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Objective To compare outcomes following inactive prothrombin complex concentrate (PCC) or recombinant activated factor VII (rFVIIa) administration during cardiac surgery. Design Retrospective propensity-matched analysis. Setting Academic tertiary-care center. Participants Patients undergoing cardiac surgery requiring cardiopulmonary bypass who received either rFVIIa or the inactive 3-factor PCC. Interventions Outcomes following intraoperative administration of rFVIIa (263) or factor IX complex (72) as rescue therapy to treat bleeding. Measurements and Main Results In the 24 hours after surgery, propensity-matched patients receiving PCC versus rFVIIa had significantly less chest tube outputs (median difference –464 mL, 95% confidence interval [CI] –819 mL to –110 mL), fresh frozen plasma transfusion rates (17% v 38%, p = 0.028), and platelet transfusion rates (26% v 49%, p = 0.027). There were no significant differences between propensity-matched groups in postoperative stroke, deep venous thrombosis, pulmonary embolism, myocardial infarction, or intracardiac thrombus. Postoperative dialysis was significantly less likely in patients administered PCC versus rFVIIa following propensity matching (odds ratio = 0.3, 95% CI 0.1-0.7). No significant difference in 30-day mortality in patients receiving PCC versus rFVIIa was present following propensity matching. Conclusions Use of rFVIIa versus inactive PCCs was significantly associated with renal failure requiring dialysis and increased postoperative bleeding and transfusions.

Background After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophilia patients, are safely and efficiently used off label for hemorrhage after bypass. However, optimal dosing, indications and contraindications, and laboratory tests to assess the efficacy of PCC use in children have not yet been established. This literature review outlines the challenges of bypass-related coagulopathy, the pharmacology, and the experience in use of PCCs, with a focus on their potential in pediatric cardiac surgery. Methods After a thorough literature search of MEDLINE, Scopus, and Ovid databases using the term "prothrombin complex concentrate AND pediatric," 23 relevant articles were selected. Results The data supporting successful use of PCCs in acquired coagulopathy after cardiac surgery in adults have been increasing. Although small volume, low immunogenicity, efficiency, and speed in correcting coagulopathy are attractive qualities of PCCs for pediatric practice, current evidence is only anecdotal. The main concerns are unknown dosing regimens, the inability to closely monitor the effects of PCCs in real time, and a possibility of thrombotic complications, which can be particularly devastating in young congenital cardiac patients whose lives frequently depend upon the patency of artificial shunts. Conclusions Extensive, high-quality research is warranted to fill in the gaps of knowledge regarding using PCCs in pediatric cardiac practice.

Hypothalamic-pituitary-adrenal (HPA) axis dysfunction may be partially responsible for the hemodynamic instability experienced by infants after cardiopulmonary bypass (CPB). We report the full spectrum of the HPA response surrounding CPB for infant congenital cardiac surgery.We enrolled 84 infants who received 1 mg/kg of dexamethasone before initiation of CPB. Total cortisol (TC), free cortisol (FC), adrenocorticotropic hormone (ACTH), and corticosteroid-binding globulin (CBG) were measured at 3 time points: immediately before CPB (TP1), on intensive care unit arrival (TP2), and at 24 hours after surgery (TP3). A 1-μg ACTH stimulation test was performed at each time point to evaluate adrenal responsiveness.Sixty-eight infants completed all study procedures. Levels of TC, FC, CBG, and ACTH decreased significantly between the preoperative and 24-hour postoperative measurements. There were no significant associations between preoperative FC responses and clinical outcomes after adjusting for weight and Risk-Adjusted Scores for Congenital Heart Surgery. Infants with subnormal TC responses to ACTH stimulation (9 μg/dL) at TP2 had greater fluid requirements (P .001) and greater chest tube output (P .001) during the first 24 hours, as well as longer length of stay (LOS) (P = .007). Except for LOS, these differences persisted for infants with subnormal stimulation tests at TP3.We observed a significant decline in all aspects of the HPA axis throughout the first 24 hours after infant CPB. TC and FC levels were not associated with clinical outcomes. Subnormal (Δ9 μg/dL) TC response to cosyntropin stimulation during the postoperative period was associated with increased fluid resuscitation and greater LOS.

Background In adults with right-sided congenital heart disease, vasoplegia during and after cardiopulmonary bypass appears to be a frequent complication. The incidence of vasoplegia in the general adult and pediatric cardiac surgical population has been investigated, but the incidence in adult patients with right-sided congenital heart disease is unknown. Perioperative vasopressin levels during cardiac surgery have been studied in other cardiac surgical patients, but are not known in adults with right-sided congenital heart disease. The purpose of this study was to investigate the incidence of vasoplegia in adult patients undergoing right-sided cardiac surgical procedures requiring cardiopulmonary bypass and to determine the vasopressin response to cardiac surgery in this population. Methods Twenty patients were enrolled and demographic, hemodynamic, cardiopulmonary bypass, and use of vasoactive medication data were collected. In addition, perioperative serum vasopressin levels were measured. Sixty adult patients undergoing left-sided cardiac surgery served as controls. Results The incidence of vasoplegia in the control patients was 10% and the incidence in the adult patients with right-sided congenital heart disease was 20%. Vasopressin levels were low at baseline (0.5 ± 0.5 pg/mL), increased slightly after induction of anesthesia (0.6 ± 0.6 pg/mL), increased after initiation of cardiopulmonary bypass (99.7 ± 168.2 pg/mL), and decreased after surgery (31.3 ± 43.6 pg/mL). Conclusions This study showed that the incidence of vasoplegia (20%) in patients with right-sided congenital heart disease undergoing cardiac surgery was double that of a population of patients undergoing aortic valve surgery (10%). Serum vasopressin concentration was not associated with vasoplegia in this population of congenital cardiac surgical patients.

Background Patients with atriopulmonary Fontan tend to undergo conversion to total cavopulmonary connections secondary to arrhythmias or poor flow dynamics. However, the ideal candidate is unknown. Methods Between December 1994 and May 2011, 70 patients (40 males [57%]) underwent Fontan conversion. Median age was 23 years (range, 4 to 46 years). Excluded were 1.5 ventricle conversions. The most common diagnoses included tricuspid atresia in 34patients (49%) and double-inlet left ventricle in 16 (23%). Atrial tachyarrhythmia was present in 62 patients (89%), 41 (59%) had atrioventricular valve (AVV) regurgitation, and 32 (46%) were in New York Heart Association class III or IV. Atriopulmonary Fontan was the original connection in 58 patients (83%), whereas the Bjork modification was performed in 8 (11%). Results Fontan was performed with an intraatrial conduit in 41 patients, an extracardiac conduit in 18, and a lateral tunnel in 11. Forty-nine patients (70%) underwent concomitant arrhythmia operations. Early death occurred in 10 patients (14%). Multivariate analysis revealed age older than 27 years ( p = 0.009), AVV regurgitation ( p = 0.016), lack of arrhythmia operation ( p = 0.04), and male sex ( p = 0.02) were predictors of perioperative death. Mean follow-up was 5 years (maximum, 17 years). Overall survival at 1, 5, and 10 years was 81%, 70%, and 67%, respectively, and 84% of patients were in New York Heart Association class I or II. Conclusions Proper selection of Fontan conversion candidates is critical. Concomitant arrhythmia operations may be associated with improved survival. Older age and AVV regurgitation increase the risk of poor outcome, and cardiac transplantation may be a better option.

