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PubMed1992

[Ruptured intracranial aneurysm. Modification of the surgical method based on the state of consciousness and age of patients. Personal experience with 468 patients admitted during 2 periods (1972-84 and 1985-89)].

The management of the ruptured intracranial aneurysm (clinical grade I to IV only) is studied in a series including 140 patients admitted from 1985 through 1989, in which selected patients were submitted to early surgery and other patients were postponed for delayed surgery. The results are compared to those of an earlier series including 328 patients admitted from 1972 through 1984, for which the general attitude was the delayed surgery: in the later series; the selection for the timing of surgery was based on two main parameters: the clinical status and the patient's age. When we compare both series, the overall management results demonstrate an improvement of 10% of satisfactory results and a decrease of 10% in the death rate in favour of the later series; for the surgical results, the figures are respectively 6% and 5% in favour of the later series. The relationship between age and outcome shows a considerable improvement: over 50 years of age, we observed plus 25% of satisfactory results and minus 22% in death in favour of the later series. Similarly, the relationship between state of consciousness and outcome, demonstrated a great improvement: for drowsy and stuporous patients the figures are respectively plus 22% and minus 21% in favour of the later series. When we consider the later series alone, the patients were admitted at 4 intervals of time from S.A.H. (D0-3, D4-6, D7-15, D16 and over). The most favorable outcome was observed for those patients admitted late (after D7) and already stabilized.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1989

Effects of cardiopulmonary bypass on cerebral blood flow in neonates, infants, and children.

Cardiopulmonary bypass (CPB) management in neonates, infants, and children requires extensive alterations in temperature, pump flow rate, and perfusion pressure, with occasional periods of circulatory arrest. The effect of these alterations on cerebral blood flow (CBF) are unknown. This study was designed to determine the relation of temperature and mean arterial pressure to CBF during hypothermic CPB (18 degrees-32 degrees C), with and without periods of total circulatory arrest. CBF was measured before, during, and after hypothermic CPB with xenon-clearance techniques in 67 pediatric patients, aged 1 day-16 years. Patients were grouped based on different CPB techniques: group A, repair during moderate-hypothermic bypass at 25 degrees-32 degrees C; group B, repair during deep-hypothermic bypass at 18 degrees-22 degrees C; and group C, repair with total circulatory arrest at 18 degrees C. There was a significant correlation of CBF with temperature during CPB. CBF significantly decreased under hypothermic conditions in all groups compared with prebypass levels under normothermia. In groups A and B, CBF returned to baseline levels in the rewarming phase of CPB and exceeded baseline levels after bypass. In group C, no significant increase in CBF was observed during rewarming after total circulatory arrest (32 +/- 12 minutes) or after weaning from CPB. During moderate-hypothermic CPB (25 degrees-32 degrees C), there was no association between CBF and mean arterial pressure. However, during deep-hypothermic CPB (18 degrees-22 degrees C), there was an association between CBF and mean arterial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1998

[Relationship between cardiac output and PETco2 as well as Paco2 during high-dose fentanyl anesthesia].

