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International audience; This document represents the first update of the Cardiothoracic and Vascular Anaesthesia Fellowship Curriculum of the European Association of Cardiothoracic Anaesthesiology and Intensive Care. After obtaining feedback from exit interviews with fellows in training, graduate fellows, and program directors, 2 modified online Delphi procedures with questionnaires were conducted. A consensus was reached when two-thirds of responding committee members gave green or yellow ratings on a traffic light system, and >70% indicated strong agreement or agreement on a 5-point Likert scale. The new regulations include the following: (1) more flexibility in the fellows` rotation, as long as the total number of days, rotations, and cases are completed during the training year; (2) recommendation for strict compliance with national working-time guidelines; (3) no extension of fellowship training to compensate for annual and/or sick leave, unless the required minimum number of cases and rotations are not reached; (4) interruption of fellowship training for >12 months is allowed for personal or medical reasons; (5) introduction of a checklist for quantitative assessment of standard clinical skills; (6) recommendations for a uniform structure of exit interviews; (7) possibility of a 1-month training rotation in a postanesthesia care unit instead of an intensive care unit; and (8) provided all other requirements have been met, the allowance of progression from the basic training year to the advanced fellowship training year without first passing the transesophageal echocardiography examination.

Objective The primary objective of this study was to compare one-year mortality in patients undergoing cardiac surgery with volatile anesthesia or total intravenous anesthesia (TIVA). Secondary objectives were to compare in-hospital and 30-day mortality, postoperative levels of creatine kinase (CK-MB) and cardiac troponin, and durations of tracheal intubation, intensive care unit (ICU) and hospital stays. Design Systematic review and meta-analysis of randomized controlled trials (RCTs). Setting International, multi-institution centers. Participants Adults patients undergoing heart surgery. Interventions Volatile anesthesia and TIVA. Measurements and Main Results Meta-analysis found no statistically significant difference between patients receiving TIVA and volatile anesthesia in one-year mortality (n = 6440, OR = 1.22, 95% CI 0.97 to 1.54, p = 0.09, Z = 1.67, I2 = 0%), troponin (n = 3127, SMD = 0.26, 95% CI -0.01 to 0.52, p = 0.05, Z = 1.92, I2 = 90%) and CK-MB concentration 24h postoperatively (n = 1214, SMD = 0.10, 95% CI -0.17 to 0.36, unadjusted p = 0.48, Z = 0.71, I2 = 79%), or time to tracheal extubation (n = 1059, SMD = 0.10, 95% CI -0.28 to 0.49, p = 0.60, Z = 0.53, I2 = 88%). The durations of ICU stay (n = 2003, SMD = 0.29, 95% CI 0.01 to 0.57, p = 0.04, Z = 2.05, I2 = 88%) and hospital stay (n = 1214, SMD = 0.42, 95% CI 0.10 to 0.75, p = 0.01, Z = 2.53, I2 = 91%) were shorter in the volatile anesthetic compared to TIVA group. Conclusions No significant differences in mortality (in-hospital, 30-day, 1-year), troponin and CK-MB concentrations 24 h postoperatively, or time to tracheal extubation were found between patients who had volatile anesthesia or TIVA. Compared to TIVA, volatile anesthesia was associated with shorter durations of hospital and ICU stays.

International audience; Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Background:Administering isoflurane 2.5% into the oxygenator during cardiopulmonary bypass results in no patient movement. However, doing so may result in an excessive depth of anaesthesia particularly, when hypothermia is induced. Bispectral index and arterial blood and oxygenator exhaust concentrations of volatile anaesthetics should be related to depth of anaesthesia. The primary aim of this study was to measure the depth of anaesthesia using bispectral index, resulting from administering isoflurane 2.5% into the oxygenator during cardiopulmonary bypass, and secondary aims were to examine the relationships between blood and oxygenator exhaust isoflurane concentrations and bispectral index.Methods:Arterial and mixed-venous blood samples were aspirated at three time points during cardiopulmonary bypass and measured for isoflurane concentration using mass spectrometry. Simultaneously, oxygenator exhaust isoflurane concentration, nasopharyngeal temperature and bispectral index were recorded.Results:When averaged across the three time points, all patients had a bispectral index score below 40 (binomial test, p Conclusion:When 2.5% isoflurane was administered into the sweep gas supply to the oxygenator during cardiopulmonary bypass, all patients experienced a bispectral index score less than 40 and no significant relationship was found between either arterial or mixed-venous blood or oxygenator exhaust concentrations of isoflurane and bispectral index.