Objectives The objective of our study was to review the long-term outcomes of patients undergoing surgical repair of aortic coarctation. Background Surgical repair of aortic coarctation has been performed at the Mayo Clinic, Rochester, Minnesota, for over 60 years. Methods Between 1946 and 2005, 819 patients with isolated coarctation of the aorta underwent primary operative repair. Medical records were reviewed and questionnaires mailed to the patients. Results Mean age at repair was 17.2 ± 13.6 years. The majority (83%) had pre-operative hypertension. Operations included simple and extended end-to-end anastomosis (n = 632), patch angioplasty (n = 72), interposition grafting (n = 49), bypass grafting (n = 30), and subclavian flap or “other” (n = 35). Overall early mortality ( 20 yrs) and pre-operative hypertension were associated with decreased survival (p Conclusions Primary repair of isolated coarctation of the aorta was performed with a low rate of mortality. However, long-term survival was reduced compared with that in an age- and sex-matched population, and many patients required further reoperation. These findings emphasize that patients with aortic coarctation need early recognition and intervention, as well as lifelong informed follow-up.

Background:The Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes.Methods:The primary objective of this retrospective study was to determine if low-dose (0.625 mg) droperidol administration was associated with episodes of torsade de pointes in the general surgical population during the 3-yr period following the reinstitution of droperidol to our institutional formulary.Results:The authors identified 20,122 surgical patients who received 35,536 doses of droperidol. These patients were cross-matched with an electrocardiogram database and an adverse outcome database. The charts of 858 patients were reviewed, including patients with documentation of prolonged QTc (>440 ms) from March 2007 to February 2011, polymorphic ventricular tachycardia (VT) within 48 h of receiving droperidol, or death within 7 days of receiving droperidol. Twelve surgical patients had VT (n = 4) or death (n = 8) documented within 48 h of droperidol administration. No patients developed polymorphic VT or death due to droperidol administration (n = 0). The eight patients that died were on palliative care. The four patients with documented VT had previous cardiac conditions: two had pre-existing implantable cardiac defibrillators, three had episodes of VT before receiving droperidol, and another had pre-existing hypertrophic obstructive cardiomyopathy. The authors found 523 patients with a documented QTc >440 ms before receiving droperidol. No patients developed VT or death as a direct result of droperidol administration.Conclusions:Our evidence suggests that low-dose droperidol does not increase the incidence of polymorphic VT or death when used to treat postoperative nausea and vomiting in the surgical population.

Objective: The aim of this prospective, randomized, double-blind, placebo controlled trial was to evaluate the safety and efficacy of continuous ropivacaine infusion of into the sternal wound. Methods: We planned to enroll 200 patients scheduled for various cardiac surgical procedures into the study. Patients, in a double-blind randomized fashion, were given either normal saline or 0.3% ropivacaine through 2 subcutaneous multiport catheters placed on either side of the sternal split at an infusion rate of 4 mL/h for 64 hours. The efficacy outcomes measured were time to extubation of the trachea, intensive care unit and hospital stay duration, pain scores, and narcotic usage. The safety outcomes measured were systemic local anesthetic toxicity, major cardiac complications, and wound infection. Measurements and Main Results: The data safety monitoring board stopped the study after enrolling 85 patients because of excessive sternal wound infections (9%, n = 44) in the ropivacaine group. This rate of infection was not statistically different from the control group (0%, n = 41, P = 0.12), but it was statistically different from our historical incidence of sternal wound infection (1.9%, no = 6381, P = 0.002). There was also a lack of evidence of efficacy for time to extubation of the trachea, narcotic usage, and pain control. Conclusions: The phase III trial did not show improvement in time to extubation of the trachea or pain control in the 0.3% ropivacaine group, but it was stopped early by the data safety monitoring board. (Reg Anesth Pain Med 2013;38: 145Y150)

Limited data exist regarding the outcomes of non-cardiac procedures (NCPs) in adult patients after Fontan operations (Fontan patients).To compare procedural outcomes after NCPs in Fontan patients with outcomes for two matched control groups: patients with repaired congenital heart disease and biventricular circulation (CHD-BiV) and patients with no heart disease (NHD). We defined cyanosis as oxygen saturation90% and procedural hypoxia as saturation80% or a decrease in saturation10% from baseline.There were 538 NCPs in 154 Fontan patients (mean age, 30 years) performed in 1990-2015. Sedation and anaesthesia types were monitored anaesthesia care (256,48%), general anaesthesia (51,9%), minimal sedation (105,20%), local anaesthesia (75,14%) and regional anaesthesia (51,9%). Ninety-three complications occurred in 79 procedures (15%) and included arrhythmia requiring intervention (9), hypotension (14), bradycardia (8), hypoxia (38), heart failure requiring intravenous diuretics (2), acute kidney injury (3), bleeding requiring blood transfusion (1), unplanned procedures for dialysis catheter placement (2), readmission (2), unplanned hospitalisation for hypoxia (8) and unplanned transfer to intensive care unit (1). Baseline cyanosis was the only multivariable risk factor for complications (HR, 1.87 (95% CI 1.14 to 3.67), p=0.04). Procedural complications were more common in the Fontan group (18%) than in the CHD-BiV (5%) and NHD groups (1.4%) (p=0.001).Complications after NCPs were more common in Fontan patients, and baseline cyanosis was a risk factor for complications. All-cause mortality was low and may be related to the multidisciplinary care approach used for Fontan patients at our centre.

Excessive bleeding and allogeneic transfusion during adult post-cardiotomy venoarterial extracorporeal membrane oxygenation (ECMO) are potentially harmful and expensive. Balancing the inhibition of clotting and distinguishing surgical from non-surgical bleeding in post-operative period is difficult. The sensitivity of coagulation tests including Thromboelastography® (TEG) to predict chest tube drainage in the early hours of ECMO was examined with the use of receiver-operating characteristics (ROC). The results are useful to incorporate in clinical evidence-based algorithms to guide management decisions. In the eighth hour of ECMO, 26 of the 53 adult patients (49%) studied were identified as non-bleeders (less than 2.0 mL/kg/h). All had experienced various types of cardiac surgical procedures. Fifty-two percent were female and the group was 54 ± 19 (mean ± 1 SD) years old. The coagulation parameter threshold with the maximum sensitivity and specificity to predict non-bleeding at 8 hours on ECMO was the kaolin plus heparinase TEG maximum amplitude (KH-TEG MA) at a significant ROC threshold (t) > 50 mm. The activated partial thromboplastin time (aPTT) t < 49 seconds, KH-TEG alpha-angle t > 51°, and the kaolin activated clotting time (ACT) t < 148 seconds were sensitive predictors of non-bleeders. The whole-blood KH-TEG MA was superior to the plasma-based aPTT or International Normalization Ratio (INR) to predict bleeding in the eighth hour of ECMO. Using coagulation laboratory thresholds that predict non-bleeding can begin a process of identifying patients earlier that are likely to bleed. Awareness of these parameter thresholds may improve care through patient protection from unnecessary transfusion and prolonging the life of the ECMO circuit. An algorithm incorporating the ROC thresholds was created to help recognize surgical bleeding to minimize unnecessary transfusions.

