Comparison GDP and conventional CPB impact on metabolism in cardiac center Sardjito general hospital

Bhirowo Yudo Pratomo; Sudadi Sudadi; Budi Yuli Setianto; Tandean Tommy Novenanto; Fiandila Elvana; Amar Rayhan; Juni Kurniawaty

doi:10.12688/f1000research.156333.1

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Research Article

Comparison GDP and conventional CPB impact on metabolism in cardiac center Sardjito general hospital

[version 1; peer review: 2 not approved]

Bhirowo Yudo Pratomo¹, Sudadi Sudadi¹, Budi Yuli Setianto², [...] Tandean Tommy Novenanto³, Fiandila Elvana³, Amar Rayhan^1,4, Juni Kurniawaty¹

Bhirowo Yudo Pratomo¹, Sudadi Sudadi¹, [...] Budi Yuli Setianto², Tandean Tommy Novenanto³, Fiandila Elvana³, Amar Rayhan^1,4, Juni Kurniawaty¹

PUBLISHED 24 Sep 2024

Author details Author details

¹ Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Dr. Sardjito General Hospital, Universitas Gadjah Mada, Yogyakarta, Special Region of Yogyakarta, Indonesia
² Department of Cardiology, Faculty of Medicine, Public Health and Nursing, Dr. Sardjito General Hospital, Universitas Gadjah Mada, Yogyakarta, Special Region of Yogyakarta, Indonesia
³ Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Special Region of Yogyakarta, Indonesia
⁴ Faculty of Medicine, Universitas Diponegoro, Semarang, Central Java, Indonesia

Bhirowo Yudo Pratomo
Roles: Conceptualization, Data Curation, Funding Acquisition, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Sudadi Sudadi
Roles: Conceptualization, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Budi Yuli Setianto
Roles: Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Tandean Tommy Novenanto
Roles: Conceptualization, Investigation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Fiandila Elvana
Roles: Formal Analysis, Methodology, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Amar Rayhan
Roles: Formal Analysis, Methodology, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Juni Kurniawaty
Roles: Conceptualization, Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Abstract*

Background

Goal-directed perfusion (GDP) aims to balance oxygen delivery (DO2) and consumption (VO2) in cardiac surgery. Elevated lactate during CPB is common and linked to higher morbidity and mortality. Evaluating lactate with base excess (BE) is vital due to their relationship. Reducing severe BE and lactate predicts cardiac surgery outcomes better.

Methods

Fifty adult patients undergoing cardiac surgery with CPB were randomly assigned to either the GDP group or the conventional group. In the GDP group, the priming solution was adjusted to target a hematocrit (HCT) level of 24 to 27% with a pump flow of 1.8 to 2.2 L/min/m2 to maintain mean arterial pressure (MAP) between 60 and 65 mmHg. The primary outcomes was oxygen delivery index (DO2i).

Results

There were increasing trends in lactate levels and decreasing trends in BE levels at all timeframes. The GDP mean difference of lactate [1.504 (1.52); p < 0.001] and BE [-0.87 (2.93); p = 0.22] levels showed better value in the GDP group, with statistically significant increased values in the control group for BE [-1.667 (2.93); p = 0.017] and lactate levels [2.215 (2.919); p < 0.001]. The postoperative outcome showed a significant difference in AKI and ventilator time.

Conclusions

The GDP low flow CPB compared with conventional flow CPB maintained DO2 matched with VO2 with a better clinical values in the lactate and BE levels and significantly lowered AKI and ventilator duration in cardiac surgery.

