1. CPB and Systemic Inflammation: Are We Doing It Right? Jefferson, MD.,Saeful, Ns Integrated Cardiovascular services Cipto Mangunkusumo Hospital Jakarta

2. Outline Introduction Mechanism and Patophysiology Therapeutic effort

3. Cardiopulmonary Bypass (ECC) Contact Activation of Complement system Bowel IschaemiaEndotoxinemia Bacterial TranslocationReperfusion Injury Macrophage Activation and Secretion of TNF ∝ Neutrophil/Endothelial adhesion + Migration Cytokines MOF Andropoulos. Anesthesia for Congenital Heart. Dis. 2nd edition. 2010

4. The Early Phase : Contact Activation 5 Cellular Components5 Humoral Components Endothelial Cells Neutrophils Monocytes Lymphocytes Platelets Contact system Intrinsic coagulation Extrinsic coagulation Complement Fibrinolysis Journal of Cardiothoracic and Vasc Anesth 2009. 23:(2)223-231

5. Humoral Component

6. Complement CPB

7. Mackay and Rosen. The Immune System. NEJM 2000

8. The Late Phase : Ischemia-Reperfusion injury Ischemic phase Endothelial injury Neutrophyl activation ROS Hydrogen peroxide Hydroxyl radicals Superoxide Anions Cell Damage Reperfusion phase Reintroduction to oxygen

9. The Late Phase : Endotoxin Gut ischemiaMucosal barrier injury Translocation of bacterial and or endotoxin Endotoxin Complement activation pro inflammatory cytokines release Activation of macrophages and other pro inflammatory cells NO release

10. Interventions designed to limit inflammatory response Preoperative Intestinal Decontamination (SDD) Preoperative inotropes Modification of circuit heparin-coating pulsatile flow ultrafiltration leukocyte filtration Pharmacological interventions Steroids Aprotinin Antioxidants Complement inhibitor

11. Our little simple data 30 patient tetralogy of fallot underwent total corrections are studied retrospectively between october 2011 to february 2012 15 pts were given single dose gentamycin for gut prophylaxis

12. Group Characteristic Genta (+) n=15 Genta (-) n=15 Age4.87 ± 2.976.81 ± 2.85 Weight11.84 ± 4.9416.78 ± 15.08 Height102.77 ± 13.58102.67 ± 34.65 McGoon1.96 ± 0.601.95 ± 0.60 Nakata309.29 ± 140.12310.89 ± 207.93 Xclamptime37.53 ±19.9633.93 ± 7.57 Bypasstime87.33 ± 28.6487.40 ± 25.51

13. Comparison of patient in both group with fever (1st day) fever (24 hrs) total yn Gentamycin y31215 n96 total1218 p = 0.06 using Chi square

14. Length of Stay, Time to Extubation, and mortality Gentamycin ynp Time to extubation 24 ± 1445.92 ±160.203 LOS ICU40.69 ± 2768.31 ± 740.219 Mortality221.000 Time to extubation and LOS ICU using t test and Mortality using chi square

15. Renal Function data Gentamycin p yn Ureum18.43 ± 2.52422.4 ±1.7010.099 Creatinine0.4 ±0.160.5133 ±0.050.119 Oliguria(+)6 / (-)9(+)8 / (-)70.358 Furosemide(+)11 / (-)4(+)10 / (-)50.500 Ureum Creatinine using t test, oliguria and frusemide using chi square

16. Things to emphasize Treatment modalities shows potency in terms of reducing inflammatory mediators Treatment modalities should be used in concert to treat multifaceted inflammatory response to bypass Outcome parameters in open heart surgery are multifactorial. Well management of cpb related systemic inflammation is only one factor. Probably this is the cause why it is difficult to correlate modification of inflammation and outcome.

17. THANK YOU