Summary Objectives To describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery. Background The Fontan procedure was developed in 1971 to palliate patients with univentricular cardiac physiology leading to long-term survival of these patients, who may now present as adults for noncardiac surgery. Methods We retrospectively reviewed the medical records of Fontan patients 16 years and older who underwent general anesthesia for noncardiac surgery at Mayo Clinic in Rochester, Minnesota. Preoperative data, perioperative course, intraoperative and postoperative hemodynamic, pulmonary, cardiovascular, and renal complications were described. Results Thirty-nine general anesthetics were administered to 31 patients for noncardiac surgery after Fontan palliation. Perioperative complications occurred in 12 of the 39 (31%) noncardiac surgeries, and there was one postoperative death that occurred on day 13 after ventral hernia repair. The two patients who had complications that did not resolve (long-term dialysis and death) had ejection fractions well below the mean for the group (22% and 28%). Conclusion It may be more appropriate for Fontan patients to undergo anesthesia for noncardiac surgery in a tertiary institution, particularly patients with an ejection fraction of

Background Atrial fibrillation (AF) occurs in 20%-50% of patients after cardiac surgery and is associated with increased morbidity and mortality. Corticosteroids are reported to decrease the incidence of postoperative AF, presumably by attenuating inflammation caused by surgery and cardiopulmonary bypass (CPB). We hypothesized that hemofiltration during CPB, which may attenuate inflammation, might decrease the incidence of AF after cardiac surgery. Methods This was a retrospective review of patients previously enrolled in a double-blind, placebo-controlled trial evaluating the effects of perioperative steroid therapy and hemofiltration during CPB on duration of postoperative mechanical ventilation. In that study, 192 patients undergoing cardiac surgery were randomized to 1 of 3 groups: controls (placebo), hemofiltration during CPB, or perioperative steroid therapy. Patient records were reviewed to determine the incidence of new onset AF defined as any electrocardiogram evidence of AF or AF diagnosed by the patients' clinicians. Results Of the 192 enrolled patients, 3 were excluded for protocol violations and 4 were excluded for history of chronic AF. Data from 185 patients from the original study were available for review. Sixty patients (32%) had new onset AF after cardiac surgery. There was no difference among groups in the incidence of AF (control group, 21%; steroid group, 41%; hemofiltration group, 36%; P = 0.057 among groups). The only risk factor for the development of AF was age (mean age of patients with AF, 65.4 +/- 10.1 yr vs patients without AF, 61.4 +/- 11.5 yr; P = 0.024). When age, procedure type, and presence or absence of chronic obstructive pulmonary disease were controlled for in multivariate analysis, the difference among study groups remained nonsignificant (P = 0.108). Conclusions Perioperative corticosteroids or the use of hemofiltration during CPB did not decrease the incidence of AF after cardiac surgery. Further studies evaluating the efficacy and safety of perioperative corticosteroids for prevention of postoperative AF are warranted before their routine use can be recommended.

Residual topical hemostatic material can serve as a nidus for infection or enhance infection in an already contaminated wound. A newly approved agent, Microporous Polysaccharide Hemospheres (MPH) (Arista AH), has rapid degradation properties, which may reduce the chance of surgical site infection.With institutional approval, 170 Wister rats underwent standardized anesthesia and abdominal surgery. An Echerichia coli inoculum was added to the incision, and MPH, gelatin matrix, or no agent (control) was placed in the site. After 72 h, the animals were sacrificed, and colony-forming units (cfu)/g were counted in the harvested tissue.Application of gelatin matrix resulted in more cfu/g of tissue and an 87% infection rate, with fewer cfu/g of tissue and a 14% and 24% infection rate in the control and MPH groups, respectively.The use of MPH in this rat abdominal infection model did not enhance infection. Gelatin matrix was associated with a greater infection rate than MPH. The rapid degradation of MPH may account for these results, making it a good hemostat in the presence of infective sources.

Objective Adequate hemostasis is extremely important in neurosurgery, commonly requiring the use of topical hemostatic agents. Apart from variable efficacy, the residual presence of these agents may cause foreign body reaction, infection, and delayed bone growth. This study compares the safety and efficacy of commonly used agents with a newly approved agent, Arista (microporous polysaccharide hemospheres; Medafor, Inc., Minneapolis, MN). Methods A brain tissue defect was created in 228 Wistar outbred rats, and either no agent (negative control), Arista, Surgicel (oxidized cellulose; Ethicon, Inc., Somerville, NJ), Avitene (microfibrillar collagen; Alcon, Inc., Humacao, PR), FloSeal (gelatin matrix thrombin sealant; Baxter Healthcare Corp., Deerfield, IL), or kaolin (positive control) was implanted. Time to hemostasis was documented. The animals were sacrificed at different intervals up to 28 days, and presence of residual material and foreign body reaction was determined. Results Arista, Avitene, FloSeal, and Surgicel performed better (defined as complete hemostasis within 1 minute) than control (no treatment). Residual material was not present at any time with Arista, markedly contrasting with the presence of residual material in 100% of lesions in the Avitene, FloSeal, and Surgicel groups on Day 14. Avitene and FloSeal also demonstrated a propensity for causing granuloma formation, whereas Arista and Surgicel showed no such evidence. Conclusion Each of these hemostatic agents was effective in controlling bleeding in the majority of standardized neurosurgical lesions. Arista degrades more rapidly than Surgicel, Avitene, and FloSeal and does not result in any foreign body reaction.

Background: The duration of time that elective noncardiac surgery (NCS) should be delayed after percutaneous coronary intervention (PCI) with bare metal stents (BMSs) is unknown. Methods: This large, single-center, retrospective study examined the relation between complication rate in patients with BMSs undergoing NCS and the duration of time between PCI and NCS. Primary endpoints included in-hospital major adverse cardiac events (death, myocardial infarction, stent thrombosis, or repeat revascularization with either coronary artery bypass grafting or PCI of the target vessel) and bleeding events. The relation between the events and the timing of noncardiac surgery after PCI with BMS was assessed using univariate analysis and multiple logistic regression. Results: From January 1, 1990, to January 1, 2005, a total of 899 patients were identified. The frequency of major adverse cardiac events was 10.5% when NCS was performed less than 30 days after PCI with BMS, 3.8% when NCS was performed between 31 and 90 days after PCI with BMS, and 2.8% when NCS was performed more than 90 days after PCI with BMS. In univariate and multivariate analyses, a shorter time interval between PCI with BMS and noncardiac surgery was significantly associated with increased incidence of major adverse cardiac events (univariate: P < 0.001; odds ratio 4.0; 95% confidence interval, 2.0‐8.3; multivariate: P 0.006; odds ratio 3.2; 95% confidence interval, 1.5‐6.9). Bleeding events were not associated with time between PCI with BMS and NCS or with the use of antiplatelet therapy in the week before NCS. Conclusions: The incidence of major adverse cardiac events is lowest when NCS is performed at least 90 days after PCI with BMS. PERCUTANEOUS coronary intervention (PCI) with stenting 1 is the most common method of myocardial revascularization. Coronary stents have been shown to provide better short- and long-term outcome when compared with balloon angioplasty alone. 2 Both bare-metal stents (BMSs) and drug-eluting stents are used in clinical practice, the former for more than 10 yr, whereas drugeluting stents have been commercially available since 2003 in the United States. 3 Although drug-eluting stents are now used in the majority of procedures, BMSs are still indicated for a variety of patients based on individual clinical situations. 4 Thrombosis of a stent is associated with major morbidity and mortality. 5 Antiplatelet therapy is routinely administered to prevent stent thrombosis after PCI with BMS. 6 Current oral pharmacotherapy includes aspirin and clopidogrel. Bare metal stent thrombosis with this regimen occurs in less than 0.5% of patients at 30 days after PCI with BMS. 7

