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CARDIOVASCULAR ANESTHESIA

Mannitol and Dopamine in Patients Undergoing Cardiopulmonary Bypass: A Randomized Clinical Trial

Olivia V. Carcoana, MD^*, Joseph P. Mathew, MD, Elizabeth Davis, RDCS^*, Daniel W. Byrne, MS, John P. Hayslett, MD, Roberta L. Hines, MD^*, and Susan Garwood, MB ChB^*

*Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN; and Department of Internal Medicine (Section of Nephrology), Yale University School of Medicine, New Haven, Connecticut

Address correspondence and reprint requests to Susan Garwood, MB, ChB, Department of Anesthesiology, Yale University School of Medicine, PO Box 208051, New Haven, CT 06520-8051. Address e-mail to susan.garwood{at}yale.edu

In this prospective, randomized, placebo-controlled, double-blinded study, we determined the effects of two commonly used adjuncts, mannitol and dopamine, on ß₂-microglobulin (ß₂M) excretion rates in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass (CPB). ß₂M excretion rate has been described as a sensitive marker of proximal renal tubular function. One-hundred patients with a preoperative serum creatinine level 1.5 mg/dL were prospectively randomized into 4 groups: 1) placebo, 2) mannitol 1 g/kg added to the CPB prime, 3) dopamine 2 µg · kg^-1 · min^-1 from the induction of anesthesia to 1 h post-CPB, or 4) mannitol plus dopamine. The primary outcome measure was ß₂M excretion rate at 1 h post-CPB. Secondary outcome measures included ß₂M excretion rate at 6 and 24 h post-CPB; urinary flow rate and creatinine clearance at 1, 6, and 24 h post-CPB; and the highest postoperative serum creatinine level. Length of intensive care stay and hospitalization, as well as adverse events, were also considered secondary outcomes. Dopamine significantly increased ß₂M excretion rate at 1 h post-CPB (2.48 ± 3.61 µg/min) compared with placebo (0.59 ± 1.04 µg/min; P = 0.001). This effect was not ameliorated by the addition of mannitol (ß₂M excretion rate, 2.05 ± 2.77 µg/min; P = 0.007 compared with placebo). ß₂M excretion rate was similar in patients given placebo or mannitol alone (P = 0.831). Rather than being a protective drug in the setting of CPB, dopamine alone or in combination with mannitol increases ß₂M excretion rate, which may be a measure of renal tubular dysfunction. The clinical implications of this increase and whether it is also seen in patients with established renal dysfunction undergoing CPB require additional investigation.

IMPLICATIONS: In many clinical settings, an increased beta-2-microglobulin (ß₂M) excretion rate indicates renal tubular injury. In this cardiopulmonary bypass (CPB) study, a dopamine infusion (alone or with mannitol) resulted in an increased ß₂M excretion rate. It is unclear whether this dopamine-related increase implies renal injury after CPB, and further investigations are required to examine the mechanism/clinical relevance of this observation.

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