Corticosteroids are often administered prophylactically to attenuate the inflammatory response associated with cardiac surgery using cardiopulmonary bypass (CPB). However, the efficacy and safety profile of corticosteroids remain uncertain. The primary aim of this systematic review and meta-analysis was to investigate the effect of corticosteroids on mortality in adult cardiac surgery using CPB. Secondary aims were to examine the effect of corticosteroids on myocardial adverse events, pulmonary adverse events, atrial fibrillation, surgical site infection, gastrointestinal bleeding and duration of stay in the intensive care unit and hospital. Randomized controlled trials (RCTs) were systematically searched in electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science) from their inception until March 2019. Observational studies, case reports, case series and literature reviews were excluded. Sixty-two studies (n = 16 457 patients) were included in this meta-analysis. There was no significant difference in mortality between the corticosteroid and placebo groups [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.81–1.14; P = 0.65, participants = 14 693, studies = 24, evidence of certainty: moderate]. Compared to those receiving a placebo, patients who were given corticosteroids had a significantly higher incidence of myocardial adverse events (OR 1.17, 95% CI 1.03–1.33; P = 0.01, participants = 14 512, studies = 23) and a lower incidence of pulmonary adverse events (OR 0.86, 95% CI 0.75–0.98; P = 0.02, participants = 13 426, studies = 17). The incidences of atrial fibrillation (OR 0.87, 95% CI 0.81–0.94; P

This article reviews fellowship training in adult cardiac, thoracic, and vascular anesthesia and critical care from the perspective of European program initiators and educational leaders in these subspecialties together with current training fellows. Currently, the European Association of Cardiothoracic Anaesthesiology (EACTA) network has 20 certified fellowship positions each year in 10 hosting centers within 7 European countries, with 2 positions outside Europe (Sao Paulo, Brazil). Since 2009, 42 fellows have completed the fellowship training. The aim of this article is to provide an overview of the rationale, requirements, and contributions of the fellows, in the context of the developmental progression of the EACTA fellowship in adult cardiac, thoracic, and vascular anesthesia and critical care from inception to present. A summary of the program structure, accreditation of host centers, requirements to join the program, teaching and assessment tools, certification, and training requirements in transesophageal electrocardiography is outlined. In addition, a description of the current state of EACTA fellowships across Europe, and a perspective for future steps and challenges to the educational program, is provided. (C) 2019 Elsevier Inc. All rights reserved.

Objective Volatile anesthetic agents such as isoflurane may be associated with fewer adverse myocardial events compared with total intravenous anesthesia in cardiac surgery. The authors aimed to determine whether reasonable isoflurane concentrations at tissue level were being achieved to protect the myocardium using this agent. The isoflurane concentration in myocardium has never been measured. The primary aim was to sample coronary sinus (CS) blood and measure its isoflurane concentration. Secondary aims were to determine whether the CS blood concentration would equilibrate with the arterial blood concentration and the relationship of CS blood concentration with oxygenator exhaust isoflurane concentrations during cardiopulmonary bypass (CPB). Design Prospective, observational study. Setting Single-center university hospital. Participants The study comprised 23 patients undergoing cardiac surgery using CPB and isoflurane. Measurements and Main Results Shortly after initiation of CPB and insertion of a CS retrograde cardioplegia catheter but before aortic cross-clamping, CS blood was aspirated, followed by radial artery blood, which then were analyzed for isoflurane with gas chromatography and mass spectrometry. The oxygenator exhaust isoflurane level was measured with an anesthetic gas analyzer. The mean arterial and CS isoflurane concentrations were 87.7 ± 50.1 and 73.0 ± 42.9 μg/mL, respectively. There was a significant mean difference of 14.7 μg/mL (95% confidence interval 6.7-22.8) between CS and arterial isoflurane concentrations. Oxygenator exhaust isoflurane levels were correlated positively with those in the CS blood ( r = 0.68, p r = 0.72, p Conclusions This was the first study in which CS blood was sampled and measured for isoflurane concentration. The CS isoflurane concentration could be estimated from the isoflurane concentration in the oxygenator exhaust gas. However, the value of this relationship is limited because the CS isoflurane concentration does not accurately represent its myocardial levels during CPB.

