Termination Of Cardiopulmonary Bypass Research Articles

Intraoperative Cell Saving: Is the Solution the Actual Problem?

Allogenic blood is a scarce, precious, and expensive resource that is not always available on demand. After termination of cardiopulmonary bypass, a large amount of residual pump blood remains in the extracorporeal circuit. The cell saver washes and concentrates this blood with .9% normal saline (NS), making autologous blood available and reducing the demand for allogenic blood. To quantify the quality of residual pump blood it was washed with either NS or a bicarbonate-buffered solution (Balsol). A qualitative in vitro analysis was conducted. Residual cardiopulmonary bypass blood from forty bypass circuits was processed with a cell saver device, using NS or Balsol solution. Measurements made compared the pH, electrolytes, metabolites, hematocrit, hemoglobin, osmolality, albumin, total protein, and strong ion difference. There were significant differences between the NS and Balsol groups. In the Balsol group, osmolality, electrolytes, and strong ion difference were similar to the constitution of Balsol solution after washing, but not with the normal saline group. Washing residual cardiopulmonary bypass pump blood with Balsol solution results in a resuspended red cell concentrate with a superior electrolyte profile and a strong ion difference similar to that of residual pump blood.

Application of Molecular Hydrogen in Heart Surgery under Cardiopulmonary Bypass.

The aim of this work was to study the effect of molecular hydrogen on oxidative processes in cardiac surgery patients with acquired valve heart disease applied during surgery under cardiopulmonary bypass (CPB).Materials and Methods.The study involved 20 patients (16 men and 4 women) with acquired heart valve disease who were operated on under CPB. Two groups of patients were formed. In group 1 (n=11), anesthesia included inhalations of molecular hydrogen, which was supplied to the breathing circuit of the ventilator at a concentration of 1.5–2.0% immediately after tracheal intubation and throughout the operation. In group 2 (n=9), inhalation of molecular hydrogen was not performed. Blood sampling was taken at 4 stages: immediately after anesthesia induction, before CPB and after its termination, and also one day after the operation. The intensity of the processes of lipid peroxidation was evaluated by the level of diene (DC) and triene (TC) conjugates, Schiff bases (SB).Results.In the patients of group 1, the arterial blood samples showed a decrease in the level of TC and SB, as compared to the first stage of the study, before the initiation of CPB and one day after the operation. An increase in the level of DC and TC was detected after the termination of CPB (p<0.05). In the venous blood samples, an increase in the level of DC was noted before the initiation of CPB, which was restored by the third stage of the study (p<0.05). At the same time, after the termination of CPB, a tendency towards a decrease in TC and SB was observed, which persisted one day after the operation.In the patients of group 2, an increase in the concentration of SB in the arterial blood samples was recorded during the study as compared to the first stage. The level of TC and SB in the venous blood samples increased one day after the operation.Conclusion.Intraoperative inhalation of molecular hydrogen leads to a decrease in the oxidative stress manifestation, it being most pronounced one day after the operation. This suggests that molecular hydrogen can be used in cardiac surgery as an effective and safe antioxidant.

Hypofibrinogenemia can be estimated by the predictive formula in aortic surgery.

Aortic surgery often causes massive bleeding due to hypofibrinogenemia. Predicting hypofibrinogenemia is useful for developing a hemostasis strategy, including preparing for blood transfusion. We made a formula for predicting the serum fibrinogen level (SFL) at the termination of cardiopulmonary bypass (CPB) in aortic surgery and examined its validity. We performed a retrospective observational study that consisted of 267 patients (group A) who underwent aortic surgery from July 2013 to December 2016 and made a formula for predicting the SFL at the termination of CPB in group A by a multiple linear regression analysis. The validity of this formula was then examined in another 60 patients (group B) who underwent aortic surgery from January 2017 to December 2017. We developed the following predictive formula: SFL at the termination of CPB (mg/dL) = 14.7 + 0.44 × preoperative SFL (mg/dL) + (-0.14) × CPB time (min) + 0.64 × preoperative body weight (kg) + (-17.3) × lateral thoracotomy (Yes/No, Yes: 1, No: 0). In group B, the predictive formula proved to be statistically valid in group B (R2= 0.531, p < 0.001). The SFL at the termination of CPB in aortic surgery can be predicted by the preoperative SFL, body weight, CPB time and surgical approach. The predictive formula is useful for developing a hemostasis strategy, including preparing for blood transfusion.