Background The American College of Cardiology released a scientific advisory that included a recommendation to delay elective of noncardiac surgery (NCS) for 1 yr after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES). Methods This single-center, retrospective study examined the risk for complications of NCS performed within 2 yr after DES placement and examined whether this risk changed based on the time between procedures. The primary endpoint was major adverse cardiac events (MACEs) during the hospitalization for NCS. Bleeding events were analyzed as a secondary endpoint. Results From April 22, 2003, to December 31, 2006, a total of 520 patients underwent NCS within 2 yr after PCI with a DES at Mayo Clinic. The majority, 84%, of the DES placed were Cypher stents. The frequency of MACE was not found to be significantly associated with the time between PCI and NCS (rate of MACEs 6.4, 5.7, 5.9, and 3.3% at 0-90, 91-180, 181-365, and 366-730 days after PCI with DES, respectively; P = 0.727 for comparison across groups). Characteristics found to be associated with MACEs in univariate analysis were advanced age (P = 0.031), emergent NCS (P = 0.006), shock at time of PCI (P = 0.035), previous history of myocardial infarction (P = 0.046), and continuation of a thienopyridine (ticlopidine or clopidogrel) into the preoperative period (P = 0.040). The rate of transfusion did not seem to be associated with antiplatelet therapy use. Conclusions The risk of MACEs with NCS after DES placement was not significantly associated with time from stenting to surgery, but observed rates of MACEs were lowest after 1 yr.

Study Objective To determine whether a new Sonoclot-based, aprotinin-insensitive activated clotting time (aiACT) assay yields stable results over a broad range of aprotinin concentrations. Design Prospective trial conducted on in vitro blood samples. Setting Tertiary-care teaching medical center. Participants 19 healthy adult volunteers. Interventions Whole blood samples were collected from volunteers. Heparin (2 U/mL) and escalating concentrations of aprotinin of 160 to 500 kallikrein inhibitory units (KIU)/mL were added in vitro. Measurements and Main Results Celite ACT, kaolin ACT, and aiACT assays were completed. The aiACT showed stable activated clotting time (ACT) results on heparinized, noncitrated blood with added aprotinin ( P = nonsignificant). In contrast, celite ACT and kaolin ACT were greatly prolonged when aprotinin was added to heparinized, noncitrated, and citrated blood ( P P = nonsignificant). Conclusions Aprotinin (160, 320, and 500 KIU/mL) significantly prolongs the ACT value with celite and kaolin activators but not with the aprotinin-insensitive activator.

Background Prior research has provided inconsistent data regarding the risk factors associated with complications from arterial cannulation. The goal of this study was to clearly define the incidence and risks factors associated with arterial cannulation complications. Methods After obtaining institutional review board approval, all patients requiring arterial line placement with documentation were included in this retrospective study between January 1, 2006, and December 31, 2012. Leveraging two robust data warehouses, the Perioperative DataMart and the Mayo Clinic Life Silences System, the authors cross-matched arterial line cannulation with a documented vascular consult, neurologic consult, infection, or return to surgery within 30 days in order to identify the initial patient population. Results A total of 62,626 arterial lines were placed in 57,787 patients, and 90.1% of the catheters placed were 20-gauge catheters. The radial artery was cannulated in 94.5% of patients. A total of 21 patients were identified as having experienced vascular complications or nerve injuries, resulting in a complication rate of 3.4 per 10,000 (95% CI, 2.1 to 5.1). Cardiac surgery had the largest number of catheters placed (n = 15,419) with 12 complications (complication rate = 7.8 per 10,000; 95% CI, 4.0 to 13.6). The rate of complications differed significantly (P < 0.001) across the three most common catheter sizes (2.7 per 10,000 [95% CI, 1.5 to 4.4] for 20 gauge, 17.2 per 10,000 [95% CI, 4.7 to 43.9] for 18 gauge, and 9.4 per 10,000 [95% CI, 1.1 to 34.1] for 5 French). Conclusion In a large retrospective study, the authors document a very low rate of complications with arterial line placement.

Fenoldopam, a selective dopamine-1-receptor agonist, decreases arterial blood pressure rapidly, with a brief duration of action similar to sodium nitroprusside (SNP), but in contrast to SNP, it increases renal blood flow. We compared the hemodynamic and renal effects of fenoldopam in patients undergoing abdominal aortic surgery requiring cross-clamping of the aorta with another therapeutic option, dopamine and SNP. Fenoldopam or 2 mcg x kg(-1) x min(-1) of dopamine and SNP was infused before incision in 60 randomly selected patients in a double-blind fashion. Hemodynamic variables were recorded before incision, immediately before clamping the aorta, 5 min after cross-clamp release and upon completion of surgery. Urine output, serum creatinine, and creatinine clearance were measured intraoperatively and postoperatively. Characteristics were compared between groups using two-sample rank sum test for continuous variables and Fisher's exact test for discrete variables. The occurrence of severe hypotension, maximum systolic blood pressure, and need for additional antihypertensive drugs were not different between the groups. Most intraoperative hemodynamic variables and all indices of renal function did not differ according to treatment. Therefore, fenoldopam has no therapeutic advantage compared with similar therapies in patients undergoing major vascular surgery involving cross-clamping of the aorta.

Objective: The purpose of this study was to determine if substitution of a heparin-coated oxygenator and salvaged autologous blood for cardiotomy suction would improve platelet function. Design: A prospective, randomized trial. Setting: A large academic medical center. Participants: Sixty adult patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass (CPB). Interventions: Patients were randomized into 1 of 4 groups in a 2 × 2 factorial design by oxygenator (heparinized v nonheparinized) and blood salvage during CPB (cardiotomy suction v salvaged autologous blood). Measurements and Main Results: Primary outcome measures were platelet function, glass-bead retention, platelet dense-body adenosine triphosphate secretion, platelet-rich plasma (PRP) aggregometry, Plateletworks platelet-function analyzer (Helena Laboratories Corp, Allen Park, MI), and platelet count. Secondary outcome measures were chest-tube drainage and allogeneic blood transfusion requirements. All platelet-function tests except thrombin-receptor activator peptide-induced PRP aggregometry showed a reduction in platelet function during and immediately after CPB (all p < 0.05). The only statistically significant difference in platelet-function tests between the groups was the glass-bead assay at 5 minutes before discontinuation of CPB (p < 0.05). This difference resolved 10 minutes after protamine administration. There were no differences between the groups in the amount of blood transfused, chest-tube drainage, and routine laboratory test results. Conclusions: The authors concluded that the effects of these changes to the CPB circuit were small and inconsequential in this cohort of patients.

