Postoperative Mediastinal Drainage Research Articles

Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study

BackgroundIt was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery.MethodsA total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch’s t tests, one-way ANOVA, chi-square tests and Fisher’s exact tests were applied.ResultsThere was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups.ConclusionsUsing mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.

Analysis of the hemostatic effect of preset wrapping technique for type A aortic dissection with abnormal coagulation.

There are many techniques to reduce anastomotic bleeding for the total arch replacement, but hemostasis is sometimes difficult to achieve after surgery for acute dissection, especially in patients with abnormal coagulation (AC). This study aimed to investigate the hemostatic effect and early efficacy of a pre-set bovine pericardium wrapper in the right heart system shunt for total arch replacement in patients with type A aortic dissection (TAAD) and preoperative AC. A retrospective analysis was conducted on 85 patients with TAAD and AC who underwent total arch replacement between January 2018 and December 2022. The patients were divided into two groups: the preset pericardium group (n=30) and the control group (n=55). There were no significant differences between the two groups in terms of Bentall surgery (ascending aorta replacement with an aortic valve artificial vessel) and cardiac arrest time. However, compared to the control group, the preset pericardium group exhibited a shorter duration of cardiopulmonary bypass (CPB) and operation (P<0.001). Additionally, the preset pericardium group required fewer transfusions of blood products and hemostatic drugs (P<0.05). Moreover, the preset pericardium group had lower 24-hour postoperative mediastinal drainage volume (P<0.001), a lower proportion of bedside hemofiltration (P=0.039), and a shorter duration of mechanical ventilation and stay in the intensive care unit (P=0.014). Although the preset pericardium group showed reductions in in-hospital mortality, re-exploration for bleeding, and neurologic dysfunction, these differences were not statistically significant compared to the control group. This study represents the first investigation into the application of the preset wrapping technique in total arch replacement for TAAD with AC. The results demonstrate that this method can reduce the duration of CPB and operation, decrease postoperative bleeding, and minimize the need for blood transfusion and hemostatic drugs. Consequently, this technique may contribute to early postoperative recovery.

Atrial Septal Defect Closure by Anterior Mini Thoracotomy with Total Peripheral Cannulation: A Step towards Establishing Mini Invasive Cardiac Surgery in a Developing Nation

Background: Atrial Septal Defect (ASD) closure is a common cardiac surgical procedure performed worldwide. Due to favourable clinical outcome, minimal invasive approach is becoming popular. Hence this study was conducted to compare the outcome of two surgical approaches, median sternotomy and mini thoracotomy with total peripheral cannulation, in a developing country Nepal. Methods: A prospective study of 62 ASD patients, randomized to undergo surgical closure either via right anterior mini thoracotomy or median sternotomy was conducted and followed up over three years. The clinical outcome parameters like intensive care unit stay, hospital stay, post-operative duration of ventilation, cardiopulmonary bypass time, aortic cross clamp time, mediastinal drainage, size of scar and complication were compared between two groups. Results: Cardiopulmonary bypass time and aortic cross clamp time were significantly longer in right anterior mini thoracotomy group as compared to median sternotomy group (43.97 min ± 12.70 min vs 34.42 min ± 10.42 min and 25.13 min ± 7.82 min vs 19.48 min ± 6.93 min respectively, p-value 0.05). There was no significant difference in duration of surgery (2.75 hrs ± 0.43 hrs vs 2.56 hrs ± 0.41 hrs, p-value = 0.09), post-operative ventilation (2.90 hrs ± 1.22 hrs and 2.88 hrs ± 1.07 hrs, p-value = 0.96) between two groups. Post-operative mediastinal drainage was significantly less in right anterior mini thoracotomy group (214.52 ml ± 91.79 ml vs 284.03 ml ± 158.91 ml, p-value = 0.04). There was no significant difference in ICU stay and hospital stay. Conclusion: Atrial septal defect can be safely closed by right anterior mini thoracotomy with a small, cosmetically acceptable submammary scar with less pain and bleeding.

Effects of Minimal Extracorporeal Circulation on the Systemic Inflammatory Response and the Need for Transfusion after Coronary Bypass Grafting Surgery.