Açık Kalp Cerrahisinde Düşük Tidal Volüm Ventilasyon: 8 ml/kg ve 6 ml/kg Tidal volümden Hangisi Daha İyi?

Objective: To compare the outcomes of 6m/kg vs. 8 ml/kg tidal volume in the lung protective ventilation - low tidal volume strategy in coronary artery bypass grafting operation. Methods: Thirty-two patients enrolled in a randomized, single-center, prospective study were divided into two groups. The outcomes of 6m/kg vs. 8 ml/kg were compared. Arterial blood pressures, heart rate, central venous pressure, expired tidal volume, respiratory frequency, the alveolar minute ventilation, the inspiratory time, static compliance, peak airway pressure, plateau pressure, driving pressure, arterial blood gas data and PaCO2-EtCO2 difference were recorded at T1 (15 min. prior to CPB), T2 (15 min. following the termination of cardio pulmonary bypass), and T3 times (at the end of the surgery). PaO2/FiO2 ratio was recorded at T1, T2 and T3 and 6th (T4) and 12th hours (T5) after extubation. Results: In Group 6ml/kg, extubation time and length of stay in the intensive care unit were significantly longer (p&amp;lt;0.001, p=0.001, respectively). Discharge times were similar in both groups. In group 6ml/kg, PaCO2 was high at all times (T1, T2, T3; p=0.002, p=0.004, p=0.001, respectively), Hemodynamic changes had a similar course in both groups, in Group 6ml/kg. The PaO2/FiO2 ratio was significantly higher in Group 8ml/kg at T2 (p=0.009) and similar at other times. Conclusion: Mechanical ventilation with a low tidal volume strategy with 8 ml/kg has more favorable outcomes by considering the shorter extubation time and length of stay in the intensive care unit comparing with 6 ml/kg.

Comparison of ringer's lactate and plasmalyt-a as cardiopulmonary bypass prime for bypass associated acidosis in valve replacement surgeries.

Introduction:A wide range of acid base fluctuations are seen during Cardiopulmonary bypass (CPB) and the development of metabolic acidosis is well recognized. We conducted a study tocompare the metabolic effects of Ringer lactate and Plasmalyte-A as CPB prime in causing bypass associated acidosis in valve replacement surgeries.Methods:We performed a prospective, randomized controlled study on a total of 80 adult patients undergoing CPB for valvular heart surgeries. The patients were randomized into two groups: Group I (Ringer Lactate) and Group II (Plasmalyte-A). Arterial blood samples were taken before initiating CPB, 30 minutes after starting CPB, then every half hourly till termination of CPB and after half an hour stay in the ICU post operatively to analyze primarily H+ ions, bicarbonates, lactate and strong ion difference.Results and Discussion:The results were analyzed in a quantitative manner. In Ringer Lactate group, during CPB, there was reduction in pH from 7.428 ± 0.029 at T1 to 7.335 ± 0.06 (P < 0.01) and 7.358 ± 0.06 (P < 0.01) at T2 and T3 respectively. Mean bicarbonates decreased in Ringer Lactate group during CPB from 24.28 ± 1.65 mEq/L at T1 to 20.98 ± 2.97 mEq/L at T2 (P < 0.01). In Plasmalyte-A group, mean pH, bicarbonate, strong ion difference (SID) were comparable at all time intervals (P > 0.05). In Ringer Lactate group, maximum surge in mean blood lactate levels was seen from 0.85 ± 0.35 mmol/l at T1 to 4.29 ± 1.78 mmol/L (P < 0.01) and 4.17 ± 1.28 mmol/L (P < 0.01) at T2 and T3, respectively. Such surge was not seen in Plasmalyte-A group. The mean SID decreased during the CPB in Ringer Lactate group from 41.102 mEq/L at T1 to 35.66 mEq/L (P = 0.033) at T2 implying metabolic acidosis. Numbered patients having hypotension and arrhythmias were also higher in Ringer Lactate group again indicating higher acidosis.Conclusion:The different composition of Plasmalyte-A and Ringer Lactate have different metabolic implications for patients undergoing cardiac surgery. Patients who received Plasmalyte-A as cardiopulmonary bypass prime developed less metabolic acidosis. Hence we conclude that Plasmalyte-A is the preferred cardiopulmonary bypass prime in adult patients undergoing valve replacement surgeries.