Keywords

cardiopulmonary bypass, goal directed perfusion, lactate, base excess, metabolic acidosis

Corresponding author: Bhirowo Yudo Pratomo

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Yudo Pratomo B et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Yudo Pratomo B, Sudadi S, Yuli Setianto B et al. Comparison GDP and conventional CPB impact on metabolism in cardiac center Sardjito general hospital [version 1; peer review: 2 not approved]. F1000Research 2024, 13:1092 (https://doi.org/10.12688/f1000research.156333.1) First published: 24 Sep 2024, 13:1092 (https://doi.org/10.12688/f1000research.156333.1) Latest published: 24 Sep 2024, 13:1092 (https://doi.org/10.12688/f1000research.156333.1)

Introduction

The utilization of cardiopulmonary bypass (CPB), which has been developed and evolving since the 19th century to the present day, has made cardiac surgery more comfortable and feasible.¹ However, due to the contact between blood with non physiologist extracorporeal circuit CPB, non-pulsatile blood flow, hemodilution, hypothermia, ischemia-reperfusion injury, and the use of anticoagulants. These can have systemic impacts on hemolysis, inflammation and organ demage.² The most common complications arise from inflammation and hemolysis, due to shear stress, which can occur from during the operation to post-operation, especially in prolonged CPB.¹^–³ In addition to those, hyperlactatemia, caused by inadequate delivery of oxygen (DO₂) to meet tissue oxygen consumption (VO₂), is also a main concern in CPB. When cells are unable to produce aerobic energy, they undergo anaerobic metabolism and produce lactic acid in oxygen deficit condition.⁴ Hyperlactatemia during CPB is frequent directly linked to higher rates of morbidity and mortality.³ This condition have a corelation with base excess (BE) concentration, which represents the deviation of actual bicarbonate concentration in the blood from a standard reference value. The accumulation of lactate, being a potent anion, disrupts ion balances, resulting in a reduction of BE.⁵

The principle of maintaining a balance between DO₂ and VO₂ is termed goal-directed perfusion (GDP). The normal of VO₂ is 260-270 ml/min/m² deterioration in outcomes due to anaerobic metabolism, maintaining a minimum DO₂ requirement above 260-270 ml/min/m² is essential for perfusionist to ensure DO₂ match with the VO₂.³^,⁶ GDP is an implementation of goal-directed therapy, a strategy aimed at improving patient outcomes by employing aggressive and intensive treatment with optimized hematocrit (HCT), cardiac output maintenance, fluid, inotropic and vasopressor ussage with advanced monitoring to control normal tissue perfusion.⁷ GDP linked to the best long-term patient outcomes, including increased rates of survival and improved performance in all major organ systems. This strategy reduces morbidity and speeds up the healing process after surgery.⁶^,⁸

Previous studies noted a limitation that did not reporting lactate levels during CPB.⁹^,¹⁰ The strong association between hyperlactatemia and poor outcomes post-cardiac surgery reported in earlier research.¹¹^,¹² Another study highlighted lactate’s correlation with BE, suggesting the need to interpret both together due to BE being a derived parameter.¹³ Reducing severe BE has a better predictor for postoperative cardiac surgery outcome.¹⁴

Due to the limited number of clinical studies on GDP, the researchers propose that the objective of this study is to evaluate the metabolic outcomes patients undergoing cardiac surgery with CPB. Consent with shear stress in CPB aim this study to compare use of GDP low flow CPB with the conventional protocol CPB to make optimal DO₂ match with oxygen metabolism. Lactate and BE will be utilized as targeted monitor of oxygen metabolism cells.

Methods

This study was approved by the Universitas Gadjah Mada Ethics Committee (reference approval number KE/FK/0232/EC/2023) and was registered on the International Traditional Medicine Clinical Trial Registry (ISRCTN 17452821) on April 4, 2023. Informed written consent was obtained from all participants.

Study design and participants

This randomized double-blind controlled trial was conducted at Dr. Sardjito General Hospital, Yogyakarta, from July to October 2023. The study included patients aged 18–65 years, classified as NYHA class 1-2, and weighing between 40 and 100 kg, who were scheduled for cardiac surgery with CPB. Exclusion criteria included patients requiring preoperative extracorporeal circulation, intra-aortic balloon pump (IABP), hemodialysis, renal replacement therapy, or intraventricular assist devices, as well as those undergoing emergency or urgent cardiac surgeries. Cardiac surgeries with a CPB time of less than 60 minutes were also excluded.