Objectives The aim of this study is to compare the effects of the minimal extracorporeal circulation (MiECT) on postoperative systemic inflammatory response and the need for transfusion in patients undergoing open heart surgery with cardiopulmonary bypass. Methods Patients were divided into two groups; Group M (n=31) included the patients operated via using the MiECT system and Group C (n=27) included the patients operated via using conventional cardiopulmonary bypass (CPB). Perioperative markers of inflammation after cardiopulmonary bypass in both groups were tested by measuring the levels via chemiluminescent immunometric assay. Blood samples were taken consecutively after anesthesia induction, 30th minute of CPB, on the 6th, 24th, and 48th hours after cardiopulmonary bypass. Results The mean amount of priming solution was significantly lower in Group M when compared to Group C (802.60 ± 48.26 and 1603.71 ± 49.85 ml). The mean hematocrit (Hct) value taken immediately after cardiopulmonary bypass was found to be significantly higher in the MiECT patients with respect to the other group (% 32.71 ± 3.98 and % 28.82 ± 4.39). The transfused amounts of erythrocyte suspension and fresh frozen plasma were found to be significantly lower in patients in Group M when compared to those in Group C. Postoperative mediastinal drainage was also significantly lower in patients in Group M with respect to the other group. There was no significant difference between markers of inflammation. Conclusion Our results show that MiECT seems to be more advantageous in terms of priming volume, perioperative hematocrit levels, need for blood and blood product transfusion, and mediastinal drainage with respect to the conventional approach after coronary artery bypass grafting.

Application value of single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer

Objective To explore the application value of single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer. Methods The retrospective descriptive study was conducted. The clinicopathological data of 27 patients who underwent single-port inflatable mediastinoscopic and laparoscopic radical resection of esophageal cancer in the General Hospital of Ningxia Medical University between September 2016 and April 2018 were collected. The surgical operators were divided into neck operation group and abdomen operation group. A Y tube was used to inflate the abdomen and mediastinum simultaneously with CO2, and the gas pressure was 12-16 mmHg (1 mmHg=0.133 kPa). Bilateral exchange free and join forces with the esophagus and xiphoid process operating small incision, the severed esophagus cardia; residual stomach was made into a 3-5 cm tubular stomach and was sutured at the top point; at the same time, esophagus was brought up from the neck, with a pouch suture between upper esophageal and stapling head; the tubular stomach through mediastinum-esophagus bed was pulled to the left neck and then gastroesophageal anastomosis manually or instrument was performed. Observation indicators: (1) surgical and postoperative recovery; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to May 2018. The measurement data with normal distribution were represented as ±s. The measurement data with skewed distribution were described as M (range). Results (1) Surgical and postoperative recovery: all the 27 patients underwent successful single-port inflatable mediastinoscopic and laparoscopic radical resection of esophageal cancer, with complete tumor resection and without conversion to open surgery. There was no arrhythmia or myocardial ischemia through intraoperative electrocardiography. Among 27 patients, 5 had intraoperative rupture of the pleura and 3 stopped intermittently inflation with CO2 due to obvious hemodynamic changes. The operation time and volume of intraoperative blood loss were (121±21)minutes and (100±30)mL. Twenty-seven patients had no thoracic incision, obviously decreased postoperative pain and out-of-bed activity at day 1 postoperatively. The volume of postoperative mediastinal drainage was (40±10)mL. The mediastinal drainage-tube was removed at 1 week after regular food intake. Of 27 patients, 5 with pleural effusion were cured by puncture drainage; 2 were complicated with anastomotic leakage, 1 of them with a small amount of subcutaneous gas under neck incision at 12 days postoperatively was cured spontaneously through oral food intake, without special treatment, and the other had a small amount of subcutaneous gas under neck incision after solid food intake at 1 month postoperatively and then was cured after 1-week fluid food intake; 1 with anastomotic stenosis was improved after dilation treatment. The squamous cell carcinoma was confirmed by postoperative pathological examination, without cancer cell infiltration in the upper and lower margins. The numbers of mediastinal lymph node dissected, abdominal lymph nodes dissected and positive lymph node, postoperative pathological staging and duration of hospital stay were respectively 9.5±2.2, 8.2±2.5, 1 (range, 0-12), T1-3N0-1M0 and 13 days (range, 11-21 days). (2) Follow-up and survival situations: 27 patients were followed up for 1-20 months, with a median time of 10 months. During the follow-up, there was no recurrence or metastasis and death. Conclusion The single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer is safe and effective, and it is especially suitable for patients with partial respiratory failure and closed thoracic cavity. Key words: Esophageal neoplasms; Combined operation; Radical resection; Mediastinoscopy; Laparoscopy