Background The active metabolite of clopidogrel binds the P2Y 12 ADP receptor on the platelet surface via a disulfide bond. N -Acetylcysteine (NAC) is able to reduce disulfide bonds. We postulated that NAC might reverse clopidogrel's effect on platelets. Methods Two groups of patients were investigated. Group 1 included 11 patients with stable coronary disease who, after discontinuation of aspirin, received 14 days of clopidogrel, 75 mg/day. Bleeding time and whole-blood platelet aggregometry (with 5 μmol/L ADP) were compared before and after the 14 days. Patients were then treated with 6 g of NAC orally, followed by repeat measurement of bleeding time and aggregometry. In group 2, 14 patients were treated with clopidogrel (300 mg) and aspirin before a percutaneous coronary intervention. Blood was drawn 22 ± 3 hours later and divided into 2 samples. One was sent immediately for platelet-rich plasma aggregometry (using 5 and 2 μmol/L ADP, collagen, and arachidonic acid as agonists), thromboelastography, and aggregometry using the Plateletworks assay (Helena Laboratories, Beaumont, Tex). The other sample was treated with NAC (500 mg/L), after which these same platelet function tests were performed. Results In group 1, NAC therapy did not significantly change the bleeding time or results of aggregometry. In group 2, neither aggregometry nor the Plateletworks assay suggested reversal of inhibition by NAC. Conclusions These studies reveal that a large dose of NAC does not reduce inhibition of platelet aggregation by clopidogrel in vitro or in vivo.

Objective : The purpose of this study was to determine if 6% HES 450/0.7 (hydroxyethyl starch 450/0.7) in normal saline (Hespan) and 6% HES 450/0.7 in lactated Ringer’s solution (Hextend) have the same inhibition of the intrinsic coagulation pathway and platelet function. Multiple studies have suggested that 6% Hespan inhibits coagulation and increases chest tube drainage and transfusion requirements in cardiac surgical patients. There have been few studies of the effects of 6% Hextend, a relatively new plasma volume expander, on coagulation and the results thus far have been mixed. Design : A prospective in vitro study. Setting : A large academic medical center. Participants : Blood was collected from 30 healthy volunteers. Interventions : The blood was fractionated and diluted by 30% with Hextend, Hespan, normal saline, and lactated Ringer’s solutions, with a native sample for a control. Measurements and main results : Primary outcome measures were thromboelastography and activated partial thromboplastin time (APTT). For each of the TEG parameters, there was no difference between samples diluted with Hextend compared with Hespan (p ≥ 0.112 in all cases). APTT did not differ significantly between samples diluted with Hextend compared with Hespan (p = 0.562). Conclusions : This prospective in vitro study suggests that Hextend and Hespan, hydroxyethyl starch 450/0.7 in different base solutions, exhibit the same effect on platelet function as measured by the TEG.

Background Activation of the inflammatory cascade is thought to account for some of the respiratory dysfunction and prolonged mechanical ventilation associated with cardiopulmonary bypass. The objective of this investigation was to identify whether perioperative steroids or hemofiltration during cardiopulmonary bypass, by their attenuation of inflammation, would reduce duration of mechanical ventilation after cardiac surgery. Methods After Institutional Review Board approval and informed consent, 192 patients scheduled to undergo elective primary coronary artery bypass grafting or valvular replacement or repair were randomized in a double-blind prospective study into three groups. One group (Control) received saline at induction and at 6-h intervals for four doses. Another group (Hemofil) received saline and hemofiltration to obtain 27 ml/kg of hemofiltrate. The final group (Steroid) received 1 g methylprednisolone before anesthesia induction and then 4 mg of dexamethasone at 6-h intervals for four doses. All patients underwent normothermic cardiopulmonary bypass and received propofol for postoperative sedation. Separate two-sample comparisons were performed to compare each experimental group versus the control group using the Wilcoxon rank sum test for continuous variables and Fisher exact test for categorical variables. In all cases, two-tailed P values Results The median time until the patient reached an intermittent mandatory ventilation of 4/min (258.5 versus 385.0 min, respectively; P = 0.02) and tracheal extubation (352.0 versus 518.0 min; P = 0.03) was significantly reduced for group Hemofil but no different for Steroid compared to Control. Conclusions Hemofiltration and steroids are both previously reported to attenuate the inflammatory response but only hemofiltration reduced time to tracheal extubation for adults after cardiopulmonary bypass in this study.

Objectives Infants and children undergoing cardiopulmonary bypass for repair of congenital heart defects are at substantial risk for excessive bleeding, contributing greatly to morbidity and mortality. Aprotinin significantly reduces bleeding and transfusion requirements in adults but is of indeterminate value for pediatric patients. The aim of this study was to determine plasma aprotinin concentrations in these patients with a functional aprotinin assay. Methods Thirty patients less than 16 years of age scheduled for cardiac surgery with aprotinin were enrolled. Aprotinin was administered as a 25,000 KIU/kg bolus, 35,000 KIU/kg cardiopulmonary bypass prime, and 12,500 KIU · kg −1 · h −1 continuous infusion. Blood samples for aprotinin concentrations (kallikrein-inhibiting units/milliliter) were obtained before aprotinin; 5 minutes post-bolus; 5 minutes after cardiopulmonary bypass initiation; 30 and 60 minutes on cardiopulmonary bypass; on discontinuation of aprotinin; 1 hour after aprotinin discontinuation; and 4 hours after permanent separation from cardiopulmonary bypass. For analysis, patients were grouped according to weight ( 20 kg). Differences between weight groups were assessed using an exact test for categoric variables and 1-way analysis of variance for continuous variables. Results Aprotinin concentrations differed significantly across weight groups. Five minutes after aprotinin bolus and initiation of cardiopulmonary bypass, there was significant correlation between weight and aprotinin concentration ( r = .57, P = .003; r = .69, P = .001, respectively). Conclusion A functional assay reveals significant variability in aprotinin concentration for pediatric patients using current weight-based aprotinin dosing. Additional investigation is necessary to determine target aprotinin concentration dosing regimens to provide better efficacy.

Compared with adults, infants and children who undergo cardiopulmonary bypass for cardiac surgery present with a myriad of anticoagulation considerations. Inadequate anticoagulation during cardiopulmonary bypass may cause “subclinical” or “overt” thrombosis, while effective anticoagulation decreases excessive bleeding and transfusions. Current strategies for heparinization and its neutralization in pediatric patients undergoing congenital heart repair requiring cardiopulmonary bypass are examined. The coagulation system of the neonate and infant is immature and is further weakened by congenital heart disease. Changes in coagulation and fibrinolytic activity occur during cardiopulmonary bypass as a result of hemodilution and exposure of the blood to the extracorporeal circuit. Adequate anticoagulation is essential to minimize the thrombin generation that will result. The extent of excessive thrombin formation in pediatric patients undergoing cardiopulmonary bypass is better appreciated today than in the past, but no controlled study defines the optimal dose or technique for heparin dosing in these patients. Heparin concentration may even fall to 1.5 U/mL during cardiopulmonary bypass. However, the activated clotting time and heparin concentration correlate poorly. The ideal method to achieve adequate thrombin inhibition is unknown. Additionally, the dangers of excessive protamine are becoming more apparent. Heparin continues to be the most effective agent to achieve anticoagulation and protamine the most effective agent to neutralize it. A technique for heparin and protamine dosing with determination of heparin concentrations, may remove many variables associated with pediatric cardiac surgery that requires cardiopulmonary bypass and may provide clinicians with new therapies to achieve better anticoagulation for patients and consequently better outcomes.