Blood management in a patient with anti-Oka antibody who underwent cardiac surgery using cardiopulmonary bypass: a case report

BackgroundCardiac surgery under cardiopulmonary bypass (CPB) is often associated with massive bleeding and blood transfusion. For patients requiring specific blood products, meticulous blood management is critical to reduce blood loss, as well as the need for transfusion. Here, we have described the intraoperative blood management in a patient with anti-Oka antibody, who underwent cardiac surgery with CPB.Case presentationA 79-year-old woman was scheduled for open aortic valve replacement and tricuspid valve annuloplasty under hypothermic CPB. Her blood type was A RhD(+) Ok(a−), and anti-Oka, an extremely rare antibody against erythrocyte antigen, was detected. Eight units of Ok(a−) frozen thawed red cells (FTRCs), and six units of red blood cells donated by three Ok(a−) individuals were collected just prior to surgery. Although she was anemic, acute normovolemic hemodilution was conducted after anesthesia induction to preserve the autologous whole blood. Four units of FTRCs were loaded in the CPB priming solution, and modified ultrafiltration was adopted during CPB to prevent further hemodilution. After CPB termination, two units of FTRCs, four units of fresh frozen plasma, and ten units of platelet concentrate were intensively transfused, facilitating surgical hemostasis and stable hemodynamics. The autologous whole blood was returned to the patient in the intensive care unit. Since the hemoglobin and hematocrit levels were maintained postoperatively, no additional transfusion was required throughout her hospital stay.ConclusionsMultidisciplinary intraoperative blood management in a patient with anti-Oka antibody facilitated successful cardiac surgery using CPB, along with effective use of limited blood products.

Clinical application of a new ternary polymer, SEC-1 coat™, for pediatric cardiopulmonary bypass circuits: a prospective randomized pilot study.

The use of biocompatible materials to reduce the systemic activation of inflammation and coagulation pathways is expanding rapidly. However, there have been few clinical studies of biocompatible circuits for pediatric cardiopulmonary bypass. This pilot study aimed to preliminarily evaluate the biocompatibility of SEC-1 coat™ (SEC) for cardiopulmonary bypass circuits in pediatric cardiac surgery. Twenty infants undergoing cardiac surgery for isolated ventricular septal defects at Kobe Children's Hospital were assigned randomly to an SEC-coated (SEC group, n = 10) or heparin-coated (control group, n = 10) circuit. Perioperative data and the following markers were prospectively analyzed: platelet counts and interleukin-6, interleukin-8, C3a, β-thromboglobulin, and thrombin-antithrombin complex levels. Neither patient characteristics nor postoperative clinical outcomes differed significantly between the SEC and control groups. Platelet counts markedly decreased during cardiopulmonary bypass in both groups, but were significantly better preserved in the SEC group. Fewer patients needed postoperative platelet transfusions in the SEC group. After cardiopulmonary bypass termination, serum levels of β-thromboglobulin and thrombin-antithrombin complex were significantly lower in the SEC than in the control group. Although the differences were not statistically significant, serum levels of interleukin-6, interleukin-8, and C3a had a tendency toward being lower in the SEC group, with good preservation of leukocyte counts, fibrinogen, and antithrombin III. SEC-1 coat™ for cardiopulmonary bypass circuits have good biocompatibility with regard to platelet preservation and in terms of attenuating inflammatory reaction or coagulation activation during pediatric cardiac surgery. It can be beneficial in pediatric as well as adult cardiac surgery.