We investigated the relationship between cardiac output and PETCO2 as well as blood PCO2 in 10 patients undergoing cardiac surgery of long duration under high-dose fentanyl anesthesia. After anesthetic induction, the minute ventilation was kept constant at 10 ml.kg-1 x 10 cycles.min-1 and a pulmonary artery catheter was inserted. PETCO2, PaCO2 and cardiac index (CI) were measured simultaneously. PaCO2 was corrected for body temperature, and alveolar dead space-to-tidal volume ratio was calculated as VD/VTalv = (PaCO2-PETCO2)/PaCO2. After body, temperature became stabilized, the measurements were started and repeated every 10 to 20 minutes during the prebypass period. One hundred and eight sets of data were taken from 10 patients. PETCO2 correlated positively with CI. Similarly, PaCO2 correlated positively with CI, but VD/VTalv, did not correlate with CI. PETCO2 correlated closely and positively with PaCO2, but it correlated negatively and only marginally with VD/VTalv. When examined in individual patients, PaCO2 correlated positively with PETCO2 in all patients, while VD/VTalv correlated negatively with PETCO2 only in 3 patients. By multiple regression analysis, VD/VTalv change accounted for only 22.3 +/- 15.0% of PETCO2 change, while PACO2 or PaCO2 change accounted for 77.6 +/- 15.0% of PETCO2 change. Decreased CI was associated with decreased CO2 delivery from the tissue to the lung (DCO2) and PaCO2 decreased with decreasing DCO2. Decreased CI was also associated with decreased oxygen uptake (VO2), and PaCO2 decreased with decreasing VO2. A decrease in CI resulted in an increase in VA/Q, and PaCO2 decreased when VA/Q increased. PETCO2 decreased when cardiac output decreased. A decrease in PACO2 explained the decrease in PETCO2 better than an increase in VD/VT did. Decreased cardiac output might cause hypocapnia through decreased CO2 delivery to the lung, decreased CO2 production and/or increased ventilation-to-perfusion ratio.

Adult↗
PubMed1980

Is reperfusion injury from multiple aortic cross-clamping a current myth of cardiac surgery?

Four hundred eighty adult patients undergoing cardiac operations had systemic and topical hypothermic anoxic arrest supplemented with potassium chloride pharmacological cardioplegia in a prospective randomiz ed study. Group 1 (217 patients) had continuous aortic cross-clamping and one single anoxic arrest period during the cardiac portion of the operation, which resulted in a transmural myocardial infarction rate of 8.3%, myocardial "injury" incidence of 12.4%, 4.6% cardiac-related deaths, 11.5% and 24.8% severe and malignant ventricular arrhythmias, 21.7% rate of severe vasopressor usage, a mean group serum glutamic oxaloacetic transaminase (SGOT) of 140 +/- 39 IU, and a mean group lactic dehydrogenase (LDH) of 636 +/- 78.2 IU. Group 2 (263 patients) had intermittent aortic cross-clamping with multiple reperfusion intervals, which resulted in a significantly lower incidence of transmural myocardial infarction at 1.9% (p < 0.01), rate of myocardial injury at 5.66% (p < 0.02), number of cardiac deaths at 0.76% (p < 0.02), 8.7% and 16.0% severe and malignant ventricular arrhythmias (p < 0.01), severe vasopressor utilization rate of 14.3% (p < 0.05), mean group SGOT at 72.0 +/- 3.1 IU (p < 0.01), and mean group LDH at 471.0 +/- 12.3 IU (p < 0.05) than Group 1. These results do not support the contention that intermittent aortic cross-clamping in conjunction with hypothermia and pharmacological cardioplegia leads to increased clinical cardiac damage compared with continuous aortic cross-clamping. The converse is implied, in that the anoxic heart may benefit from the physiological effects of briefly reperfused oxygenated blood.

Aorta, Thoracic↗
PubMed1998

Centrifugal pumps as left ventricular assist for coronary revascularization on a beating heart.

During recent years, coronary bypass surgery has progressed toward minimizing invasiveness. One important feature of this approach is performing surgery on a beating heart. During the crucial phase of such surgery, the mechanical support of the heart with a left ventricular assist device (LVAD) is a possible option. During the period from October 1, 1994 until June 30, 1997, we employed a centrifugal pump system in 118 cases of coronary artery bypass graft (CABG) procedures with LVAD support (mechanically supported CABG [SUPPCAB]). A total of 179 distal anastomoses with an average of 1.5 +/- 0.5 coronary anastomoses per patient was performed. Three types of pumps were used: 23 BioPump, 87 Isoflow, and 8 Capiox systems. The median time on mechanical support was 44 min (range, 16-116 min). The mean flow rate during support time was 3.5 +/- 0.8 L/min, which results in a calculated flow of 1.7 +/- 0.6 L/min/m2 body surface area (BSA). The average flow was 3.2 +/- 0.8 L/min with the BioPump and 3.7 +/- 0.8 L/min with the Isoflow pump, respectively (p < 0.01). The mean arterial pressure during mechanical support was 75 +/- 12 mm Hg. In 2 patients, the pump system was kept running postoperatively in the ICU. Eight of the patients received operations under resuscitation or in cardiogenic shock. Nine (7.9%) of the patients did not survive the early postoperative phase. For coronary revascularization of the anterolateral and diaphragmatic parts of the heart, the SUPPCAB procedure is feasible with excellent mechanical support of the heart by centrifugal pumps. Especially in high risk cases, this procedure can be recommended.