Fifty patients were randomized using a consecutive double-block randomization method into two groups: GDP and control, with 25 patients in each group. The randomization list was kept in sealed envelopes, ensuring that both patients and outcome assessors were blinded to the group assignments.

Surgical and anesthesia protocol

Cardiac surgeries were performed by two experienced surgeons, anesthesiologists, and perfusionists. All patients underwent open-heart surgery with CPB, including coronary artery bypass grafting (CABG), valve repair, and defect closure, following the institutional protocol. Median sternotomy was used as the surgical approach. Continuous arterial line monitors and central venous catheters were installed, with pulmonary artery catheters (PAC) used as needed. All patients received premedication with fentanyl 3-4 μg/kg, followed by induction with propofol 1-2 mg/kg and rocuronium 0.6 mg/kg. Anesthesia was maintained with 50% oxygen in the air, 1-2% sevoflurane, fentanyl 4 μg/kg/hr, and rocuronium 1 mg/kg/hr.

Cardiopulmonary circuit protocol

The CPB protocol was standardized for all patients, using the Livanova Stockert S5 machine (Sorin Group Japan Co., Ltd.) and a CAPIOX FX oxygenator with an integrated arterial filter (Terumo Cardiovascular Group). CPB was initiated after administering heparin at a dose of 3 mg/kg body weight, ensuring an activated clotting time (ACT) exceeding 480 seconds. Both groups received mannitol at 2.5 cc/kg, sodium bicarbonate at 30 mEq, methylprednisolone at 20 mg, 50 cc of 20% albumin, heparin at 5000 IU, and tranexamic acid at 50 mg/kg, according to protocol. Myocardial protection was achieved using 2000 cc of Custodiol Histidine-Tryptophan-Ketoglutarate (HTK) as crystalloid cardioplegia. Protamine was administered post-CPB, along with 50 cc of 20% albumin. Patients were then transferred to the Intensive Care Unit (ICU) for mechanical ventilation and standard postoperative care.

Standard perfusion and GDP protocol

The GDP protocol focused on dynamically adjusting the CPB pump flow to achieve target DO₂ levels. The priming fluid in the GDP group was acetated Ringer’s solution, adjusted based on body weight to maintain a HCT of 24–27% or hemoglobin levels of 7.5–9 g/dl. Body temperature was maintained between 30–33°C. Pump flow rates were adjusted to 1.8–2.2 L/min/m² to meet target DO₂ levels, with mean arterial pressure (MAP) maintained >65 mmHg using norepinephrine (0.1–0.2 μg/kg) as necessary. This approach differs from conventional perfusion, which uses fixed pump flow rates based on body surface area (BSA) without dynamic adjustment according to DO₂ targets.

Data collection and analysis

Demographic information, involving age, gender, comorbidities, and relevant patient characteristics, will be systematically collected to offer a comprehensive overview of the study population. This comprehensive data collection approach aims to provide a thorough understanding of the study’s primary and secondary outcomes, allowing for a comprehensive analysis of the impact of the intervention on various physiological parameters and patient recovery. The primary outcome measures were oxygen delivery index (DO₂i). Secondary outcome measures include the evaluation of cardiac index (CI), and metabolic parameters such as BE and lactate levels that will be monitored at critical time points, namely pre-CPB (T0), 30-minutes CPB (T1), 60-minutes CPB (T2), 90-minutes CPB (T3), post-CPB (T4), and upon entering the ICU (T5). Trends over time will be assessed to understand variations in metabolic levels during the surgical procedure.