Introduction: Bispectral index (BIS) and monitoring of end-tidal concentration may be associated with a reduction in the incidence of awareness during volatile-based general anaesthesia. An analogue of end-tidal concentration during cardiopulmonary bypass (CPB) is measuring exhausted isoflurane concentration from the oxygenator as an estimate to blood and, so, brain concentration. The aim of this study was to determine the relationships between oxygenator exhaust and blood concentrations of isoflurane and the BIS score during CPB when administering isoflurane into the sweep gas supply to the oxygenator. Methods: Seventeen patients undergoing elective cardiac surgery using CPB and isoflurane with BIS monitoring were recruited in a single-centre university hospital. Isoflurane gas was delivered via a calibrated vaporiser at the beginning of anaesthetic induction. Radial arterial blood samples were collected after the initiation of CPB and before aortic cross-clamping, which were analysed for isoflurane by gas chromatography and mass spectrometry. The BIS score and the concentration of exhausted isoflurane from the oxygenator membrane, as measured by an anaesthetic gas analyser, were recorded at the time of blood sampling. Results: The mean duration of anaesthetic induction to arterial blood sampling was 90 min (95%CI: 80,100). On CPB, the median BIS was 39 (range, 7-43) and the mean oxygenator exhaust isoflurane concentration was 1.24 ± 0.21%. No significant correlation was demonstrated between BIS with arterial isoflurane concentration (r=-0.19, p=0.47) or oxygenator exhaust isoflurane concentration (r=0.07, p=0.80). Mixed-venous blood temperature was moderately correlated to BIS (r=0.50, p=0.04). Oxygenator exhaust isoflurane concentration was moderately, positively correlated with its arterial concentration (r=0.64, pDiscussion: In conclusion, in patients undergoing heart surgery with CPB, the findings of this study indicate that, whilst oxygenator exhaust concentrations were significantly associated with arterial concentrations of isoflurane, neither had any association with the BIS scores, whereas body temperature has moderate positive correlation.

This special article summarizes the design and certification process of the European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia (CTVA) Fellowship Program.The CTVA fellowship training includes a two-year curriculum at an EACTA-accredited educational facility. Before fellows are accepted into the program, they must meet a number of requirements, including evidence of a valid license to practice medicine, a specialist degree examination in anesthesiology, and appropriate language skills as required in the host centers. The CVTA Fellowship Program has 2 sequential and complementary levels of training-both with a modular structure that allows for individual planning and also takes into account the differing national healthcare needs and requirements of the 36 countries represented in EACTA. The basic training period focuses on the anesthetic management of patients undergoing cardiac, thoracic, and vascular surgery and related procedures. The advanced training period is intended to deepen and to extend the clinical and nontechnical skills that fellows have acquired during the basic training.The goal of the EACTA fellowship is to produce highly trained and competent perioperative physicians who are able to care for patients undergoing cardiac, thoracic, and vascular anesthesia. (C) 2019 Elsevier Inc. All rights reserved.