Adult↗
PubMed1982

Surgical treatment of patients with triple heart valve disease. Results and analysis of factors affecting the surgical outcome.

During a 10-year period (1972 to 1981), 48 patients underwent repair of combined aortic, mitral and tricuspid disease at our Institution. The aortic valve was replaced in 47 cases and treated by valvulotomy in one; the mitral valve was replaced in 47, and conservatively managed in one by means of open mitral commissurotomy; the tricuspid valve was treated by annuloplasty in 37, by commissurotomy in 3 and replaced in 8. Operative mortality decreased from 67% among those cases operated on normothermic cardiopulmonary bypass (CPB) with coronary artery perfusion (1972 to 1973) to 23% in those operated with mild hypothermic CPB and intermittent aortic cross-clamping (1974 to 1976), to 8% in patients treated with mild to deep hypothermic CPB and cold cardioplegic solutions (1977 to 1981) (p = 0.012). Analysis of the factors affecting the surgical risk has demonstrated that age at the time of operation, preoperative functional class, duration of the disease, preoperative cardiothoracic ratio and insertion of a prosthesis in the tricuspid position did not significantly influence the operative result. On the contrary, the recent techniques of myocardial protection with the use of cold cardioplegia, possibly associated with an earlier indication for operation and a prompter treatment of postoperative complications, were the major determinants of the improved surgical outcome.

Adult↗
PubMed1993

The efficacy of subcutaneous recombinant human erythropoietin in the correction of phlebotomy-induced anemia in autologous blood donors.

The efficacy of subcutaneous recombinant human erythropoietin (rhEPO) (500 U/kg; administered twice a week during the 3 weeks before surgery) in the recovery of preoperative hemoglobin concentrations within a 3-week period was studied in 40 patients, each of whom donated 2 units (900 mL) of blood for their own use before total hip replacement surgery. Twenty autologous blood donors received rhEPO (EPO group) and 20 were not treated (control group). The initial hemoglobin concentration (14.0 +/- 1.0 g/dL [140 +/- 10 g/L]) was completely recovered before surgery (14.0 +/- 1.6 g/dL [140 +/- 16 g/L]) in the EPO group, while a decrease from 13.8 +/- 1.1 to 12.2 +/- 1.3 g per dL (138 +/- 11 to 122 +/- 13 g/L) was observed in the control group. The preoperative reticulocyte count showed more than sixfold increase in the EPO group, whereas a twofold to threefold increase was found in the control group. Serum ferritin concentration fell to 42 +/- 29 micrograms per L in the EPO group and to 54 +/- 35 micrograms per L in the control group. The postoperative serum erythropoietin concentration in the EPO group was significantly lower than that in the control group, but it did not differ from the pretreatment value and was attended by a higher hemoglobin concentration after surgery. Only transient flu-like symptoms were mentioned by patients who were treated with rhEPO. Changes in blood pressure or platelet count or other adverse events were not observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1983

Haemorrhagic complications during pulmonary resection. A retrospective review of 1428 resections with 113 haemorrhagic episodes.