Hemoglobin, HCT, CPB time, aortic cross clamp time, blood glucose, and creatinine levels. The study will also assess the duration of ventilator use and the length of stay (LOS) in the ICU. Acute kidney injury (AKI) was diagnosed using Kidney Disease: Improving Global Outcomes (KDIGO) 2012 criteria, which defined as a rising serum creatinine (SCr) levels by ≥0.3 mg/dl within 48 hours.¹⁵ We evaluated the SCr levels before and after CPB and determined the AKI status. Hyperlactatemia was defined as a blood lactate level >3 mmol/l. According to this level, hyperlactatemia was correlated with adverse outcomes in cardiac surgery. Lactate acidosis refers to hyperlactatemia patients with a pH lower than 7.35.¹⁶^,¹⁷

Data were presented as mean ± standard deviation for normally distributed variables, and median (interquartile range) for non-Gaussian variables. Categorical data were reported as numbers and percentages. Statistical analysis was performed using SPSS version 25 (IBM SPSS Statistics, New York, NY). An independent t-test was used for continuous variables with normal distribution, while the Mann-Whitney test was used for non-parametric data. Categorical data were compared using the chi-squared test. Mean differences between T0 and T2, and T0 and T5, were analyzed using a paired t-test or Wilcoxon test, as appropriate. Statistical significance was set at p < 0.05.

Results

From July 2023 to November 2023, fifty patients were enrolled in the study, with 25 allocated to the GDP group and 25 to the control group. Patient characteristics and clinical data showed no significant differences between the two groups (p > 0.05) (see Table 1). Intraoperative variables revealed a statistically significant difference in CI, with the control group showing a median of 2.74 (0.73) compared to the GDP group’s median of 2.27 (0.155) (see Table 2). Postoperative outcomes indicated a significant difference in acute kidney injury (AKI) incidence. Six patients in the control group exhibited a serum creatinine increase of 0.3 mg/dL post-CPB, whereas only one patient in the GDP group showed such an increase. Additionally, the median ventilator time was significantly lower in the GDP group (20 hours) compared to the control group (23 hours) (see Table 3).

Table 1. Demographic and baseline characteristics.

Variables	Mean (SD)/Median (IQR)		P-value
Variables	Control (n=25)	GDP (n=25)	P-value
Gender, n (%)			0.254
Male	12 (48%)	16 (64%)
Female	13 (52%)	9 (36%)
Age (years)	49.08 (14)	42.8 (12.96)	0.106
Body Height (cm)	160 (14)	161 (18)	0.307
Body Weight (kg)	59.72 (17.8)	61.24 (17.2)	0.761
BMI (kg/m²)	22.18 (8.125)	23.3 (6.285)	0.961
BSA (m²)	1.6176 (0.263)	1.6506 (0.278)	0.669
Risk factor, n (%)
Hypertension	9 (36%)	7 (28%)	0.544
Diabetes	4 (16%)	1 (4%)	0.157
History of cardiac surgery	0	1 (4%)	0.312
Others (obesity, smoking, stroke, dyslipidemia, arrythmia)	4 (16%)	9 (36%)	0.107
Hemoglobin (g/dL)	12.81 (1.69)	13.15 (1.6)	0.47
Hematocrit (%)	39.82 (5.02)	40.14 (4.67)	0.817
Creatinine (mg/dL)	0.91 (0.325)	0.96 (0.42)	0.225

Table 2. Intraoperative data.

Variables	Mean (SD)/Median (IQR)		P-value
Variables	Control (n=25)	GDP (n=25)	P-value
Surgery Type, n (%)			0.513
CABG	7 (28%)	7 (28%)
Valve repair/replacement	15 (60%)	12 (48%)
ASD/VSD closure	3 (12%)	6 (24%)
Maximum Flow Rate (L/min)	4.28 (1.78)	3.55 (1.55)	0.123
Flow Rate (L/min/m²)	2.74 (0.73)	2.17 (0.155)	0.008
DO2i (mL/min/m²)	400.29 (93.43)	356.82 (83.27)	0.05
CPB time (mins)	81 (44)	86 (34.5)	0.522
Aortic cross clamp time (mins)	64.5 (37.5)	63 (27.5)	0.669

Table 3. Postoperative outcome.