The Role of Inflammation in Atrial Fibrillation following Open Heart Surgery

This study investigated the role of systemic inflammation in the development of atrial fibrillation (AF) after coronary artery bypass grafting (CABG). CABG was performed using cardiopulmonary bypass in 77 patients. Pre-operative AF was present in six patients (7.8%) and postoperative AF developed in 13 (18.3%) of the 71 patients with pre-operative sinus rhythm. Post-operative mediastinal drainage was significantly increased in patients with post-operative AF compared with those with sinus rhythm. Plasma E-selectin, P-selectin and vascular cell adhesion molecule levels were not significantly different between patients with pre- and post-operative sinus rhythm, those with pre-operative sinus rhythm and post-operative AF, and those with pre- and post-operative AF. There were significant differences between pre- and post-operative C-reactive protein, interleukin (IL)-6 and IL-10 levels within all three groups, but no differences in these parameters between the groups. Thus, in all groups there were significant alterations in mediators indicative of systemic inflammation following CABG, but comparisons between the groups revealed no differences predictive of AF.

A Comparison of Bilateral with Single Internal Mammary Artery Grafts on Postoperative Mediastinal Drainage and Transfusion Requirement

The superiority of the left internal mammary artery (LIMA) graft over autogenous saphenous vein as a bypass conduit in coronary artery bypass surgery has been well established. Early and late patency rates of bilateral internal mammary artery (BIMA) grafts exceed those of vein grafts, and patients who receive BIMA have improved long-term survival rates and more freedom from reoperations and other cardiac events. But because of other concerns, particularly the question of increased risk of postoperative bleeding, controversy still surrounds the perioperative period. In the present study we sought to determine whether BIMA grafting was an independent risk factor of postoperative bleeding and of blood product use in patients undergoing primary elective coronary artery revascularization. For this purpose, 33 consecutive patients scheduled for BIMA grafting were matched with 66 patients operated on by single LIMA grafting. Patients in the LIMA group had significantly less postoperative mediastinal drainage than those in the BIMA group (median: 722 vs 920 mL, P = 0.0001). Fifty-six patients received blood products (56% vs 51% in LIMA and BIMA groups, respectively; P = 0.67). In multivariate analysis, BIMA and operative duration were independent predictors of increased postoperative drainage. Nevertheless, in logistic regression, BIMA was not significantly associated with blood product use, unlike precardiopulmonary bypass hematocrit and duration of surgery (OR and 95% CI: 0.89 [0.80-0.96] P = 0.01; 1.009 [1.001-1.019] P = 0.04, for an increase of 1% in hematocrit and 1 min in duration of surgery, respectively). In conclusion, these data support the idea that BIMA graft slightly increases postoperative drainage but not transfusion requirement.

Platelet Dysfunction During Cardiopulmonary Bypass Assessed by a Novel Whole-Blood Aggregometer

The purpose of this study was to assess perioperative platelet function with 2 types of monitors (a whole-blood aggregometer [WBA analyzer; Mebanix, Tokyo, Japan]) and the Sonoclot monitor [Sienco, Wheat Ridge, CO]) in patients undergoing hypothermic cardiopulmonary bypass (CPB). Prospective, observational study. Single-center study at a university hospital. Twenty-six patients who underwent coronary artery bypass grafting or valve replacement under hypothermic CPB without platelet transfusion or fresh frozen plasma administration. Blood sampling was performed at the following time periods: after anesthetic induction, after CPB, and on the first postoperative day. These samples were assessed with the WBA analyzer and the Sonoclot. Significant attenuation of adenosine diphosphate-induced platelet aggregation was detected shortly after CPB by 2 WBA analyzer-derived parameters: a decrease in the filtration pressure rate and an increase in the platelet aggregatory threshold index. Platelet aggregation returned to the preoperative level on the next day. There was no correlation between the amount of postoperative mediastinal drainage and defects in platelet aggregation. On the other hand, time to peak obtained by the Sonoclot did not show any significant changes. Whole-blood aggregation measured with the WBA analyzer detected transient platelet dysfunction shortly after CPB, whereas the Sonoclot was less sensitive to this change.