The use of prothrombin complex concentrate as a warfarin reversal agent in pediatric patients undergoing orthotopic heart transplantation.

Patients supported with a ventricular assist device are predisposed to severe bleeding at the time of orthotopic heart transplant due to several risk factors including anticoagulation with vitamin K antagonists. Kcentra, a four-factor prothrombin complex concentrate, has been approved by the FDA for warfarin reversal in adults prior to urgent surgery. There is a lack of published data on the preoperative use of four-factor prothrombin complex concentrates in pediatric patients undergoing cardiacsurgery. This is a single-center retrospective analysis of pediatric patients with a continuous-flow ventricular assist device who underwent heart transplant, comparing patients who received Kcentra for anticoagulation reversal with a historical patient cohort who did not. Consecutive patients from January 2013 to December 2017 were analyzed. The primary outcome was volume of blood product transfusion prior to cardiopulmonary bypass initiation. Secondary outcomes include blood product transfusion after cardiopulmonary bypass intraoperatively and up to 24hours postoperatively, chest tube output within 24hours of surgery, time to extubation, incidence of thromboembolism, and post-transplant length ofstay. From 2013 to 2017, 31 patients with continuous-flow ventricular assist devices underwent heart transplant, with 27 patients included in the analysis. Fifteen patients received Kcentra compared with 12 patients who received fresh-frozen plasma for anticoagulation reversal. Compared with the control group, patients who received Kcentra had less packed red blood cells, fresh-frozen plasma, and platelets transfused prior to cardiopulmonary bypass initiation. The Kcentra group also received less packed red blood cells on bypass and less packed red blood cells after cardiopulmonary bypass termination. There were no differences in chest tube output, time to extubation, intensive care unit length of stay, or overall hospital length of stay. Neither group had thromboembolic complications detected during the first seven postoperative days. This small retrospective study indicates that preoperative warfarin reversal with Kcentra reduces blood product exposure in pediatric patients with ventricular assist devices undergoing heart transplant.

Current Practice of Calcium Use During Cardiopulmonary Bypass Weaning: Results of an International Survey

To describe international practices on the use of calcium salts during cardiopulmonary bypass (CPB) weaning in adult cardiac surgery patients. Multiple-choice survey on current practice of CPB weaning. Online survey using the SurveyMonkey platform. Departments of cardiac anesthesiology worldwide. None. Out of 112 surveys sent, 100 centers from 32 countries replied. The majority of centers (88 of 100 = 88%) administer calcium salts intraoperatively: 71 of 100 (71%) are using these drugs for CPB weaning and 78 of 100 (78%) for correction of hypocalcemia. Among the 88 centers that use calcium salts intraoperatively, 66% (58 of 88) of respondents use calcium chloride, 22% (19 of 88) use calcium gluconate, and 12% (11 of 88) use both drugs. Calcium salts are routinely used during normal (47 of 71 centers = 66%) and difficult (59 of 71 centers = 83%) weaning from CPB. Doses of 5 to 15 mg/kg during termination of CPB were used by 55 of 71 centers (77%) either by bolus (39 of 71, 55%) or over a time period longer than 1 minute (32 of 71 = 45%). Norepinephrine is the most commonly used first line vasopressor or inotropic agent used to support hemodynamics during termination of CPB in 32 out of 100 centers (32%), and calcium is the second one, used by 23 out of 100 centers (23%). This survey demonstrates that the majority of cardiac centers use calcium in adult patients undergoing cardiac surgery, especially during weaning from CPB. There is variability on the type of drug, dose, and modality of drug administration.