A series of 1428 standard pulmonary resections (pneumonectomy 30%, lobectomy 66%, segmentectomy 4%) performed over a 13-year period was reviewed with regard to haemorrhagic complications. The incidence of intra-operative vascular injuries was 5%. The pulmonary artery was damaged in 50 of these 73 injuries, the pulmonary vein in 21, and the superior vena cava and the subclavian vein in one case each. Two deaths were associated with the intra-operative bleeding. The vascular lesions could be repaired without extensive resection of pulmonary tissue in all but 3 of the other patients, in whom two, three and five pulmonary segments, respectively, had to be sacrificed. Postoperative bleeding necessitated emergency thoracotomy in 37 patients (2.6% of the series), and in 3 patients autopsy disclosed such haemorrhage. The cause of the bleeding in 12 cases was slipping or cutting through of ligatures applied to divided major vessels (pulmonary artery in 8 cases, pulmonary vein in 3 and azygos vein in 1 case). Systemic arterial haemorrhage occurred in 15 patients and diffuse bleeding in 12, while one patient had a coagulation disorder causing bleeding. Nine of the 40 patients died, 7 of the haemorrhage and 2 of bronchopleural fistula. The death rate was significantly higher in postoperative than in intra-operative bleeding. The study demonstrated that the widely used and recommended transfixion suture is not absolutely safe to prevent slipping of ligatures from divided major intrathoracic vessels. A purse-string suture has proved to be a safer alternative.

Constriction↗
PubMed1990

High-dose contrast agent administration during complex coronary angioplasty.

To examine the necessity and consequences of high-dose contrast media administration during coronary angioplasty, the records of 730 consecutive patients over a 6-month period were reviewed. The 54 patients (7%) requiring contrast agent doses greater than or equal to 400 ml were examined in detail. The mean contrast dose in this group was 496 +/- 76 ml (range 400 to 785 ml). Their mean age was 63 +/- 11 years (range 36 to 83 years), 10 patients had diabetes mellitus (19%), and four patients had a baseline creatinine level greater than or equal to 1.5 mg/dl (7%). Following coronary angioplasty, the serum creatinine rose from 1.1 +/- 0.2 to 1.2 +/- 0.3 (p = 0.08). The creatinine rose greater than or equal to 0.5 mg/dl in six patients (11%) and greater than or equal to 1.0 mg/dl in one patient (2%). Five of these six patients had either diabetes mellitus, baseline renal insufficiency, or both. Oliguria was not observed. The most important procedural factors contributing to the high doses of contrast media were multilesion and multivessel angioplasty in 96% and 83% of patients, respectively, prior bypass surgery in 52%, and combined diagnostic cardiac catheterization and angioplasty in 13%. Thus renal dysfunction following high-dose contrast agent administration during complex coronary angioplasty is infrequently associated with nephrotoxicity. Whenever possible, contrast doses in patients with diabetes mellitus and renal insufficiency should be minimized.

Adult↗
PubMed1991

Are blood cultures effective in the evaluation of fever in perioperative patients?

Blood cultures are routinely performed as part of the evaluation of fever in the perioperative period. Results of 364 blood culture vials representing 108 consecutive febrile events (temperature greater than or equal to 101.5 degrees F) in 72 patients on adult surgical services without evidence of sepsis in a metropolitan hospital were prospectively studied. Eighty-nine percent of patients had undergone an operation prior to the febrile episode. Microorganisms were isolated in blood culture vials from 9 of 108 patient febrile events. Of these blood cultures, five were positive (contained pathogens), and four represented contaminants. Two of five positive blood cultures occurred in patients with an identifiable source of bacteremia. The cost of processing all blood culture vials was $13,992, which amounted to $2,798 spent to identify each of the five patients with positive blood cultures. Blood culture vials were more likely to be positive if blood was drawn during postoperative days 4 through 10, as opposed to days 1 through 3, or if it was drawn from patients with factors depressing immune function or who had indwelling devices. Neither the magnitude of the absolute leukocyte count nor the maximum temperature at the time of phlebotomy predicted a positive blood culture. The use of resin vials produced sterile cultures in the 10 vials submitted. In no case did a positive blood culture have a measurable effect on reducing patient morbidity or mortality.