Comparison of two heparin-coated extracorporeal circuits with reduced systemic anticoagulation in routine coronary artery bypass operations

Objectives: The use of heparin-coated circuits for cardiopulmonary bypass attenuates the postperfusion inflammatory response. Postoperative bleeding and the need for allogeneic blood transfusions are reduced, particularly in combination with lowered systemic anticoagulation. The two most commonly used heparin-coated systems are the Carmeda BioActive Surface (Medtronic Inc, Minneapolis, Minn) and the Duraflo II coating (Baxter Healthcare Corp, Bentley Laboratories Division, Irvine, Calif). The 2 surfaces are technically unequal, and previous experimental studies have demonstrated disparities in effects on the immune system and the blood cells. However, no larger comparative studies of relevant clinical end points have thus far been reported. Methods: Over a 24-month period, all patients undergoing coronary artery bypass were prospectively randomized to one of the two heparin-coated circuits. Altogether, 1336 consecutive patients were included. The heparin dose was reduced in all cases, with an activated coagulation time of more than 250 seconds. Clinical data were consecutively collected and stored on a computer for comparative analyses. Results: There were no statistically significant differences in any demographic or operative parameters. The Duraflo II patients required less heparin to keep the target-activated clotting time, confirming the previous finding of some leakage of heparin from the surface to the circulation. Otherwise, there were no significant differences in time for ventilatory support (Duraflo II, 1.7 ± 1.3 hours; Carmeda BioActive Surface, 1.6 ± 1.0 hours; P =.37), amount of postoperative mediastinal drainage (Duraflo II, 665 ± 257 mL; Carmeda BioActive Surface, 688 ± 243 mL; P =.07), need for allogeneic blood-plasma transfusions (Duraflo II, 4.2% of the patients; Carmeda BioActive Surface, 4.4% of the patients; P =.93), or hemoglobin concentration at hospital discharge (Duraflo II, 120 ± 13 g/L; Carmeda BioActive Surface, 119 ± 13 g/L; P =.08). The effects on renal function and platelets were similar, as were the incidences of perioperative myocardial infarction (Duraflo II, 1.5%; Carmeda BioActive Surface, 1.5%; P =.96), stroke (Duraflo II, 1.3%; Carmeda BioActive Surface, 1.2%; P =.47), and hospital mortality (Duraflo II, 1 [0.14%] patient; Carmeda BioActive Surface, 3 [0.45%] patients; P =.31). Conclusions: Despite differences in technology, complexity, and effects on biologic markers, no clinical differences were observed between the Carmeda BioActive Surface system and the Duraflo II coating after coronary artery bypass operations. The overall clinical results were favorable in both groups, confirming the safety and feasibility of routine use of heparin-coated circuits in combination with reduced systemic anticoagulation. (J Thorac Cardiovasc Surg 2001;121:324-30)

Prediction of the mediastinal drainage after coronary artery bypass surgery.

Using multiple correlation and linear regression approaches, we investigated the association between the amount of mediastinal drainage for the first 24 postoperative hours and clinical variables as well as multiple haematological tests performed at three time points: before anaesthesia induction, 10 minutes after protamine administration and just after skin closure, on 46 patients undergoing primary coronary artery bypass grafting. Three models from the three times were then developed to predict mediastinal drainage. The number of internal mammary grafts, the total number of grafts and plasma fibrinogen concentration were useful predictors of mediastinal drainage at all three times. The platelet count taken only after skin closure was found to provide additional predictive information. Each regression model explained approximately 60% of the variation in postoperative mediastinal drainage. The information obtained from these predictive models is useful in defining high-risk populations.

