Article of the Month – September 2020

Current Practice of Calcium Use During Cardiopulmonary Bypass Weaning: Results of an International Survey

Authors: Lomivorotov VV, Guvakov D, Belletti A, Boboshko V, Shmyrev V, Kunst G, Stoppe C, Akselrod B, Kamenshchikov N, Efremov S, Chernyavskiy A, Landoni G.

URL: https://www.jcvaonline.com/article/S1053-0770(20)30132-4/fulltext

DOI: doi: 10.1053/j.jvca.2020.02.010.

Published: J Cardiothorac Vasc Anesth. 2020 Aug;34(8):2111-2115.

Click here to read the article for free, thanks to an agreement among EACTA and Elsevier

Article Description:

• The authors conducted a web-based international survey to better understand the current clinical practice on calcium use during weaning from CPB in adult patients undergoing cardiac surgery.
• The authors investigated demographic data (including respondent country, name, and type of the hospital, in addition to the number of surgeries and cardiac intensive care unit beds), indications, type of the drug, dosages, and mode of calcium administration and first-line inotropic or vasopressor drug used for CPB weaning. 
• Only one response representing the current practice was allowed from each hospital.
• Out of 112 surveys sent, 100 centers from 32 countries replied (a response rate of 89%). 

Summary:

• Various drugs including calcium salts are used to support hemodynamics during weaning from CPB in terms of increased cardiac index, stroke volume, and MAP.
• However, there are potential risks of systemic administration of calcium salts such as the “stone heart” phenomenon, pancreatic injury, and inhibition of inotropic effects of catecholamines.
• The number of adult cardiac surgery procedures under CPB varied from 50 to 5,500 per year with approximately half of responding centers performing 500 to 1,000 surgeries. 
• The vast majority of centers (88%) administer calcium salts intraoperatively as part of their clinical routine.
• Indications for using calcium salts can be summarized as follows;
• Correction of hypocalcemia (78%).
• For CPB weaning (71%), 66% of these respondents use calcium salts during normal weaning and 83% reserve using calcium salts for only difficult weaning from CPB. Twentythree percent reported that they use calcium salts as the second line of vaso-inotropic drug for weaning from the CPB
• After transfusion of blood components (54%).
• For optimization of hemostasis (33%).  
• Most of the respondents are using calcium chloride (66%).
• Doses of 5 to 15 mg/kg during the termination of CPB were used by 77% of centers either by bolus (55%) or over a time period longer than 1 minute (45%).
• The results of the survey might have been affected by the sampling error.
• Completion of the survey by one representative from each department may not represent the routine practice of the department.
• A large multicenter, randomized, double-blind, placebo-controlled trial (ICARUS trial) that is aimed to answer the question of whether calcium chloride is beneficial during weaning from CPB is currently underway (NCT03772990). 

Conclusion:

• In conclusion, the majority of cardiac centers use calcium in adult patients undergoing cardiac surgery, especially during weaning from CPB. There is variability in the type of drug, dose, and modality of drug administration.

Infographic

Thanks to prof. Vladimir Lomivorotov, Novosibirsk, Russia for the infographic slide