Hypothermic effects on gas exchange performance of membrane oxygenator and blood coagulation during cardiopulmonary bypass in pigs

Whether hypothermic cardiopulmonary bypass could attenuate both blood coagulation and platelet activation compared to normothermic cardiopulmonary bypass remains elusive. Biocompatibility of a polymer-coated cardiopulmonary bypass circuit was comparatively assessed by plasma proteomics between juvenile pigs undergoing hypothermic (23°C) cardiopulmonary bypass and those undergoing normothermic (37°C) cardiopulmonary bypass (n = 6, respectively). Plasma samples were taken three times: 5 minutes after initiation of cardiopulmonary bypass (T5, before cooling), just before declamping and rewarming (Tc), and just before termination of cardiopulmonary bypass (Trw, 120 minutes). Proteomic analysis was quantitively performed by isobaric tags for relative and absolute quantification labeling. Thrombin-antithrombin complexes (TAT III) were measured by enzyme immunoassay, and vitamin K-dependent protein C (PROC), β-thromboglobulin (TG), and P-selectin were measured by enzyme-linked immunosorbent assay. Blood gas analyses evaluated oxygenator performance. Hypothermic cardiopulmonary bypass had a significantly higher PaO2 at Tc and lower PaCO2 at Trw than normothermic cardiopulmonary bypass. Two hundred twenty-four proteins were identified with statistical criteria of both protein confidence (>95%) and false discovery rate (<5%). Six of these proteins significantly decreased at Tc than at T5 in hypothermic cardiopulmonary bypass (p = 0.02-0.04), with three related to platelet degranulation. Protein C decreased at Trw compared with T5 in normothermic cardiopulmonary bypass (p = 0.04). Thrombin-antithrombin complex had a slightly larger increase with normothermic cardiopulmonary bypass at Trw than with hypothermic cardiopulmonary bypass. β-thromboglobulin and P-selectin levels were significantly lower at Trw with hypothermic cardiopulmonary bypass than with normothermic cardiopulmonary bypass (p = 0.04). Hypothermic cardiopulmonary bypass attenuated platelet degranulation/blood coagulation and maintained better oxygenator performance compared to normothermic cardiopulmonary bypass in juvenile pigs.

The N-terminal lectin-like domain of thrombomodulin reduces acute lung injury without anticoagulant effects in a rat cardiopulmonary bypass model.

Systemic inflammation evoked by cardiopulmonary bypass (CPB) leads to acute lung injury (ALI) and respiratory failure. Although recombinant human soluble thrombomodulin (rTM) consists of three domains (D1-3), is reported to attenuate systemic inflammation through the N-terminal lectin-like domain (D1), anticoagulant domain (D2) may exacerbate coagulopathy after CPB. We investigated the potential of selective D1 against CPB-mediated ALI free from anticoagulant effects using a rat CPB model. Rats were divided into three groups: control (CPB alone, n = 5), D1 (CPB + D1, n = 4), and D123 (CPB + D123, n = 6). D1 or D123 was administratedto the rats of each group before CPB establishment. Blood samples are collected before, during and after CPB. Blood coagulability was assessed by a coagulation analyzer. Lung samples are collected at 1h after the termination of CPB for histological analyses. D123 group exhibited significantly prolonged glass beads-activated clotting time with heparinase after CPB compared to that in control group, whereas no significant prolongation in control and D1 group (control vs. D1 vs. D123: 65.4 ± 9.2 vs. 65.3 ± 10.9 vs. 83.5 ± 4.6s, p = 0.036 [control vs. D123], 0.99 [control vs. D1]) indicating the absence of anticoagulant activities of D1. Histological studies revealed less congestion, edema, inflammation, and hemorrhage in both D1 and D123 groups compared to those in control group indicating protective effects of both D1 and D123 against ALI mediated by CPB. N-terminal lectin-like domain of rTM may reduce the risk of ALI without anticoagulant effects.

Combined effect of left stellate ganglion blockade and topical administration of papaverine on left internal thoracic artery blood flow in patients undergoing coronary revascularization.