Objective The aim of this study was to compare cognition following coronary artery bypass grafting (CABG) surgery with or without cardiopulmonary bypass (CPB) (on- or off-pump). Design Systematic review and meta-analysis of randomized control trials comparing cognitive outcome in patients undergoing CABG surgery on- or off-pump as assessed by continuous measures from a battery of 7 psychometric tests. Setting Multi-institutional centers performing CABG surgery. Participants Patients with coronary artery disease requiring CABG surgery. Interventions CABG surgery with or without CPB. Measurements and main results A structured literature search identified 13 randomized control trials that included a total of 2,405 patients. Results from 7 psychometric tests were grouped into early (≤3 months) and late (6-12 months) postoperative periods. No significant differences were found between on- and off-pump groups in any of the 7 psychometric tests in either the early (p range 0.21-0.78) or late (p range 0.09-0.93) postoperative period. Conclusion The results suggested that CPB may not be associated with cognitive decline that is associated with CABG surgery.

Tranexamic acid reduces blood loss and transfusion in on-pump coronary artery bypass graft (CABG) surgery. Compared with on-pump, off-pump surgery is associated with less blood loss and transfusion. Therefore, tranexamic acid may be less effective for off-pump surgery, and its safety profile may be different in this setting. The aim of this study was to determine the efficacy and safety of tranexamic acid for off-pump CABG surgery.Systematic review and meta-analysis.University of Edinburgh.The administration of tranexamic acid.A systematic review of randomized controlled trials administering tranexamic acid to patients undergoing off-pump CABG surgery. A meta-analysis of 24-hour blood loss, postoperative allogeneic transfusion, and thromboembolic events.Eight trials were identified. The lack of appropriate data limited the meta-analysis on blood loss. Tranexamic acid significantly reduced the overall risk of allogeneic blood component transfusion (risk ratio = 0.47; 95% confidence intervals, 0.33-0.66; p0.0001) and packed red blood cell transfusions (risk ratio = 0.51; 95% CI, 0.36-0.71; p = 0.0001). No association was found between tranexamic acid and myocardial infarction, stroke, or pulmonary embolism. Population sizes of meta-analyses ranged from 466 to 544.Tranexamic acid reduces blood transfusion after off-pump surgery. Although no association with adverse events was found, the population sample size was too small to detect rare but clinically significant adverse events. A well-designed randomized controlled trial with an appropriate sample size is required to confirm tranexamic acid effectiveness and safety in off-pump CABG surgery.

Objective The primary aim was to poll the opinions of cardiac anesthesiologists and surgeons as to the effect of the suspension of the license for aprotinin on patients undergoing cardiac surgery. Design A mailed questionnaire. Setting United Kingdom. Participants Members of the Association of Cardiothoracic Anaesthetists and the Society for Cardiothoracic Surgery in Great Britain and Ireland with a UK address. Interventions A structured questionnaire. Measurements and Main Results Of the 546 dispatched surveys, 285 (52%) were returned. While the majority of respondents (61%) felt it had not had any effect, 29% of respondents felt the suspension of the license for aprotinin had had a detrimental effect on patient care and 2% an extremely detrimental effect. Eight percent of respondents reported a beneficial effect. Since license suspension, the reported use of aprotinin had declined and tranexamic acid use had risen. The majority of respondents reported no change in the use of packed red cells (66%), blood products (53%), mechanical cell salvage (84%), factor VIIa (79%), or frequency of reopening for bleeding (65%). Respectively, 32%, 45%, 24%, and 20% of respondents reported a perceived increased use of these products, and 30% reported an increased frequency of reopening for bleeding. Apart from knowledge regarding local aprotinin stock, there was no significant difference in opinions between surgeons and anesthesiologists. Conclusions While the majority of respondents felt that the suspension of the license for aprotinin had no effect, almost a third felt it had impacted negatively on the care of patients undergoing cardiac surgery.