Variables	Mean (SD)/Median (IQR)		P-value
Variables	Control (n=25)	GDP (n=25)	P-value
AKI, n (%)	6 (24)	1 (4)	0.042*^a
Hyperlactemia, n (%)	8 (32)	6 (24)	0.529^b
Lactate Acidosis, n (%)	4 (16)	3 (12)	0.684^b
Hemoglobin (g/dL)	10.67 (1.48)	10.856 (1.24)	0.782^c
Hematocrit (%)	33.3 (7.15)	33.9 (5.95)	0.969^b
Creatinine (mg/dL)	1.01 (0.615)	1.06 (0.48)	0.823^b
Ventilator time (hours)	23 (20)	20 (9)	0.008*^b
ICU stay (hours)	79 (48)	80 (53)	0.607^b

* p-value mark as significant.

a p-value was analyzed using Chi Square.

b p-value was analyzed using Mann Whitney.

c p-value was analyzed using Independent T-test.

Lactate and BE values across all timeframes (T0–T5) did not differ significantly between the GDP and control groups (p > 0.05) (see Table 4, Figure 1 and Figure 2). However, lactate levels increased over time from the initiation of CPB (T1) to ICU arrival (T5) in both groups. Peak lactate levels during CPB were similar between the groups, with a median of 2.38 (1.555) in the control group and 2.01 (1.985) in the GDP group (see Figure 3). We also compared the change in lactate levels between two specific timeframes, T0 and T4. Both groups showed an improvement in the GDP group correlated to CPB time. The mean difference in lactate levels between T0 and T2 was similar in both groups (0.596 vs. 0.641). However, during 60 minutes of CPB, the post-CPB mean difference in lactate levels was greater in the control group than in the GDP group (1.504 vs. 2.215). Statistically significant differences were observed in BE and lactate levels in the control group (see Table 5 and Figure 4).

Table 4. Comparison blood lactate and base excess level.

Time	Mean (SD)/Median (IQR)		P-value
Time	Control group (n=25)	GDP group (n=25)	P-value
Lactate
Pre-CPB^b	0.88 (0.38-1.8)	1.1 (0.46-2.6)	0.143
30 mins^b	1.37 (1.1-2.68)	1.34 (0.88-2.7)	0.505
60 mins^b	1.47 (0.48-2.99)	1.59 (0.5-4.72)	0.557
90 mins^b	1.92 (0.36-4.56)	1.65 (0.5-3.4)	0.457
Post-CPB^b	2.38 (1.19-9.85)	2.32 (1.19-7.46)	0.789
ICU^b	4.9 (1.6-14.3)	3.9 (2-17.3)	0.634
Base excess
Pre-CPB^b	-2 (- 5)	-2 (-4)	0.666
30 mins^b	1 (-7-2)	2 (-3)	0.217
60 mins^b	-1 (- 7)	-2 (- 3)	0.461
90 mins^a	-3.083 (- 2.9)	-3.3 (-2.6)	0.859
Post-CPB^b	-3 (-2)	-3 (-2)	0.478
ICU^a	-4.844 (-4.5)	-3.772 (-4.4)	0.399

* p-value mark as significant.

a p-value was analyzed using Independent T-test.

b p-value was analyzed using Mann Whitney.

Figure 1. Blood lactate levels T0-T5.

Figure 2. Base excess levels T0-T5.

Figure 3. Mean of peak lactate levels.

Table 5. Mean difference of blood lactate and base excess level.