Adolescent↗
PubMed2005

Infection of the surgical site after arthroplasty of the hip.

We wished to estimate the incidence of surgical-site infection (SSI) after total hip replacement (THR) and hemiarthroplasty and its strength of association with major risk factors. The SSI surveillance service prospectively gathered clinical, operative and infection data on inpatients from 102 hospitals in England during a four-year period. The overall incidence of SSI was 2.23% for 16,291 THRs, 4.97% for 5769 hemiarthroplasty procedures, 3.68% for 2550 revision THRs and 7.6% for 198 revision hemiarthroplasties. Staphylococcus aureus was identified in 50% of SSIs; 59% of these isolates were methicillin-resistant (MRSA). In the single variable analysis of THRs, age, female gender, American Society of Anesthesiologists (ASA) score, body mass index, trauma, duration of operation and pre-operative stay were significantly associated with the risk of SSI (p < 0.05). For hemiarthroplasty, the ASA score and age were significant factors. In revision THRs male gender, ASA score, trauma, wound class, duration of operation and pre-operative stay were significant risk factors. The median time to detection of SSI was eight days for superficial incisional, 11 days for deep incisional and 11 days for joint/bone infections. For each procedure the mean length of stay doubled for patients with SSI. The multivariate analysis identified age group, trauma, duration of operation and ASA score as significant, independent risk factors for SSI. There was significant interhospital variation in the rates of SSI. MRSA was the most common pathogen to cause SSI in hip arthroplasty, especially in patients undergoing hemiarthroplasty, but coagulase-negative Staph. aureus may be more important in deep infections involving the joint.

Age Factors↗
PubMed2006

Serum S-100B protein levels during and after successful carotid artery stenting or carotid endarterectomy.

PURPOSE: To characterize the course of S-100B serum levels, a reliable marker for cellular brain damage, in patients undergoing carotid artery stenting (CAS) or endarterectomy (CEA) for carotid artery stenosis compared to control groups undergoing hemithyroidectomy (HT) or coronary angiography (CA). METHODS: Forty-six consecutive patients scheduled for revascularization of internal carotid artery (ICA) stenosis were included in the study. Fourteen patients (11 men; median age 70 years, interquartile range [IQR] 63-74) were selected for treatment with CAS, while CEA was performed in 31 patients (24 men; median age 68 years, IQR 54-78) during the same time period. Fourteen consecutive patients (8 men; median age 60 years, IQR 48-70) undergoing CA for suspected coronary heart disease and 14 patients (10 women; median age 36 years, IQR 26-54) undergoing HT for a single thyroid nodule served as controls. RESULTS: All procedures were completed successfully. During ICA clamping in CEA patients without postoperative neurological deficits, median S-100B serum levels transiently increased from 0.04 to 0.26 ng/mL (p<0.01) and returned to baseline levels after declamping. Median S-100B serum levels of CAS patients without neurological impairment remained at baseline values. No increase in S-100B levels occurred in either control group. Three CEA patients who suffered from neurological deficits (1 transient ischemic attack and 1 major stroke) showed sustained elevation of S-100B serum levels 6 hours after extubation. CONCLUSION: In patients without neurological complications, CEA but not CAS was associated with a transient increase in the S-100B serum levels. Results indicate that the increase in S-100B does not originate from extracerebral sources, but rather appears to represent an impairment of the blood-brain barrier integrity or subtle brain cell damage probably due to hypoperfusion during clamping. Sustained elevation of S-100B serum levels corresponded to the development of postoperative neurological deficits.

Adult↗
PubMed1992

[Changes in plasma sulfoconjugated catecholamines during perioperative period of cardiac operations--effect of continuous infusion of dopamine].