Background:Left stellate ganglion blockade (LSGB) may have additive effect to topical administration of papaverine on prevention of vasospasm of left internal thoracic artery (LITA).Aims:This study aims to compare LITA blood flow with topical application of papaverine alone or in combination with LSGB.Setting:Tertiary care hospital.Design:Prospective randomized controlled study.Materials and Methods:A total of 100 patients operated for coronary revascularization were randomly and equally allocated into two groups. In control Group-C, papaverine was applied topically during the dissection of LITA. In Group-S, the additional LSGB was performed. Blood flow was measured from cut end of the LITA for 15 s. Primary objectives of the evaluation were to observe differences in the LITA blood flow. Observing incidence of radial-femoral arterial pressure difference after cardiopulmonary bypass (CPB) was secondary objective.Statistical Analysis:Student's unpaired t-test and Fisher's exact test to find out a significant difference between the groups.Results:LITA flow in Group-S was insignificantly more (49.28 ± 7.88 ml/min) than Group-C (47.12 ± 7.24 ml/min), (P = 0.15). Radio-femoral arterial pressure difference remained low for 40 min after termination of CPB in the Group-S compared to the Group-C (−0.99 ± 1.85 vs. −1.92 ± 2.26).Conclusion:Combining LSGB with papaverine does not increase the LITA blood flow compared to when the papaverine is used alone. However, ganglion blockade reduces radial-femoral arterial pressure difference after CPB. Blockade can be achieved successfully under the ultrasound guidance without any complications.

Normothermia versus Hypothermia during Cardiopulmonary Bypass in Cases of Repair of Atrioventricular Septal Defect.

Background:Cardiopulmonary bypass (CPB) used for cardiac surgery is now uniformly carried out under normothermic conditions in adult patients; however, the temperature applied in pediatric CPB vary significantly, ranging from deep hypothermia to normothermia due to the lack of a consistent approach to CPB temperature in pediatric cardiac surgery, which is related to a lack of supportive evidence. Organs protection aim to decrease metabolic requirement and provide energy and oxygen, hypothermia has reached these goals by arresting and cooling the heart, delivering oxygen, and modifying reperfusion. Recently, a large number of studies investigated effect of hypothermia to decrease the negative impact of hypothermia. It has been suggested that the degree of hypothermia affects the inflammatory responses triggered by CPB. However, the use of normothermia during CPB had been introduced and resulted in acceptable results. We hypothesized that the use of normothermia during corrective surgery of AV septal defects improves the outcome of the CPB.Objective:The study aimed to compare the outcome of normothermic technique and mild hypothermic technique during (CPB) in pediatric cardiac patients undergoing repair of atrioventricular (AV) septal defect and their effect on tissue perfusion, serum lactate level, duration of patient intubation, and postoperative hospital stay.Patients and Methods:Forty patients presented for repair of AV defect aged from 1 month to 36 months were divided randomly into two equal groups (20 patients in each): Group I (Normothermic group) of body temperature more than 35°C up to 37°C and Group II (mild Hypothermic group) body temperature between (32°C–35°C). Basal data include complete blood count, electrolytes, arterial blood gases (ABGs), coagulation profile, and liver function tests were collected. Hemodynamic variables, ABG, serum lactate, and activated clotting time (ACT) measured in different time intervals related to CPB. With the termination of CPB, aortic cross-clamping time (minutes), CPB time (minutes), spontaneous regaining of the heart function, need for inotropic administration, and/or vasopressor requirements to wean the heart from CPB were reported in all patients.Results:This study showed statistically significant lower PH and HCO3 levels and significantly higher serum lactate levels in Group II (hypothermic) than Group I (normothermic) after weaning from CPB. Furthermore, ACT level was statistically significantly higher in Group II than Group I after weaning of CPB. During postoperative period, hypothermic group showed significantly higher liver enzymes than the normothermic group. The duration of inotropes administration and duration of intubation were significantly longer in Group II than Group I.Conclusion:Normothermia during CPB showed better global tissue perfusion than hypothermia in elective surgeries for repair of AV defects in the form of less degree of lactic acidosis, less effect on coagulation system, shorter duration of inotropic support, shorter intubation period, and shorter stay in the intensive care unit.