Blood transfusion remains one of the commonest interventions carried out upon individuals undergoing cardiac surgery. Despite this, the scientific rationale on which to base this decision is limited. Currently, hemoglobin concentration is often used as the sole guide as to when a transfusion may be required. A fall in hemoglobin concentration is often assumed to be associated with a similar drop in red cell volume. A review was undertaken of all the relevant peer-reviewed literature to determine what factors we should consider when deciding to transfuse elective cardiac surgery patients. The large fluid load associated with cardiac surgery, primarily from the cardiopulmonary bypass circuit, may have a significant dilutional effect. In such a scenario, several interlinked protective mechanisms may ensure that tissue oxygenation is maintained, including a reduction in blood viscosity, a decrease in systemic afterload, and an increase in cardiac output. Furthermore, oxygen requirements during the initial perioperative phase are reduced because of the effect of general anesthesia and hypothermia during cardiopulmonary bypass. When deciding to transfuse, consideration should be given to red cell volume, circulatory status, and oxygen requirement. It is possible that such an all-encompassing approach would reduce the incidence of unnecessary, and potentially counterproductive, red cell transfusion in cardiac surgery.

Since its inception, and to this day, measurement of the depth anaesthesia during cardiopulmonary bypass (CPB) has been challenging. Bispectral index (BIS) is commonly used but remains controversial. One pragmatic approach to anaesthesia is to administer 2.5% isoflurane into the sweep gas supply to the oxygenator and allow neuromuscular blockade to fade so that patient movement indicates an insufficient depth of anaesthesia.

For over four decades, pump flow rate during cardio-pulmonary bypass (CPB) has been estimated using body surface area (BSA). As patients presenting for heart surgery are increasingly obese, this approach may no longer be appropriate and other estimates of systemic metabolism should be used, such as body mass index and lean body mass. Mixed venous oxygen saturation (SvO2) is a robust and independent estimate of the global efficacy of CPB. The aim of this study was to determine which factors, including body surface area, body mass index and lean body mass, best predict SvO2 during CPB. Forty-eight patients undergoing elective cardiac surgery requiring CPB were studied. Patients’ height, weight and skinfold thickness at four sites (biceps, triceps, subscapularis and suprailiac) were measured. Body surface area, lean body mass and body mass index were then calculated. Pump flow rate was maintained at 2.4 L/min/m2 during CPB as per standard unit protocol. Arterial and mixed venous blood samples were taken during the cooling, stable hypothermia and rewarming phases of CPB. Nasopharyngeal temperatures and flow rates were recorded contemporaneously. The blood samples were analysed for oxygen saturation, haemoglobin concentration and partial pressures of oxygen and carbon dioxide. The values of the three time points were meaned. All potential predictor variables were then univariately correlated with mixed venous oxygen saturation (SvO2). Those correlating significantly ( p < 0.1) were entered into a multivariate linear regression model. Nasopharyngeal temperature (β=0.615, p < 0.001) and lean body mass (β=0.256, p < 0.028) were the only significant predictors of SvO2 ( r2= 0.433, p < 0.001). Pump flow rates maintained at 2.4 L/min/m2 throughout CPB results in relative over-perfusion during hypothermia. Lean body mass may be a more sensitive estimate of systemic metabolism and, therefore, may provide a more accurate means of determining pump flow rate than body surface area in patients undergoing heart surgery.

Metabolic acidosis is a frequent complication of cardio-pulmonary bypass (CPB). Commonly, its cause is ascribed to hypoperfusion; however, iatrogenic causes, related to the composition and volume of intravascular fluids that are administered, are increasingly being recognized. The aim of this study was to determine if metabolic acidosis during CPB was associated with hypoperfusion, change in strong ion difference (SID) or haemodilution. Forty-nine patients undergoing cardiac surgery using CPB in the Royal Infirmary of Edinburgh (RIE) or the HCI, Clydebank were included in the study. Arterial blood samples were aspirated before induction of anaesthesia and the end of CPB. Samples were subjected to blood gas analysis and measurement of electrolytes and lactate. Changes in concentrations were then calculated. Change variables that were found to be significant (p B-0.1) univariate correlates of the change in hydrogen ion concentration were identified and entered into a multivariate regression model with hydrogen ion concentra tion at the end of CPB as the outcome variable (r2=0.65, p