Minimally invasive mitral valve surgery: the subxiphoid approach

Background. This report describes mitral valve replacement using a unique subxiphoid approach with a lower ministernotomy and a skin crease incision and compares the operative and echocardiographic results to patients undergoing mitral valve replacements using previously described strategies. Methods. Fifty-four patients underwent mitral valve replacement using a subxiphoid approach (group 1); 32 patients underwent mitral valve replacement, 11 patients underwent mitral valve replacement + tricuspid reconstruction, 2 patients underwent mitral valve replacement + tricuspid valve replacement, and 9 patients underwent mitral reconstruction. This group of patients was compared to 11 patients who underwent mitral valve replacement through a superior ministernotomy (group 2) and 29 patients who underwent mitral valve replacement with full median sternotomy (group 3, 22 mitral valve replacements, 2 mitral valve replacements + tricuspid reconstruction, 2 mitral reconstructions, and 3 mitral reconstructions + tricuspid reconstruction). Results. There was no operative mortality in all groups. The operation lasted significantly longer in group 2 patients compared to group 1 and 3 patients ( p < 0.01). Postoperative mediastinal drainage was significantly lower in groups 1 and 2 ( p < 0.001). Pain assessment revealed no difference between the groups. Three patients in group 1 presented with pericardial effusion. Except for this complication, early postoperative echocardiographic findings of the patients were similar in all three groups. All patients were in New York Heart Association functional class I or II at the second postoperative month, irrespective of the surgical technique used. Conclusions. There was no prominent superiority of the ministernotomy approaches over the standard median sternotomy approach. However, the reliability of the subxiphoid approach is documented echocardiographically and any type of mitral replacement can be performed with this approach.

Hemorrhage and the Use of Blood Products After Adult Cardiac Operations: Myths and Realities

Background. Several patient-, procedure-, and prescriber-related factors are thought to influence the decision to administer allogeneic blood products. We reexamine a number of assertions applied commonly to the practice of transfusion in cardiac operations. Methods. More than 50 original articles including a total of more than 10,000 patients from 70 centers were reviewed. Data from 5,426 patients operated on between 1990 and 1994 at the Montreal Heart Institute are presented. Results. From our review of the literature, we conclude that postoperative mediastinal fluid drainage averages 917 mL and that aspirin therapy increases drainage by less than 300 mL in most studies, which should not increase use of blood products, insofar as a strict transfusional protocol is adhered to. Across centers, transfusions can vary eightfold for the same postoperative drainage. Data from our institution show that postoperative mediastinal drainage per se is not influenced by reoperation or by the type of operation. However, total blood losses and transfusion requirements remain increased in reoperative and complex procedures. Excessive mediastinal drainage resulting in increased transfusions occurs in 29% of patients. Conclusions. Exposure to allogeneic transfusions remains institution dependent. Constant reevaluation of local practice is essential to implement efficient blood conservation strategies.

Heparinized cardiopulmonary bypass and full heparin dose marginally improve clinical performance

The use of completely heparin coated cardiopulmonary bypass circuits in combination with a reduced systemic heparin dose has previously been shown to reduce postoperative bleeding after cardiac operations. However, it has remained unknown whether this effect was related to the improved biocompatibility of the heparin-treated surfaces per se or to the reduced exposure to circulating heparin. Therefore we investigated patients undergoing heparin-coated extracorporeal circulation and full systemic heparinization. Two hundred seventeen patients having first-time myocardial revascularization were prospectively randomized either to a group in which a completely ("tip-to-tip") heparin-coated circuit (Duraflo II) was used for perfusion (n = 107) or to a control group (n = 110) in which an uncoated, but otherwise identical, circuit was used. Full systemic heparinization was induced in both groups (activated clotting time, > 480 seconds). The postoperative blood loss, requirements for homologous blood transfusions, clinical performance, and complications were recorded. The amount of postoperative mediastinal drainage was nearly identical in the two groups. The mean 18-hour drainage was 694 +/- 313 mL in the heparin-coated group and 679 +/- 269 mL in the control group (p = not significant). Three patients in the heparin-coated group and 6 patients in the control group received homologous red blood cell transfusions (p = not significant). The incidence of postoperative atrial fibrillation was significantly lower in the heparin-coated group (21.8%) than in the control group (43.1%) (p = 0.002). Otherwise, there were no significant differences in the extubation times, the incidence of perioperative myocardial infarction, the creatinine concentration, the incidence of neurologic dysfunction, the progress in physical rehabilitation, or the hemoglobin concentration at discharge. The use of completely heparin coated cardiopulmonary bypass circuits and full systemic heparinization in patients undergoing coronary artery bypass procedures did not reduce postoperative bleeding or change clinical performance, except for a significant decrease in the incidence of postoperative atrial fibrillation.