A case of aortic dissection after termination of cardiopulmonary bypass

A case of aortic dissection after termination of cardiopulmonary bypass

Safety of del Nido cardioplegia in coronary artery bypass grafting combined with heart valve replacement in adults

Objective: To investigate the safety and myocardial protective effect of del Nido cardioplegia in coronary artery bypass grafting combined with heart valve replacement in adults. Methods: From April 2018 to April 2019, 84 patients undergoing coronary artery bypass grafting combined with heart valve replacement under cardiopulmonary bypass (CPB) in the Second Affiliated Hospital of Nantong University and Shanghai Chest Hospital were selected, and divided into del Nido cardioplegia (n=44) group and Thomas cardioplegia (n=40) group using a random number table. The concentration of troponin was measured before anesthesia induction and 2, 12 and 24 hours after the termination of CPB, respectively. Results: The preoperative characteristics of each group were similar, including age, underlying diseases, and body surface area (all P>0.05). The frequency of intraoperative cardioplegia infusion in the del Nido group was significantly lower than that in the Thomas group (P=0.03). Compared with the del Nido group, troponin concentration in the Thomas group increased significantly at 12 hours [(4.59±0.76) μg/L vs (2.20±0.53) μg/L, t=-16.653, P<0.001] and 24 hours [(6.70±0.97) μg/L vs (1.96±0.58) μg/L, t=-26.975, P<0.001] after CPB. No statistically significant differences were found in the postoperative recovery of cardiac autonomic rhythm (P=0.887), cardiac defibrillation (P=0.880), positive inotropic drugs (P=0.163) and left ventricular ejection fraction (P=0.338) between the two groups. Conclusions: It is safe to use del Nido cardioplegia in coronary artery bypass grafting combined with heart valve replacement in adults, which can reduce the frequency of cardioplegia infusion and simplify the surgical procedure. The trend of troponin concentration suggests that del Nido cardioplegia has a better myocardial protective effect.

Transfusing Platelets During Bypass Rewarming in Neonates Improves Postoperative Outcomes: A Randomized Controlled Trial.

In neonates, transfusion of platelets after hemodilution from cardiopulmonary bypass (CPB) has been standard. We hypothesize that platelet administration during the rewarming phase before termination of CPB would reduce coagulopathy, enhance hemostasis, reduce transfusion, and improve postoperative outcomes after neonatal cardiac surgery. A prospective, randomized trial was performed in 46 neonates. Controls received platelets only at the end of bypass with other blood products to assist in hemostasis. The treatment group received 10 mL/kg of platelets during the rewarming phase of bypass after cross-clamp release. After protamine, transfusion and perioperative management protocols were identical and constant among groups. Two neonates in each group were excluded secondary to postoperative need for extracorporeal support. Controls (n = 21) and treatment patients (n = 21) were similar in age, weight, case complexity, associated syndromes, single ventricle status, and CPB times. Compared to controls, the treatment group required 40% less postbypass blood products (58 ± 29 vs 103 ± 80 mL/kg, P = .04), and case completion time after protamine administration was 28 minutes faster (P = .016). The treatment group required fewer postoperative mediastinal explorations for bleeding (P = .045) and had a lower fluid balance (P = .04). The treatment group had shorter mechanical ventilation (P = .016) and length of intensive care unit times (P = .033). There were no 30-day mortalities in either group. Platelet transfusion during the rewarming phase of neonatal cardiac surgery was associated with reduced bleeding and improved postoperative outcomes, compared to platelets given after coming off bypass. Further studies are necessary to understand mechanisms and benefits of this strategy.