During the early postoperative period after coronary artery bypass grafting (CABG) surgery, many patients experience jugular bulb oxyhemoglobin desaturation (SjO(2)50%). We sought to determine whether SjO(2) during cardiopulmonary bypass and the early postoperative period influenced long-term cognitive performance after CABG surgery. One hundred two patients completed a battery of cognitive tests the day before and 3 mo after CABG surgery. A General Cognitive Score was generated from these tests as an overall measure of cognitive function. Intraoperatively, SjO(2) was determined by intermittent blood sampling, and postoperatively, the area under the curve of SjO(2)50% and time was calculated from continuous reflectance oximetry. No significant correlations between cognitive performance and either intra- or postoperative SjO(2) were found. Preoperative cognitive performance was the main determinant of cognition at 3 mo (r(2) = 0.83, P0.001), and palpable atheroma of the ascending aorta made a small, but significant, contribution to a decline in cognition (r(2) = 0.018, P = 0.001).

Coronary artery bypass grafting (CABG) surgery may be undertaken with or without cardiopulmonary bypass (CPB) that is on- or off-pump. Although mortality and the incidences of coronary artery graft occlusion, myocardial infarction and stroke are equivalent, off-pump is associated with less blood loss, transfusion, requirement for inotropes, atrial fibrillation and chest infection compared with on-pump CABG surgery. Traditional high-dose opioid techniques of general anaesthesia should be avoided and either inhalation or total intravenous (IV) anaesthesia may be used. Meticulous monitoring, including electrocardiograph (ECG) and invasive arterial pressure measurement, is required. During grafting, good communication between anaesthetist and surgeon is essential. Maintenance of diastolic arterial pressure (DAP) is the key to preventing myocardial ischaemia and cardiovascular collapse. Surgical positioning for grafting to minimize hypotension is paramount and during grafting, IV fluid loading or vasoconstrictors and inotropes are effective treatments. Correction of bradycardia with atropine 0.3 mg IV or epicardial pacing also helps to maintain DAP. Persisting hypotension may require intra-aortic balloon pumping or conversion to on-pump CABG surgery. As there is less blood loss, there is a minimal requirement for cardiovascular support and early recovery of consciousness associated with off-pump compared with on-pump CABG surgery; patients in some institutions may be managed in a recovery room then transferred to a high-dependency unit, thus bypassing ICU.

Background Hyperglycaemia is a common occurrence during cardiac surgery, however, there remains some uncertainty surrounding the role of tight glycaemic control (blood glucose Method The literature was systematically reviewed, based on pre-determined search criteria, for clinical trials evaluating the effect of tight versus normal glycaemic control during and/or after cardiac surgery. Each paper was reviewed by two, independent reviewers and data extracted for statistical analysis. Data from identified studies was combined using meta-analysis (RevMan5®). The results are presented either as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CIs). Results A total of seven randomised controlled trials (RCTs) were identified in the literature, although not all trials could be used in each analysis. Tight glycaemic control reduced the incidence of early mortality (death in ICU) (OR 0.52 [95% CI 0.30, 0.91]); of post-surgical atrial fibrillation (odds ratio (OR 0.76 [95%CI 0.58, 0.99]); the use of epicardial pacing (OR 0.28 [95%CI 0.15, 0.54]); the duration of mechanical ventilation (mean difference (MD) -3.69 [95% CI -3.85, -3.54]) and length of stay in the intensive care unit (ICU) (MD -0.57 [95%CI -0.60, -0.55]) days. Measures of the time spent on mechanical ventilation (I2 94%) and time spent in ICU (I2 99%) both had high degrees of heterogeneity in the data. Conclusion The results from this study suggest that there may be some benefit to tight glycaemic control during and after cardiac surgery. However, due to the limited number of studies available and the significant variability in glucose levels; period of control; and the reporting of outcome measures, further research needs to be done to provide a definitive answer on the benefits of tight glycaemic control for cardiac surgery patients.