Completely heparinized cardiopulmonary bypass and reduced systemic heparin: Clinical and hemostatic effects

When heparinized circuits are used for cardiopulmonary bypass, the amounts of heparin and protamine administered systemically can be reduced. However, it is not entirely known what effects this reduction in systemic anticoagulation has on clinical performance and on the coagulation and fibrinolytic systems. Two hundred three patients undergoing first-time elective myocardial revascularization were prospectively randomized either to a group in which a completely heparin-coated circuit was used for perfusion (group H; n = 101 patients) and in which a reduced heparin dose was given (activated clotting time, > 250 seconds) or to a control group (group C; n = 102 patients) in which an uncoated, but otherwise identical, circuit was used and in which full systemic heparinization was induced (activated clotting time, > 480 seconds). Indicators of thrombin generation, platelet activation, and fibrinolytic activity were studied in a subset of 34 patients. The total amount of postoperative mediastinal drainage was significantly reduced in group H (median, 575 mL) compared with that in group C (median, 635 mL; p = 0.002). Two patients in group C but none in group H received homologous red blood cell transfusions (p = not significant). The loss of hemoglobin in group H was a median of 21 g/L, and this was significantly lower than the 25 g/L noted in the control group (p = 0.006). During cardiopulmonary bypass, the plasma levels of thrombin-antithrombin complex and prothrombin fragment 1.2 increased in both groups. At the end of cardiopulmonary bypass the plasma levels of these markers of thrombin formation were significantly higher in group H, although the increase was modest compared with the major increase observed 2 hours after operation in both groups. There were no significant intergroup differences in the platelet counts, the concentration of beta-thromboglobulin, or the plasma levels of fibrinogen and D-dimer. No differences in perioperative morbidity, the postoperative kidney function, or the intubation time were observed, and there were no hospital deaths. The combination of complete heparin-coated cardiopulmonary bypass circuits and low systemic heparinization is safe for patients undergoing elective coronary artery bypass procedures and reduces the perioperative blood loss. There was no evidence of increased thrombogenicity, fibrinolytic activity, or consumption of coagulation factors. No clinical or technical side effects were observed.

Consistent non-pharmacologic blood conservation in primary and reoperative coronary artery bypass grafting

Because much interest has been focused on blood conservation using different drugs and complicated blood cell processing devices, we analyzed our results with the use of a non-pharmacologic, simple and inexpensive program for blood salvage in 2326 patients undergoing myocardial revascularization. The material was divided into two groups: patients undergoing a primary coronary bypass operation (Group P, n = 2298) and a smaller subset of patients undergoing repeat coronary bypass operation (Group R, n = 28). At least one internal mammary artery was grafted in 99% of the patients, with supplemental saphenous vein grafts. Intraoperatively, autologous heparinized blood was removed before bypass and retransfused at the conclusion of extracorporeal circulation. The volume remaining in the extracorporeal circuit was returned without cell processing or hemofiltration. Autotransfusion of the shed mediastinal blood was continued hourly up to 18 h after surgery in all patients. The mean postoperative mediastinal drainage in group R was 543 +/- 218 ml, compared to 703 +/- 340 ml in Group P (P = 0.01). In Group R, 1 patient (3.6%) received packed red cells and no patients were given other homologous blood products, compared to 33 patients (1.4%) given red cells and 35 patients (1.5%) given plasma transfusion in Group P (NS). Thus, in total, 2257 patients (97.0%) were not exposed to any homologous blood products during hospitalization. Total hemoglobin loss was significantly higher in Group R, resulting in a mean hemoglobin concentration at discharge of 109 +/- 13 g/l, compared to 121 +/- 14 g/l in Group P (P = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

Heparin Dosing and Monitoring for Cardiopulmonary Bypass. A Comparison of Techniques with Measurement of Subclinical Plasma Coagulation