In order to clarify the physiological significance of sulfate conjugation of catecholamines and the effect of continuous dopamine infusion on the conjugate formation, we measured the plasma levels of free and sulfoconjugated catecholamines during the perioperative period of cardiac operations. The study group consisted of 12 adult patients who underwent cardiac operations. There were 13 study intervals starting from a day before each operation to 72 hours after each operation for the collection of blood specimen. The plasma levels of free and sulfoconjugated catecholamines were measured by radioenzymatic assay. The plasma levels of free dopamine did not show significant change by the induction of anesthesia, but they increased rapidly after the start of dopamine infusion to the level of 7654.9 +/- 731.7 pg/ml. Thereafter, the plasma free dopamine levels remained steady during the 24 hours after operation at 7516.7 pg/ml to 8449.2 pg/ml. On the other hand, the plasma levels of conjugated dopamine increased progressively by dopamine infusion during the 24 hours after operation. The plasma levels of free adrenaline increased significantly to the level of 1049.5 +/- 117.7 pg/ml by dopamine infusion, and lasted with plateau until the 24th hour after operation at the range of 1076.8 pg/ml to 1218.9 pg/ml. Conjugated adrenaline followed a similar pattern to that of conjugated dopamine, with a progressive increase due to the infusion of dopamine. In the case of noradrenaline, free noradrenaline started to increase at the time of cardiopulmonary bypass and showed a further increase by dopamine infusion during the first hour after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1989

Selective per-operative cholangiography and scoring method for selection.

A prospective clinical study was undertaken over a period of 3 years on a series of 210 consecutive cases of gall stones to review a selective policy for per-operative cholangiography (PC). All patients had elective cholecystectomy and routine PC. A scoring method (SM) based on pre and per-operative surgical criteria was adopted to determine the necessity of PC before this was attempted. The study revealed that PC was indicated in 64 cases (30.5%) only. Of these 64 patients 20 had abnormal cholangiograms of which 18 proved positive on exploration. There were two false positive results (0.95%) of PC but no false negative result. Of 146 patients (69.5%) not clinically indicated for routine PC, 145 had normal cholangiograms and one had a small (5 mm diameter) silent stone (0.47%) in the Common Bile Duct (CBD). The scoring method failed to predict this case of silent stone. PC was technically unsatisfactory in 4 cases (1.9%). Thus by adopting the selective policy X-rays could have been avoided in 69.5% cases in which only a small silent stone would have been overlooked. However, this stone could have passed into the duodenum spontaneously or else it could have been removed by endoscopic sphincterotomy had it caused any symptoms. It is concluded that routine PC is not always necessary, a selective policy may be preferred and a scoring method may be used as a guide for selection of the cases.

Adult↗
PubMed1994

Right heart function and prediction of respiratory morbidity in patients undergoing pneumonectomy with moderately severe cardiopulmonary dysfunction.