Background Infants and children undergoing cardiopulmonary bypass become substantially hemodiluted secondary to the volume used to prime the oxygenator. Fresh-frozen plasma has been included in the prime to lessen dilution of clotting factors and correspondingly minimize blood loss and transfusions. Methods We prospectively randomized 56 patients weighing 10 kg or less who required cardiopulmonary bypass to receive either one unit of fresh-frozen plasma or 200 mL of albumin 5% in the prime. After protamine administration, samples for prothrombin time, fibrinogen, platelet count, and thromboelastogram were obtained. Mediastinal chest tube drainage and transfusion requirements were documented. Results There were no significant differences between groups regarding demographic or surgical characteristics. Blood loss during the first 24 hours was similar in both groups, but total transfusions were significantly greater in those who received fresh-frozen plasma instead of albumin 5% in the prime (8.0 ± 4.2 versus 6.1 ± 4.5 U, respectively; p = 0.035). Post hoc analyses suggest that for cyanotic patients and patients undergoing complex operations, fresh-frozen plasma in the prime results in less blood loss than albumin 5%. Conclusions Substitution of albumin 5% for fresh-frozen plasma in the prime of acyanotic patients weighing 10 kg or less who undergo noncomplex operations requiring cardiopulmonary bypass significantly reduces perioperative transfusions without increasing blood loss. Further investigation is needed to determine whether increased blood loss is associated with increased transfusions when albumin 5% is substituted for fresh-frozen plasma in the prime of infants and children who are cyanotic or undergoing complex operations.

Objective: To assess the effect of heparin-coated circuits on bleeding, transfusion, and platelet count in patients undergoing primary coronary artery bypass grafting with full heparinization. Design: Randomized, double-blind study. Setting: Tertiary-care academic medical center. Participants: Eighty-eight patients undergoing coronary artery bypass grafting requiring cardiopulmonary bypass (CPB) without previous sternotomy. Interventions: Subjects received either a heparin-coated or an uncoated extracorporeal circuit for CPB. Heparin, 300 μ/kg, was administered, and supplemental amounts were administered to maintain an activated coagulation time of greater than 480 seconds. Platelet counts were determined during CPB. Mediastinal chest tube drainage was collected in the intensive care unit for 24 hours. Measurements and Main Results: The mean platelet counts were similar between the groups during CPB. There was no significant difference in 24-hour mediastinal chest tube drainage (mean ± standard deviation; median) between the heparin-coated (n = 44, 1096 ± 401, 1015 mL) and uncoated group (n = 44, 1150 ± 548,1040 mL; p = 0.91). The heparin-coated group received less allogeneic packed red blood cells (0.9 ± 1.6, 0.0 v 1.5 ± 1.8, 1.0 U; p = 0.04). Conclusions: The use of a heparin-coated or uncoated cardiopulmonary bypass circuit and full heparinization marginally reduced only red blood cell transfusion but was not associated with platelet sparing or reduced perioperative bleeding. © 2003 Elsevier Inc. All rights reserved.

UNLABELLED Aprotinin is effective during cardiac surgery for reducing blood loss and transfusion requirements, but it is expensive. Aprotinin is usually administered to adults according to a fixed protocol regardless of the patient's weight. We previously developed a weight-based dosing protocol for aprotinin. The purpose of this prospective observational study was to determine aprotinin levels in four patient groups (n = 10 each) using the new weight-based aprotinin dosing schedule that should achieve concentrations over 100, 150, 200, and 250 kallikrein inhibitory units/mL compared with full-dose aprotinin regimen (n = 10) by a simple functional aprotinin assay. There was no difference in patient demographic or surgical variables among groups. There was less within patient variation in plasma aprotinin concentrations over time in the new weight-based aprotinin dosing schedule groups compared with the full-dose aprotinin regimen group (P < 0.02 for all comparisons). The mean plasma aprotinin concentration achieved with the new weight-based aprotinin dosing schedule was similar to the desired concentrations, but we were unable to reduce between-patient variability in aprotinin concentrations. IMPLICATIONS The current dosing schedule for aprotinin results in a large variation in aprotinin plasma concentrations between patients and a large variation within each patient over time. A new weight-based dosing schedule reduced variation of aprotinin concentration over time, but was unable to reduce between-patient variability in aprotinin concentration.

Purpose of review Miss-transfusion of blood has become one of the leading causes of death related to blood transfusion. New technology is able to better prevent miss-transfusions than older methods. Recent findings New computer-based technology is available and is very effective in preventing miss-transfusion of blood. Summary Humans make errors. New technology can prevent those errors.

Background We conducted a retrospective study to assess whether providing extracorporeal membrane oxygenation (ECMO) support to elderly patients (aged 70 years or more) who failed separation from cardiopulmonary bypass after cardiac surgery was a viable option. Methods From 2003 to 2013, 45 patients aged 70 years or more underwent 47 runs of ECMO postoperatively. Results There were 31 men (68.9%). The mean age was 76.8 years. Five patients were in cardiogenic shock preoperatively. Forty-four patients required venoarterial ECMO support for cardiogenic shock. Mean duration of support was 103.8 ± 74.3 hours. Twenty-one patients (46.6%) died while on ECMO support. Twenty-four patients (53.3%) were weaned off ECMO initially, and 11 patients were discharged from hospital. Inhospital mortality was 75.6%. Postoperative complications included acute kidney injury in 30 patients (44.4%), pneumonia in 12 (26.7%), and sepsis in 11 (24.4%). There were 30 deaths (88.2%) attributable to cardiac causes. Preoperative atrial fibrillation, chronic kidney injury, lactic acidosis on ECMO support, and persistent coagulopathy were associated with higher mortality. Conclusions Postcardiotomy ECMO support in elderly patients is associated with high postoperative morbidity and mortality. Nevertheless, it often provides the last line of therapy for these critically ill patients and may provide positive outcomes in selected subgroups.

Although tranexamic acid is used to reduce bleeding after cardiac surgery, there is large variation in the recommended dose, and few studies of plasma concentrations of the drug during cardiopulmonary bypass (CPB) have been performed. The plasma tranexamic acid concentration reported to inhibit fibrinolysis in vitro is 10 microg/mL. Twenty-one patients received an initial dose of 10 mg/kg given over 20 min followed by an infusion of 1 mg. kg(-1). h(-1) via a central venous catheter. Two patients were removed from the study secondary to protocol violation. Perioperative plasma tranexamic acid concentrations were measured with high-performance liquid chromatography. Plasma tranexamic acid concentrations (microg/mL; mean +/- SD [95% confidence interval]) were 37.4 +/- 16.9 (45.5, 29.3) after bolus, 27.6 +/- 7.9 (31.4, 23.8) after 5 min on CPB, 31.4 +/- 12.1 (37.2, 25.6) after 30 min on CPB, 29.2 +/- 9.0 (34.6, 23.8) after 60 min on CPB, 25.6 +/- 18.6 (35.1, 16.1) at discontinuation of tranexamic acid infusion, and 17.7 +/- 13.1 (24.1, 11.1) 1 h after discontinuation of tranexamic acid infusion. Four patients with renal insufficiency had increased concentrations of tranexamic acid at discontinuation of the drug. Repeated-measures analysis revealed a significant main effect of abnormal creatinine concentration (P = 0.02) and time (P0.001) on plasma tranexamic acid concentration and a significant time x creatinine concentration interaction (P0.001).A 10 mg/kg initial dose of tranexamic acid followed by an infusion of 1 mg.kg(-1).h(-1)produced plasma concentrations throughout the cardiopulmonary bypass period sufficient to inhibit fibrinolysis in vitro. The dosing of tranexamic acid may require adjustment for renal insufficiency.