Safety and efficacy of tranexamic acid in paediatric cardiac surgery: study protocol for a double-blind randomised controlled trial

IntroductionAn initial retrospective study suggested that tranexamic acid (TXA) administration increased the incidence of seizures in paediatric patients undergoing cardiac surgery. However, the efficacy of TXA in paediatric cardiac surgery...

Interval changes in ROTEM values during cardiopulmonary bypass in pediatric cardiac surgery patients

IntroductionRotational thromboelastometry (ROTEM) has been shown to reduce the need for transfused blood products in adult and pediatric cardiac surgery patients. However, similar evidence in newborns, neonates, and young infants is lacking. We quantified ROTEM value changes in pediatric patients on cardiopulmonary bypass (CPB) before, during and after blood product transfusion.MethodsEach surgery had at least four interventions: initiating CPB; platelet administration during rewarming phase; post-CPB and following protamine and human fibrinogen concentrate (HFC) administration; and further component therapy if bleeding persisted and ROTEM indicated a deficiency. ROTEM assays were performed prior to surgery commencement, on CPB prior to platelet administration and following 38 mL/kg platelets, and post-CPB after protamine and HFC administration. ROTEM assays were also performed in the post-CPB period after further blood component therapy administration.ResultsData from 161 patients were analyzed. Regression models suggested significant changes in HEPTEM clotting time after all interventions. PLT administration during CPB improved HEPTEM α by 22.1° (p < 0.001) and FIBTEM maximum clot firmness (MCF) by 2.9 mm (p < 0.001). HFC administration after CPB termination significantly improved FIBTEM MCF by 2.6 mm (p < 0.001). HEPTEM MCF significantly increased after 3/4 interventions. HEPTEM α significantly decreased after two interventions and significantly increased after two interventions. Greatest perturbances in coagulation parameters occurred in patients ≤90 days of age.ConclusionCPB induced profound perturbations in ROTEM values in pediatric cardiac surgery patients. ROTEM values improved following PLT and HFC administration. This study provides important clinical insights into ROTEM changes in pediatric patients after distinct interventions.

Management of refractory hypotension after termination of cardiopulmonary bypass in a patient undergoing coronary artery bypass grafting: a case report

Management of refractory hypotension after termination of cardiopulmonary bypass in a patient undergoing coronary artery bypass grafting: a case report

Cerebral Circulation During Retrograde Cerebral Perfusion: Evaluation Using Laser Speckle Flowgraphy

The cerebroprotective effect of retrograde cerebral perfusion (RCP) and selective antegrade cerebral perfusion (SCP) still remains controversial. Laser speckle flowgraphy has shown much promise for novel perioperative neuromonitoring by assessing blood flow of the optic nerve head. This study aimed to evaluate the cerebral microcirculation in humans using laser speckle flowgraphy during simple circulatory arrest, RCP, and SCP under moderate hypothermia and to investigate whether RCP under moderate hypothermia is a reliable method of cerebral protection. A total of 23 consecutive patients who underwent a scheduled aortic arch or hemiarch surgical procedure on thoracic aorta aneurysm were enrolled. The laser speckle flowgraphy measurement that calculates mean blur ratio, a parameter of cerebral circulation, was obtained 6 times: after induction of anesthesia, baseline (T1), after initiation of cardiopulmonary bypass with cardiac arrest (T2), simple circulatory arrest (T3), RCP (T4), SCP (T5), and after the termination of cardiopulmonary bypass (T6). Both mean blur ratios of simple circulatory arrest and RCP were significantly decreased compared with baseline. In contrast, no significant differences were observed between simple circulatory arrest and RCP. The mean blur ratio of SCP was significantly increased compared with both simple circulatory arrest and RCP. In conclusion, no significant difference was observed in the cerebral circulation between RCP and simple circulatory arrest without adjunctive strategy under moderate hypothermia. In contrast, the cerebral circulation during SCP was significantly higher than simple circulatory arrest and RCP. These results suggest that cerebral microcirculation may not be adequate during RCP compared with SCP under moderate hypothermia.