Section snippets
Patient Selection
Fifty-nine patients undergoing first-time cardiac valve replacement at University College London Hospitals constituted the study population during a period from November 1993 to November 1994. Study approval was obtained from the local ethics committee. Written informed consent was obtained from all study patients. Exclusion criteria included the following: ongoing sepsis, esophageal or gastric abnormalities, pregnancy, coagulopathy, age younger than 18 years, participation in another
RESULTS
Fifty-nine patients were enrolled in the study. There was no significant difference between groups preoperatively above and below the median EndoCAb (100 MU/mL) of a healthy population in either IgG or IgM antibody class with regard to sex, age, weight, height, operating surgeon, total CPB time, and aortic cross-clamp time (Table 2).
However, the group that subsequently developed complications had a significantly higher (p<0.05) Parsonnet preoperative mortality risk score and spent a
DISCUSSION
High preoperative EndoCAb levels of both IgG and IgM classes appear to be protective against postoperative complications following cardiac valve surgery. All patients developing complications had IgM EndoCAb levels below the median value of a healthy population (100 MU). Similarly, all but one of these patients had IgG levels <100 MU.
Many patients with low preoperative EndoCAb levels subsequently went on to have an uncomplicated recovery, but it is recognized that many factors contribute to
CONCLUSION
While conventional risk scoring systems are useful for predicting those patients likely to develop complications following cardiac surgery, they do little to contribute toward the preoperative condition. The preoperative measurement of EndoCAb levels makes possible the targeting of a group of patients who may be unable to cope immunologically with a surgically induced endotoxin challenge and thus are at risk for perioperative complications. This information may allow manipulation by either
REFERENCES (32)
- et al.
Endotoxemia in human septic shock
Chest
(1991) - et al.
Presence of circulating endotoxin during cardiac operations
J Thorac Cardiovasc Surg
(1987) Antibodies to lipopolysaccharide
J Immunol Methods
(1995)Immunotherapy with antibodies to core lipopolysaccharide: a critical appraisal
Infect Dis Clin North Am
(1991)- et al.
Patterns of mortality in a surgical intensive care unit
Surg Gynecol Obstet
(1981) Surgical intensive care units
Introduction of new technology into critical care practice: a history of Ha-IA human monoclonal antibody against endotoxin
Crit Care Med
(1993)- et al.
Gram-negative bacteremia: III. Reassessment of etiology, epidemiology and ecology in 612 patients
Am J Med
(1980) Pathophysiologic response of the subhuman primate in experimental shock
Lab Invest
(1975)- et al.
Multi-organ damage resulting from faecal peritonitis
Clin Sci
(1989)
Endotoxemia and bacteremia during hemorrhagic shock: the link between trauma and sepsis?
Ann Surg
The cardiovascular response of normal humans to the administration of endotoxin
N Engl J Med
Microvascular effects of anaphylatoxins C3a and C5a
J Immunol
Direct evidence for Hageman factor (factor XII) activation by bacterial lipopolysaccharides
J Exp Med
The role of intestinal barrier failure and bacterial translocation in the development of systemic infection and multiple organ failure
Arch Surg
Effect of hemorrhagic shock on bacterial translocation, intestinal morphology and intestinal permeability in conventional and antibiotic-decontaminated rats
Crit Care Med
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