Aprotinin is an effective but expensive drug used during cardiac surgery to reduce blood loss and transfusion requirements. Currently, aprotinin is administered to adults according to a fixed protocol regardless of the patient's weight. The purpose of this study was to determine aprotinin levels in patients receiving full- and half-dose aprotinin regimens by a simple functional aprotinin assay and to design a more individualized aprotinin dosage regimen for cardiac surgical patients. The mean plasma aprotinin concentration peaked 5 min after the initiation of cardiopulmonary bypass (full 401 +/- 92 KIU/mL, half 226 +/- 56 KIU/mL). The mean plasma aprotinin concentration after 60 min on cardiopulmonary bypass was less (full 236 +/- 81 KIU/mL, half 160 +/- 63 KIU/mL). There was large variation in the aprotinin concentration among patients. A statistically significant correlation was found between aprotinin concentration and patient weight (r(2) = 0.67, P0.05).The current dosing schedule for aprotinin results in a large variation in aprotinin plasma concentrations among patients and a large variation within each patient over time. We combined the information provided by our study with that of a previous pharmacokinetic study to develop a potentially improved, weight-based, dosing regime for aprotinin.

Objective: To determine the blood loss associated with coronary angiography and its impact on hemoglobin and transfusion requirements for subsequent coronary artery bypass graft (CABG) surgery. Design: Retrospective chart review. Setting: Tertiary-care, academic medical center. Participants: A total of 506 adult patients undergoing coronary angiography and CABG surgery. Interventions: None (observational study). Measurements and Main Results: Coronary angiography was associated with a reduction in hemoglobin of 1.8 g/dL. This reduction in hemoglobin was a significant predictor of allogeneic red blood cell transfusion. Conclusion: Coronary angiography contributes to a 1.8 g/dL reduction in hemoglobin concentration before CABG surgery and was associated with increased transfusion of allogeneic blood products. Measures aimed at maintaining red cell volume during coronary angiography, increasing erythropoiesis, or delaying surgery beyond 2 weeks may result in a decrease in transfusion requirements for patients undergoing CABG surgery.

Objectives To determine, in patients undergoing total hip arthroplasty (THA), clinical predictive criteria for preoperative autologous blood donation and to propose guidelines to increase the efficiency and reduce the cost of preoperative autologous blood donation. Patients and Methods In this retrospective analysis of 165 adult patients undergoing primary THA, a stepwise regression analysis was used to determine which clinical variables predict erythropoiesis in patients donating autologous blood before THA. The surgical blood order equation (SBOE), which includes values for hemoglobin lost at surgery, preoperative hemoglobin level, and minimal acceptable hemoglobin level, was used to estimate the number of units of red blood cells (RBCs) needed for each patient at surgery and thus identify which patients should have made preoperative autologous blood donations. Results The statistically significant indicators for RBC production were predonation hemoglobin concentration ( P P =.003). Combining the regression equation for erythropoiesis with the SBOE allowed development of guidelines for the use of preoperative autologous RBC donation and erythropoietic therapy. For primary THA surgery, a patient with a predonation hemoglobin level higher than 14.7 g/dL does not need preoperative autologous donation. Preoperative autologous RBC donation would be effective for men with hemoglobin concentrations of 14.7 g/dL or less and for women with predonation hemoglobin levels of 13.2 to 14.7 gldL. In women whose hemoglobin level is less than 13.2 gl dL, erythropoietic therapy should accompany autologous donation. Conclusion Incorporation of patient factors with the SBOE system may result in increased efficiency and decreased cost of autologous blood ordering practices before THA.

Background . We hypothesized that normothermic cardiopulmonary bypass (CPB) would be associated with decreased blood loss and allogeneic transfusion requirements relative to hypothermic CPB. Methods . After obtaining institutional review board approval and informed patient consent, we conducted a prospective, randomized study of 79 patients undergoing CPB for a primary cardiac operation at normothermic (37°C) (n = 44) or hypothermic temperature (25°C) (n = 35). Blood loss and transfusion requirements in the operating room and for the first 24 hours in the intensive care unit were determined. A paired t test and rank sum tests were used. A p value of less than 0.05 was considered significant. Results . The normothermic and hypothermic CPB groups did not differ in demographic variables, CPB or cross-clamp duration, heparin sodium or protamine sulfate dose, prothrombin time, or thromboelastogram results. There were no differences between the two CPB groups in blood loss or transfusion requirements. Conclusions . We found that when there was no difference in duration of CPB, normothermic and hypothermic CPB groups demonstrated similar blood loss and transfusion requirements even though other studies have shown hypothermia induces platelet dysfunction and alters the activity of the coagulation cascade.

BACKGROUND: The majority of crossmatched blood is for surgical patients, and most of it is never transfused. An alternative system for ordering red cell (RBC) units, called the surgical blood order equation (SBOE), which incorporates specific patient variables for surgical patients, has been developed. STUDY DESIGN AND METHODS: A prospective double-blind randomized trial compared the SBOE with the maximal surgical blood order schedule (MSBOS) system for ordering allogeneic RBC units in 60 patients undergoing total hip arthroplasty. Autologous RBCs were available for none of the patients. RESULTS: There were no differences in patient demographic, surgical, or laboratory variables at any time. The median number (range) of allogeneic RBC units ordered was 2 (2–3) for the MSBOS and 0 (0–3) for the SBOE (p

Objective. With the practice of warm cardiopulmonary bypass (CPB) at our institution we have observed an apparent increase in heparin requirements. CPB temperature predictability affects pharmacokinetics and differences in drug metabolism can be expected. We hypothesized that heparin requirements would increase with increasing CPB temperature. Methods. Following Institutional Review Board approval, we reviewed the charts of 354 patients undergoing primary coronary artery bypass graft surgery. We recorded patient demographic data, CPB duration, heparin requirements, and temperature during CPB. CPB was conducted between 24 °C and 37 °C. The Spearman's correlation coefficient, Pearson chi-square, and rank-sum tests were used for data analysis. Results. Core temperature during CPB correlated with heparin requirements (r = 0.13, p < 0.02). However, CPB duration was shorter in warm patients than in cold patients (r = −0.455, p < 0.0001). Additional heparin requirements adjusted for duration of CPB (units/minute) were also significantly greater in the warm group (p = 0.018). Conclusions. Maintenance of adequate heparin anticoagulation during CPB is clinically important. Warm CPB patients required more heparin per minute than those undergoing cold CPB. More frequent assessment of anticoagulation and administration of additional heparin should be considered in patients undergoing warm CPB.