Time	Group	Mean Difference (SD)	p-value	Delta comparison	P value
Lactate
T0 and T2	GDP group	0.641 (1.021)	0.007^a*	0.641 vs 0.596	0.858^c
T0 and T2	Control group	0.596 (0.515)	<0.001^b*	0.641 vs 0.596	0.858^c
T0 and T4	GDP group	1.504 (1.522)	<0.001^b*	1.504 vs 2.22	0.285^d
T0 and T4	Control group	2.22 (2.196)	<0.001^b*	1.504 vs 2.22	0.285^d
Base Excess
T0 and T2	GDP group	-0.007 (3.779)	0.435^a	-0.007 vs 1.095	0.501^d
T0 and T2	Control group	1.095 (3.645)	0.184^b	-0.007 vs 1.095	0.501^d
T0 and T4	GDP group	-0.870 (3.228)	0.220^a	-0.870 vs -1.667	0.403^c
T0 and T4	Control group	-1.667 (2.938)	0.017^a*	-0.870 vs -1.667	0.403^c

* p-value mark as significant.

a p-value was analyzed using Paired T-Test.

b p-value was analyzed using Wilcoxon.

c p-value was analyzed using Independent T-test.

d p-value was analyzed using Mann Whitney.

Figure 4. Mean difference of blood lactate and base excess in two timeframse (T0 and T4).

Discussion

This study compared lactate levels at three time points: pre-, during, and post-CPB in cardiac surgery patients. Both groups showed similar results, with no significant differences in baseline characteristics, indicating that they were comparable. Our GDP protocol focused on optimizing DO₂ during CPB by adjusting flow rates (1.8–2.2 L/min/m²), hemodilution (HCT 24-27%), mild hypothermia (30–33°C), and maintaining a mean arterial pressure (MAP) >65 mmHg.

During CPB, the most fundamental hemodynamic change is the generation of cardiac output by the CPB pump instead of the patient’s heart. Perfusionists typically regulate the pump flow based on patient-specific factors such as height, weight, and core temperature. In this study, the CI and DO₂i during CPB significantly aligned with the set flow rates, indicating effective management of DO₂. Despite maintaining cardiac output and arterial pressure, CPB often results in decreased VO₂, making it crucial to match DO₂ with metabolic demands. However, increases in serum lactate levels and evidence of post-CPB organ dysfunction suggest potential impairments in tissue perfusion. Factors contributing to this may include arteriolar constriction, increased edema, loss of pulsatile flow, hypothermia-induced capillary changes, and microemboli formation.

Proposed methods to enhance microcirculatory function during CPB include the use of vasopressors or inotropes, hemodilution, mild to moderate hypothermia, maintaining systemic blood pressure, and setting the low flow rate that we applied in this study.¹⁸ A recent study reported an association between nadir HCT during CPB and lactate levels, with higher lactate values observed at lower nadir HCT levels. Conversely, the absolute risk of severe hyperlactatemia is 4.3% at a nadir HCT of 25% during CPB, increasing to 8.7% at a nadir HCT of 20% (a relative risk increase of 100%). Hemodilution during CPB is an independent determinant of hyperlactatemia. This association, more evident in cases of severe hyperlactatemia, supports the hypothesis that poor DO₂ during CPB, leading to organ ischemia, is the mechanism responsible for hemodilution-associated adverse outcomes.¹⁹

The protective effect of hypothermia is provided mainly by slowing the cellular metabolism and thus decreasing its VO₂ and energy demand. Metabolic protection offered by hypothermia enables safe circulatory arrest during cardiac surgical intervention. Blood viscosity increases with hypothermia and allows for the maintenance of a higher perfusion pressure despite hemodilution.¹²^,²⁰ A previous report revealed that patients with mild hypothermia during CPB experienced increased postoperative renal failure and a longer length of stay in the intensive care unit. Although there is no difference in long-term survival, mild hypothermia does not appear to provide significant benefit to patients compared with normothermia. The mild hypothermia was maintained at a temperature of around 32–35°C.²¹

