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Cardiopulmonary bypass (CPB) is required to facilitate these operations but elicits a systemic inflammatory response, leading to postoperative organ dysfunction, morbidity and prolonged recovery after the surgery. Subzero-balance ultrafiltration (SBUF) has been shown to extract proinflammatory cytokines continuously throughout the CPB exposure. We hypothesize that a high-exchange SBUF (H-SBUF) will have a clinically relevant anti-inflammatory effect compared with a low-exchange SBUF (L-SBUF).<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods and analysis<\/jats:title><jats:p>The ULTrafiltration to enhance Recovery After paediatric cardiac surgery (ULTRA) trial is a randomised, double-blind, parallel-group randomised trial conducted in a single paediatric cardiac surgery centre. Ninety-six patients less than 15 kg undergoing cardiac surgery with CPB will be randomly assigned to H-SBUF during CPB or L-SBUF during CPB in a 1:1 ratio with stratification by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) score 1 and STAT score 2\u20135. The primary outcome is peak postoperative vasoactive-ventilation-renal score. Time series and peak values of vasoactive-ventilation renal score, vasoactive-inotrope score, ventilation index and oxygenation index will be collected. Secondary clinical outcomes include acute kidney injury, ventilator-free days, inotrope-free days, low cardiac output syndrome, mechanical circulatory support, intensive care unit length of stay and operative mortality. Secondary biomarker data include cytokine, chemokine and complement factor concentrations at baseline before CPB, at the end of CPB exposure and 24 hours following CPB. Analyses will be conducted on an intention-to-treat principle.<\/jats:p><\/jats:sec><jats:sec><jats:title>Ethics and dissemination<\/jats:title><jats:p>The study has ethics approval (#1024932 dated August 31, 2021) and enrolment commenced in September 2021. The primary manuscript and any subsequent analyses will be submitted for peer-reviewed publication.<\/jats:p><\/jats:sec><jats:sec><jats:title>Trial registration number<\/jats:title><jats:p><jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT04920643\">NCT04920643<\/jats:ext-link>.<\/jats:p><\/jats:sec>","DOI":"10.1136\/bmjopen-2023-080597","type":"journal-article","created":{"date-parts":[[2024,8,29]],"date-time":"2024-08-29T04:50:15Z","timestamp":1724907015000},"page":"e080597","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":4,"title":["High-exchange ULTrafiltration to enhance recovery after paediatric cardiac surgery (ULTRA): study protocol for a Canadian double-blinded randomised controlled trial"],"prefix":"10.1136","volume":"14","clinical-trial-number":[{"clinical-trial-number":"nct04920643","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4579-5674","authenticated-orcid":false,"given":"Joel","family":"Bierer","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roger","family":"Stanzel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mark","family":"Henderson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kristina","family":"Krmpotic","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pantelis","family":"Andreou","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jean S.","family":"Marshall","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John","family":"Sapp","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Horne","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2024,8,28]]},"reference":[{"key":"2025010105102028000_14.8.e080597.1","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.116.023544"},{"key":"2025010105102028000_14.8.e080597.2","doi-asserted-by":"publisher","DOI":"10.1053\/j.jvca.2008.08.007"},{"key":"2025010105102028000_14.8.e080597.3","doi-asserted-by":"publisher","DOI":"10.1016\/0003-4975(93)91048-R"},{"key":"2025010105102028000_14.8.e080597.4","doi-asserted-by":"publisher","DOI":"10.1097\/PCC.0000000000000759"},{"key":"2025010105102028000_14.8.e080597.5","doi-asserted-by":"publisher","DOI":"10.1016\/S1010-7940(01)01099-5"},{"key":"2025010105102028000_14.8.e080597.6","doi-asserted-by":"publisher","DOI":"10.1111\/aor.14171"},{"key":"2025010105102028000_14.8.e080597.7","doi-asserted-by":"publisher","DOI":"10.1016\/j.athoracsur.2006.02.073"},{"key":"2025010105102028000_14.8.e080597.8","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1177\/2150135119870176","article-title":"Ultrafiltration in pediatric cardiac surgery review","volume":"10","author":"Bierer","year":"2019","journal-title":"World J Pediatr Congenit Heart Surg"},{"key":"2025010105102028000_14.8.e080597.9","doi-asserted-by":"publisher","DOI":"10.1177\/026765919100600106"},{"key":"2025010105102028000_14.8.e080597.10","doi-asserted-by":"crossref","first-page":"1515","DOI":"10.1016\/0003-4975(93)90743-2","article-title":"Hemofiltration modifies complement activation after extracorporeal circulation in infants","volume":"56","author":"Andreasson","year":"1993","journal-title":"Ann Thorac Surg"},{"key":"2025010105102028000_14.8.e080597.11","doi-asserted-by":"crossref","first-page":"1518","DOI":"10.1016\/0003-4975(93)90744-3","article-title":"Ultrafiltration and modified ultrafiltration in pediatric open heart operations","volume":"56","author":"Elliott","year":"1993","journal-title":"Ann Thorac Surg"},{"key":"2025010105102028000_14.8.e080597.12","doi-asserted-by":"publisher","DOI":"10.1016\/0008-6363(95)00237-5"},{"key":"2025010105102028000_14.8.e080597.13","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1186\/s12967-023-04255-8","article-title":"Novel inflammatory mediator profile observed during pediatric heart surgery with cardiopulmonary bypass and continuous ultrafiltration","volume":"21","author":"Bierer","year":"2023","journal-title":"J Transl Med"},{"key":"2025010105102028000_14.8.e080597.14","doi-asserted-by":"crossref","first-page":"785","DOI":"10.1177\/02676591211027788","article-title":"Subzero balance - 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