Platelet dysfunction is a major cause of bleeding after cardiopulmonary bypass (CPB). No timely, simple, point-of-care determinant of platelet function is available for clinical use. Adding platelet-activating factor to conventional activated clotting time methods (platelet-activated clotting test [PACT]) (HemoSTATUS; Medtronic, Inc., Parker, CO) produces rapid results (

Objective: The purpose of this study was to examine the effect of cardiopulmonary bypass flow rate on cerebral blood flow and cerebral metabolic rate for oxygen during hypothermic (27°C) cardiopulmonary bypass. Design, Setting, and Participants: The investigation was a prospective, randomized study in a tertiary care hospital setting. The 30 participants were volunteer adult cardiac surgical patients at a single institution. Interventions: The N20 saturation method of Kety and Schmidt was used to determine global cerebral blood flow and metabolic rate during four periods: prebypass, cardiopulmonary bypass (CPB) (27°C) flow rates of 2.3 and 1.2 L/min/m2, and 30 minutes post-CPB. Anesthesia consisted of fentanyl and midazolam; pH management was a-stat, and mean arterial pressure was maintained at 50 to 70 mmHg throughout CPB. Measurements and Main Results: In the context of an unchanged mean arterial pressure, the pump flow did not affect cerebral blood flow or metabolic rate during hypothermic CPB. Systemic venous oxygen saturation was also maintained during reduced flow at 27°C. Hemodilution during hypothermic CPB maintained cerebral blood flow at prebypass levels. In the postbypass period, persistent hemodilution resulted in an elevated cerebral blood flow. Conclusions: Brain oxygenation is well maintained at lower than conventional pump flow levels during CPB. There may be practical advantages to reduced flows during hypothermia, and flow reductions do not appear to adversely affect cerebral blood flow or metabolism.

To assess the clinical utility of ketamine as an anesthetic agent for electroconvulsive therapy (ECT), based upon recent findings that ketamine may have antidepressant properties. Depressed ECT patients were randomly assigned to receive anesthesia with either ketamine or methohexital. Outcome measures included assessments of depressive severity, cognition, post-anesthesia side effects, and hemodynamics. Twenty one patients were treated with ketamine and 17 with methohexital. There were no significant differences in depression or cognitive outcomes between the two drugs. Additionally, there were no measures of post-anesthesia tolerability or hemodynamics which favored ketamine. Ketamine anesthesia does not accelerate the antidepressant effect of ECT or diminish the cognitive side effects, at least as measured in this study. Furthermore, there is no apparent benefit of ketamine for speed or quality of post-ECT recovery, and it is associated with higher systolic blood pressures after the treatments. Ketamine is associated with longer motor seizure duration than methohexital.

The objective of our study was to review the long-term outcomes of patients undergoing surgical repair of aortic coarctation.Surgical repair of aortic coarctation has been performed at the Mayo Clinic, Rochester, Minnesota, for over 60 years.Between 1946 and 2005, 819 patients with isolated coarctation of the aorta underwent primary operative repair. Medical records were reviewed and questionnaires mailed to the patients.Mean age at repair was 17.2 ± 13.6 years. The majority (83%) had pre-operative hypertension. Operations included simple and extended end-to-end anastomosis (n = 632), patch angioplasty (n = 72), interposition grafting (n = 49), bypass grafting (n = 30), and subclavian flap or "other" (n = 35). Overall early mortality (30 days) was 2.4%. In the previous 30 years (n = 225), there were no operative deaths. Mean follow-up was 17.4 ± 13.9 years, with a maximum of 59.3 years. Actuarial survival rates were 93.3%, 86.4%, and 73.5% at 10, 20, and 30 years, respectively. When compared to an age- and sex-matched population, long-term survival was decreased (p0.001). Older age at repair (20 yrs) and pre-operative hypertension were associated with decreased survival (p0.001). Patients age9 years age at repair had significantly less hypertension at 5 to 15 years of follow-up (p0.001). Rates of freedom from re-intervention on the descending aorta were 96.7%, 92.2%, and 89.4% at 10, 20, and 30 years, respectively. Younger age at time of repair (p0.001) and an end-to-end anastomosis technique (p0.001) were independently associated with lower rates of re-intervention on the descending aorta.Primary repair of isolated coarctation of the aorta was performed with a low rate of mortality. However, long-term survival was reduced compared with that in an age- and sex-matched population, and many patients required further reoperation. These findings emphasize that patients with aortic coarctation need early recognition and intervention, as well as lifelong informed follow-up.

A noninvasive, simple, and continuous method to assess cerebral perfusion during cardiopulmonary bypass (CPB) could help prevent cerebral ischemia. Transcranial Doppler sonography (TCD) allows a noninvasive, on-line measurement of blood flow velocity in cerebral arteries. The correlation of TCD-estimated and actual cerebral blood flow (CBF) has not been well studied during CPB. We determined the correlation of middle cerebral artery (MCA) mean velocity and CBF determined by the Kety-Schmidt method during nonbypass and two hypothermic bypass flow conditions. Sixteen patients undergoing hypothermic (27 degrees C) CPB for coronary artery bypass grafting and/or valve replacement surgery were enrolled in the study. We were able to determine MCA velocity in only 12 patients. We determined CBF and MCA velocity in each patient during four 15-min study periods: 1) prebypass after sternotomy before aortic cannulation; 2) hypothermic (27 degrees C) CPB with 1.2 L.min-1.m-2 pump flow; 3) hypothermic CPB with 2.4 L.min-1.m-2 pump flow, and 4) 30 min after weaning from CPB. There was no difference in the mean arterial pressure between the two CPB pump blood flows. The pooled change in MCA velocity and CBF as percentage of baseline (prebypass) for all patients and at all time points had a correlation of 0.33 (r). A decrease or increase in MCA velocity did not necessarily indicate a corresponding decrease or increase in CBF. This technology may be of limited usefulness during the circulatory condition of hypothermic, nonpulsatile CPB.

Background. The neurologic effects of warm heart operations is a subject of popular interest. The purpose of this study was to examine the adequacy of cerebral oxygenation during normothermic cardiopulmonary bypass and better define the relationship between hematocrit, temperature, and brain oxygen delivery. Methods. Cerebral blood flow, metabolic rate, and oxygen delivery were measured in 60 patients randomized to normothermic (37°C) or hypothermic (27°C) cardiopulmonary bypass. The nitrous oxide saturation technique of Kety and Schmidt was used for cerebral blood flow determinations. Both temperature groups underwent moderate (31%) hemodilution. Results. During normothermic cardiopulmonary bypass, cerebral blood flow increased secondary to hemodilution and decreased cerebral vascular resistance; a normal matching of oxygen demand and delivery was maintained. During hypothermic bypass, hemodilution and hypothermia had essentially equal, opposing effects on cerebral vascular resistance and blood flow. With hypothermia, brain oxygen demand and delivery were both reduced but not closely coupled. Conclusions. From the standpoint of global cerebral perfusion and oxygenation, our data support the practice of "warm" heart operations. It clarifies the marked influence of hematocrit on cerebral blood flow and delineates the interaction of temperature and hematocrit on cerebral oxygen delivery. It also suggests that additional investigation to better define "temperature-appropriate" hemodilution during cardiopulmonary bypass is indicated.