Since its introduction into clinical practice in the early 1950s, cardiopulmonary bypass (CPB) has been the keystone that enabled many millions of patients to undergo heart surgery around the world.1 However, brain damage has long been recognized as a complication of heart surgery with CPB.2–4 By the 1970s, major neurological complications were frequently associated with heart surgery with an incidence of 19%.5 In the intervening years, the incidences of major neurological complications have fallen to very low levels and, currently, less than two percent of patients undergoing coronary artery bypass grafting (CABG) surgery will develop strokes.6–8 Nevertheless, with the burgeoning of CABG surgery in the 1980s, it became increasingly recognized that heart surgery was very commonly associated with another form of brain damage, cognitive decline, as almost 80% of patient had decrements in the early postoperative period following surgery.9 Today, about 20–40% of patients undergoing CABG surgery will experience long-term cognitive decline, defined as 1 month or longer after surgery.10–13 This form of brain damage is now so widely attributed to CPB that it is commonly referred to as “pump head,” being a reference to the pump that is used to mechanically drive the blood around the body.14 A news item in 2008 even cited the CPB used for his CABG surgery as the cause of former President Bill Clinton’s uncharacteristic behavior when he was easily angered by hecklers and made factual mistakes and racial slurs while aggressively defending his wife, Hillary Clinton, and her campaign for presidency.15

Theoretically, systemic carbon dioxide (VCO2) production should be an alternative means to systemic oxygen uptake (VO2) for estimating the global efficacy of cardiopulmonary bypass (CPB). This study compared two methods of estimating VCO2: Fick’s principle and oxygenator exhaust carbon dioxide (CO2) output. Both of these estimates were then compared with VO2. Fifty-one patients (39 male and 12 female) undergoing elective cardiac surgery requiring CPB were studied. Blood sampling was performed and measurements recorded during active cooling, environmental cooling/stable hypothermia and during rewarming. Blood samples were measured for CO2 tension from which content was estimated. VCO2 was calculated as the product of the arteriovenous difference in CO2 content and pump flow rate (Fick’s principle), or the fresh gas flow rate and concentration of the oxygenator exhaust CO2 (output technique). Over all measurements, method comparison analysis revealed a large mean bias of 41 (95% confidence intervals (CI) 32-50) mL/min with very wide limits of agreement (-23, 105 mL/min). Regression analysis found that the bias was also proportional to the size of measurement (β=0.75 (95% CI 0.55, 0.95)). Although both methods of VCO2 correlated significantly with VO2 ( p2 cannot be used interchangeably, and both are imprecisely related to VO2 as estimated by Fick’s principle.

The Gas STAT is a monitor which continuously measures PO2. PCO2 and pH inline during cardiopulmonary bypass. Using an in vitro model, the monitor's accuracy was compared to standard blood gas analysis over a range of PO2 (2·0–66·7 kPa), PCO2 (2·7–12·0 kPa) and pH (7–8). Its stability as affected by time, temperature, flow and haematocrit and the presence of halothane, enflurane, isoflurane and sodium nitroprusside was examined. Good correlations were found between the monitor and standard blood gas analysis for PO2 (r = 0·999, P < 0·001) and PCO2 (r = 0·996, P < 0·001). However, large and unpredictable systematic errors occurred. It was stable under all conditions examined, except that in one sensor there was a statistically significant decline in PCO2 measurement with time (P < 0·005) and the PCO2 readings were affected by temperature (P < 0·021). The monitor provides useful information for blood gas management during cardiopulmonary bypass, but should not be used without recourse to standard blood gas analysis.

The Gas STAT is a monitor which continuously measures pO2, pCO2 and pH inline during cardiopulmonary bypass. A clinical evaluation of the inline monitor compared to the standard method of monitoring, that is, intermittent isolated blood sampling and distant measurement on a blood gas analyser (BGA), was undertaken. During stable moderate hypothermia, 115 paired measurements were made in 54 patients undergoing coronary artery or heart valve surgery. The correlations between pO2, pCO2 and pH, as measured by the BGA and the inline monitor, were respectively 0.536 ( P2 as measured by the inline monitor was significantly lower than the BGA ( P2 measurements. Possible explanations for the finding of less than complete correlations are discussed and it is suggested that although inline monitoring is of value in the control of PO2, pCO2 and pH during cardiopulmonary bypass, it should not be used without recourse to the standard method of blood gas analysis.