Subclinical plasma coagulation during cardiopulmonary bypass has been associated with marked platelet and clotting factor consumption in monkeys. To better define subclinical coagulation in man, we measured plasma fibrinopeptide A concentrations before, during, and after cardiopulmonary bypass. Patients were assigned to one of three groups of heparin management: group 1 (n = 10)--initial heparin dose 300 IU/kg, with supplemental heparin if the activated coagulation time fell below 400 seconds; group 2 (n = 6)--initial heparin dose 250 IU/kg, with supplemental heparin if activated coagulation time was less than 400 seconds; and group 3 (n = 5)--initial heparin dose 350 to 400 IU/kg, with supplemental heparin if whole blood heparin concentration was less than or equal to 4.1 IU/ml. Activated coagulation time and heparin concentration were measured every 30 minutes during cardiopulmonary bypass, and fibrinopeptide A was measured at hypothermia, normothermia, and whenever activated coagulation time was less than 400 seconds. Quantitative and qualitative blood clotting competence was assessed after cardiopulmonary bypass, including mediastinal drainage for the first 24 hours. Fibrinopeptide A values were markedly elevated during cardiopulmonary bypass but were well below the levels present before and after cardiopulmonary bypass. Fibrinopeptide A correlated inversely with heparin concentration during cardiopulmonary bypass (r = -0.46, p = 0.03), but higher fibrinopeptide A levels during cardiopulmonary bypass did not correlate with post-cardiopulmonary bypass coagulopathy. Group 3 patients received the highest heparin doses (p less than 0.05) and had the greatest postoperative blood loss (p less than 0.05). Protamine dose and heparin concentration during cardiopulmonary bypass correlated best with postoperative mediastinal drainage. Our findings support the following conclusions: (1) compensated subclinical plasma coagulation activity occurs during cardiopulmonary bypass despite activated coagulation time greater than 400 seconds or heparin concentration greater than or equal to 4.1 IU/ml; (2) post-cardiopulmonary bypass mediastinal drainage correlates strongly with increased heparin concentration during cardiopulmonary bypass (p less than 0.05) and protamine dose (p less than 0.05); and (3) during cardiopulmonary bypass at both normothermia and hypothermia, activated coagulation times greater than 350 seconds result in acceptable fibrinopeptide A levels and post-cardiopulmonary bypass blood clotting.

Heparin dosing and monitoring for cardiopulmonary bypass: A comparison of techniques with measurement of subclinical plasma coagulation

Subclinical plasma coagulation during cardiopulmonary bypass has been associated with marked platelet and clotting factor consumption in monkeys. To better define subclinical coagulation in man, we measured plasma fibrinopeptide A concentrations before, during, and after cardiopulmonary bypass. Patients were assigned to one of three groups of heparin management: group 1 (n = 10)--initial heparin dose 300 IU/kg, with supplemental heparin if the activated coagulation time fell below 400 seconds; group 2 (n = 6)--initial heparin dose 250 IU/kg, with supplemental heparin if activated coagulation time was less than 400 seconds; and group 3 (n = 5)--initial heparin dose 350 to 400 IU/kg, with supplemental heparin if whole blood heparin concentration was less than or equal to 4.1 IU/ml. Activated coagulation time and heparin concentration were measured every 30 minutes during cardiopulmonary bypass, and fibrinopeptide A was measured at hypothermia, normothermia, and whenever activated coagulation time was less than 400 seconds. Quantitative and qualitative blood clotting competence was assessed after cardiopulmonary bypass, including mediastinal drainage for the first 24 hours. Fibrinopeptide A values were markedly elevated during cardiopulmonary bypass but were well below the levels present before and after cardiopulmonary bypass. Fibrinopeptide A correlated inversely with heparin concentration during cardiopulmonary bypass (r = -0.46, p = 0.03), but higher fibrinopeptide A levels during cardiopulmonary bypass did not correlate with post-cardiopulmonary bypass coagulopathy. Group 3 patients received the highest heparin doses (p less than 0.05) and had the greatest postoperative blood loss (p less than 0.05). Protamine dose and heparin concentration during cardiopulmonary bypass correlated best with postoperative mediastinal drainage. Our findings support the following conclusions: (1) compensated subclinical plasma coagulation activity occurs during cardiopulmonary bypass despite activated coagulation time greater than 400 seconds or heparin concentration greater than or equal to 4.1 IU/ml; (2) post-cardiopulmonary bypass mediastinal drainage correlates strongly with increased heparin concentration during cardiopulmonary bypass (p less than 0.05) and protamine dose (p less than 0.05); and (3) during cardiopulmonary bypass at both normothermia and hypothermia, activated coagulation times greater than 350 seconds result in acceptable fibrinopeptide A levels and post-cardiopulmonary bypass blood clotting.