case study
Ultrafiltration In A
High-Risk, Peri-Operative Setting Following Complex Cardiac Surgery
Chief Complaint
The patient was an 80 year old male who presented with shortness
of breath, signs of right heart failure, and ascites.
History of Illness
He had a right heart catheterization and right ventricular biopsy
to rule out restrictive cardiomyopathy and infiltrative diseases
of the heart. He had equalization of pressures suggestive of pericardial
constriction. The patient had been on high dose diuretics and had
multiple abdominal paracenteses for drainage of ascitic fluid.
Peri-operative Details
He underwent a limited incision exploration of the pericardium because
of the presence of a loculated pericardial effusion on echocardiography.
This was then converted to a complete median sternotomy. There were
dense pericardial adhesions and a radical stripping of the pericardial
was performed from phrenic nerve to phrenic nerve. The posterior
aspects of the myocardium were freed up to the inferior pulmonary
veins. He did well immediately post-operatively, but had a low urine
output despite a good cardiac output. Despite adequate blood pressure
and cardiac output, he developed oliguria and his creatinine started
to rise. He was extubated and was oxygenating well.
After the first 20 hours post-op, we ultrafiltered
him with the Aquadex FlexFlow (CHF Solutions Inc. Brooklyn Park,
MN). We were able to take between 50 and 120 mL of fluid off every
hour for 36 hours in the cardiac surgery ICU with a dramatic improvement
in urinary output. His creatinine fell to baseline and he was discharged
to the ward on the 4th post-operative day. He was then discharged
home within a week after surgery.
Discussion
Peri-operative fluid overload is common in cardiac surgery patients.
Many of them have been on diuretics for months if not years prior
to seeking medical attention and surgical intervention. Post-operative
renal failure carries a high mortality in cardiac surgery patients.
This patient illustrates the efficacy of ultrafiltration
in actually promoting urine output and allowing incipient renal
failure to actually regress. The mechanism of this might be debatable,
but the presence of tissue edema and higher right sided filling
pressures predispose to end-organ dysfunction
Case history courtesy of:
Jai Raman, M.D., FRACS, Ph.D.
Associate Professor of Surgery, Director of Research
The University of Chicago Medical Center
Chicago, Illinois
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