Hyperlactatemia is strongly associated with poor outcomes after cardiac surgery, as reported in previous studies. Blood lactate concentration is one important clinical marker that can reflect the adequacy of systemic perfusion during cardiac surgery. Patients with hyperlactatemia should be treated by normalizing the global delivery of oxygen.¹¹^,¹² A previous study showed that severely reduced BE was a better predictor of post-cardiac surgery. Lactate levels upon ICU admission (3.9 mmol/l cutoff) and BE (-6.7 cutoff) were predictors of ICU mortality.¹⁴ Other studies reported lactate being correlated with BE, suggesting interpreting both together due to BE being a derived parameter.¹³

In previous goal-directed randomized controlled trials (RCTs), lactate levels were presented in different results and times, mainly postoperative.²²^–²⁵ The majority of comparisons of lactate levels were not significant, except one study reported significant differences at four different times, which were immediately after surgery, 6, 12, and 24 hours after ICU admission.²⁵ Even though the research had various lactate levels, the goal-directed group was the group with the lowest mean or median of blood lactate levels compared with the control group, as in the result of this study. A previous goal-directed cohort study reported a decrease in lactate levels after surgery in goal-directed groups.²⁶^–²⁸ Blood lactate was significantly lower than the control group but was similar 16 hours after the end of suturing.²⁸ In the early goal-directed therapy showed lactate levels decreased gradually from about 4 mmol/l to below 2 mmol, with a slight spike in 2 days after cardiac surgery.²⁷

GDP strategies were reported to have a better postoperative outcome than the control group. A recent study presented that GDP is not associated with a decrease in AKI. The GDP cohort performed significantly worse than the retrospective control group in terms of acute renal failure (ARF), mortality, intensive care unit readmission, and red blood cells and platelet transfusions.¹⁰ Post-CPB lactate in patients with developed AKI and non-AKI was similar.²⁶ Other studies showed different results that GDT strategies reduced AKI incidence and surgery outcome, which were similar to the recent study.²⁹ Perioperative GDP was also shortening the duration of ventilator usage.²²^,²⁵

We accepted that the main limitation of this study was the number of patients included. The differences were clear enough to present the GDP strategy of lowering lactate levels, which correlated with several positive outcomes. Nevertheless, this research provides the data that supports the GDP protocols to increase the clinical outcome of cardiac surgery. For further research, it is important to conduct a similar study with a larger-scale study design and add the additional outcome of inflammation and hemolysis to fulfill the development of goal-directed strategies in cardiac surgery.

In conclusion, Low flow CPB (GDP protocols) maintained DO₂ matched with VO₂ compared with conventional CPB (lactate and BE levels not significant different). GDP strategy that maintained the hemodynamic parameters with a controlled hemodilution, body temperature, and vasopressor or inotropic administration had a better tendency lactate and BE levels. GDP improved cardiac surgery with CPB patients outcome significantly lowered AKI and ventilator duration compared to conventional flow CPB.

Ethical considerations

This study followed the principles of the Declaration of Helsinki and was approved by the Medical and Health Research Ethics Committee at Universitas Gadjah Mada (Approval No. KE/FK/0232/EC/2023; Date of Approval: 14 February 2023). Written informed consent was obtained from all participants or their legal guardians, with assent from minors where applicable. Identifiable data were not published without consent, and anonymized data were used to protect privacy without affecting the scientific validity of the findings.

Data availability

Due to ethical considerations and the need to protect participant privacy, the data from this randomized controlled trial cannot be publicly shared. The data contain sensitive information that cannot be sufficiently de-identified. The Medical and Health Research Ethics Committee at Universitas Gadjah Mada has stipulated that data access may be granted upon reasonable request, subject to ethical approval and participant consent. Interested researchers can contact the authors for details on the application process, including the specific conditions under which access may be granted, such as research use only and compliance with confidentiality agreements.

Reporting guidelines

Open Science Framework: CONSORT Checklist and Flow Diagram: Comparison GDP and Conventional CPB Impact on Metabolism In Cardiac Center Sardjito General Hospital. https://doi.org/10.17605/OSF.IO/B6359.³⁰

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

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