title: Endotoxemia related to cardiopulmonary bypass is associated with increased risk of infection after cardiac surgery: a prospective observational study.
abstract: BACKGROUND
  Previous studies have documented a high frequency of endotoxemia associated with cardiopulmonary bypass (CPB). Endotoxemia may be responsible for some of the complications associated with cardiac surgery. The purpose of the study was to examine the prevalence of endotoxemia during cardiopulmonary bypass supported aortocoronary bypass grafting surgery (ACB) using a new assay, the Endotoxin Activity Assay (EAA), and explore the association between endotoxemia and post-operative infection.
  
  
  METHODS
  The study was a single center prospective observational study measuring EAA during the perioperative period for elective ACB. Blood samples were drawn at induction of anesthesia (T1), immediately prior to release of the aortic cross-clamp (T2), and on the first post-operative morning (T3). The primary outcome was the prevalence of endotoxemia. Secondary outcomes assessed included infection rates, intensive care unit (ICU) and hospital length of stay. An EAA of < 0.40 units was interpreted as "low", 0.41 to 0.59 units as "intermediate", and ≥ 0.60 units as "high".
  
  
  RESULTS
  A total of 57 patients were enrolled and 54 patients were analyzable. The mean EAA at T1 was 0.38 +/- 0.14, at T2 0.39 +/- 0.18, and at T3 0.33 +/- 0.18. At T2 only 13.5% (7/52) of patients had an EAA in the high range. There was a positive correlation between EAA and duration of surgery (P = 0.02). In patients with EAA ≥ 0.40 at T2, 26.1% (6/23) of patients developed post-operative infections compared to 3.5% (1/29) of those that had a normal EAA (P = 0.0354). Maximum EAA over the first 24 hours was also strongly correlated with risk of post-operative infection (P = 0.0276).
  
  
  CONCLUSIONS
  High levels of endotoxin occur less frequently during ACB than previously documented. However, endotoxemia is associated with a significantly increased risk of the development of post-operative infection. Measuring endotoxin levels during ACB may provide a mechanism to identify and target a high risk patient population.
authors.affiliation: Department of Critical Care and the Li Ka Shing Knowledge Institute, St, Michael's Hospital, University of Toronto, 4-054C Queen Wing, 30 Bond Street, Toronto, ON M5B 1W8, Canada. kleind@smh.ca
authors.forename: David J
authors.initials: DJ
authors.lastname: Klein
authors.forename: Francoise
authors.initials: F
authors.lastname: Briet
authors.forename: Rosane
authors.initials: R
authors.lastname: Nisenbaum
authors.forename: Alexander D
authors.initials: AD
authors.lastname: Romaschin
authors.forename: C David
authors.initials: CD
authors.lastname: Mazer
mesh_terms: D000368:Aged; D002315:Cardiopulmonary Bypass / Q000009:adverse effects*; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D017558:Elective Surgical Procedures / Q000009:adverse effects; D019446:Endotoxemia / Q000453:epidemiology* / Q000209:etiology; D004731:Endotoxins / Q000097:blood; D005260:Female; D006801:Humans; D007239:Infections / Q000453:epidemiology* / Q000209:etiology; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment
chemical_list: D004731:Endotoxins