Objective: Inhibition of cyclooxygenase 2 provides analgesia in ambulatory patients. We prospectively evaluated the safety and efficacy of a newly introduced cyclooxygenase 2 inhibitor in patients undergoing coronary artery bypass grafting surgery through a median sternotomy in a randomized clinical trial.Methods: A total of 462 patients with New York Heart Association classes I to III who were less than 77 years of age and were from 58 institutions in the United States, Canada, Germany, and the United Kingdom participated in this multicenter, phase III, placebo-controlled, double-blind, randomized, parallel-group trial. Patients were allocated at a ratio of 2:1 to parecoxib/valdecoxib or standard care (control) groups, respectively. Intravenous study drug (40 mg) was administered within 30 minutes after extubation and every 12 hours for a minimum of 3 days. Subsequently, oral treatment at a dose of 40 mg every 12 hours was initiated and administered for a combined total of 14 days. Patient-controlled analgesia with morphine, oral opioids, or acetaminophen was available as required. Assessment of the analgesic efficacy of the study drug was primarily based on morphine and morphine equivalent use. Additional efficacy evaluations included daily pain intensity, patient and physician global evaluation of study medication, and pain effect on quality of life. Clinical adverse events were assessed by the principal investigator at each site from the time of the first dose through the 30-day postdosing period.Results: Patients in the parecoxib/valdecoxib group received significantly less morphine or morphine equivalents than patients in the control group during the 0- to 24-hour (P = .009), 24- to 48-hour (P = .017), 72- to 96-hour (P = .002), 96- to 120-hour (P = .004), and 120- to 144-hour (P = .037) periods. Both patients (P < .001) and physicians (P < .001) evaluated the study medication as significantly better than control therapy. The modified Brief Pain Inventory questionnaire used in the oral dosing period detected significant improvements in the parecoxib/valdecoxib treatment group in 6 of 8 domains tested (eg, current pain, worst pain, and mood) beginning on day 4 and continuing for at least 4 days. Although there were no differences between the groups in overall adverse events, serious adverse events occurred twice as frequently in parecoxib/valdecoxib-treated patients (19.0%, 59/311 patients) than in control patients (9.9%, 15/151 patients; P = .015). Regarding individual serious adverse events, a greater incidence in sternal wound infection was found in the parecoxib/valdecoxib patients (10 [3.2%]) versus control patients (0 [0%]) (P = .035). The incidences of other individual serious adverse events, including cerebrovascular complications, myocardial infarction, and renal dysfunction, were proportionally greater but not significantly different between the groups.Conclusions: In patients undergoing coronary artery bypass grafting surgery, the cyclooxygenase 2 inhibitor combination, parecoxib/valdecoxib, was effective for postoperative analgesia. However, the 14-day treatment regimen also was associated with an increased incidence of serious adverse events overall and sternal wound infections in particular. Therefore our study raises important concerns requiring their comprehensive evaluation in a large-scale trial before these cyclooxygenase 2 inhibitors are used in patients undergoing coronary artery bypass grafting surgery.

Background Acidosis during cardiopulmonary bypass (CPB) has been related to the strong ion difference (SID) and the composition of intravascular fluids that are administered. Less intravascular fluids tend to be administered during off- than on-pump CABG and should influence the degree of acidosis that develops. This study aimed to explore the role of CPB in the development of acidosis by comparing changes in hydrogen ion concentration ([H+]) and electrolytes in patients undergoing on- and off-pump coronary artery bypass graft (CABG) surgery. Methods Eighty two patients had arterial blood gas measurements pre-operatively, following CABG and at approximately 0600 h the morning after surgery. Carbon dioxide tension (PaCO2) and concentrations of sodium, potassium, chloride, [H+], bicarbonate and haemoglobin were measured and strong ion difference calculated. Data was analysed using mixed repeated-measures analysis of variance. Results Intra-operatively, mean SID decreased more in the on- compared to the off-pump group (4.0 mmol/L, 95% confidence interval 2.8-5.3 mmol/L, p