Detailed hemodynamic monitoring was performed in 20 patients undergoing pneumonectomy with moderately severe chronic obstructive pulmonary disease. Flow-directed pulmonary artery catheters capable of determining thermal dilution right ventricular ejection fraction and other indexes of right ventricular performance were placed in each patient. The mean actual and percent values for forced expiratory volume in 1 second in this group were 1.8 +/- 0.5 L and 66% +/- 18%, respectively. Pulmonary hypertension was present in 76.5% of patients at the baseline nonintubated state. At pulmonary artery clamping, 53.8% of this subgroup had no change or a mean drop of 8 mm Hg in pressure. The remaining had a mean rise of 12 mm Hg. Mean systolic pulmonary artery pressures in this subset (41 mm Hg) did not change from the nonintubated state to pulmonary artery clamping. Patients with normal pulmonary artery pressures before intubation had an average rise of only 4 mm Hg at pulmonary artery clamping. In the immediate postoperative period, only 10.0% of the entire group had normal pulmonary artery pressures. Right ventricular ejection fraction and pulmonary vascular resistance were normal in 58.8% and 94.1%, respectively, at the baseline nonintubated state. Abnormal right ventricular ejection fraction values (< 45%) were present in 70.0% of patients at pulmonary artery clamping; 25.0% fell below 35%. Pulmonary vascular resistance increased above 200 dyne.sec.cm-5 in 30.0% at pulmonary artery clamping. No correlation was found between right ventricular ejection fraction and pulmonary vascular resistance or pulmonary artery pressure during operation. No pulmonary function test or hemodynamic variable measured in this study accurately predicted the days of hospital stay or early postoperative cardiopulmonary morbidity. At the baseline nonintubated state, no parameter consistently predicted late New York Heart Association class III/IV. At the time of pulmonary artery clamping, a right ventricular ejection fraction of less than 35%, a pulmonary vascular resistance greater than or equal to 200 dyne.sec.cm-5, and a pulmonary vascular resistance/right ventricular ejection fraction ratio greater than or equal to 5.0 predicted the development of long-term cardiopulmonary disability. Thirteen patients (65.0%) in this series with abnormally low preoperative pulmonary function could have been excluded from pneumonectomy. Only five of 13 patients (38.5%) had late class III/IV symptoms. Four of these five patients had a right ventricular ejection fraction less than 35% during operation.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1998

Perioperative blood transfusion and postoperative mortality.

CONTEXT: The risks of blood transfusion have been studied extensively but the benefits and the hemoglobin concentration at which patients should receive a transfusion have not. OBJECTIVE: To determine the effect of perioperative transfusion on 30- and 90-day postoperative mortality. DESIGN: Retrospective cohort study. SETTING: A total of 20 US hospitals between 1983 and 1993. PARTICIPANTS: A total of 8787 consecutive hip fracture patients, aged 60 years or older, who underwent surgical repair. MAIN OUTCOME MEASURES: Primary outcome was 30-day postoperative mortality; secondary outcome was 90-day postoperative mortality. The "trigger" hemoglobin level was defined as the lowest hemoglobin level prior to the first transfusion during the time period or, for patients in the nontranfused group, as the lowest hemoglobin level during the time period. RESULTS: Overall 30-day mortality was 4.6% (n=402; 95% confidence interval [CI], 4.1%-5.0%); overall 90-day mortality was 9.0% (n=788; 95% CI, 8.4%-9.6%). A total of 42% of patients (n=3699) received a postoperative transfusion. Among patients with trigger hemoglobin levels between 80 and 100 g/L (8.0 and 10.0 g/dL), 55.6% received a transfusion, while 90.5% of patients with hemoglobin levels less than 80 g/L (8.0 g/dL) received postoperative transfusions. Postoperative transfusion did not influence 30- or 90-day mortality after adjusting for trigger hemoglobin level, cardiovascular disease, and other risk factors for death: for 30-day mortality, the adjusted odds ratio (OR) was 0.96 (95% CI, 0.74-1.26); for 90-day mortality, the adjusted hazard ratio was 1.08 (95% CI, 0.90-1.29). Similarly, 30-day mortality after surgery did not differ between those who received a preoperative transfusion and those who did not (adjusted OR, 1.23; 95% CI, 0.81-1.89). CONCLUSIONS: Perioperative transfusion in patients with hemoglobin levels 80 g/L (8.0 g/dL) or higher did not appear to influence the risk of 30- or 90-day mortality in this elderly population. At hemoglobin concentrations of less than 80 g/L (8.0 g/dL), 90.5% of patients received a transfusion, precluding further analysis of the association of transfusion and mortality.

Aged↗
PubMed1999

Beta-blockade versus Buckberg blood-cardioplegia in coronary bypass operation.

OBJECTIVE: Continuous perfusion of the coronary arteries with beta-blocker (esmolol)-enriched normothermic blood during cardiac surgery has been suggested as an alternative technique for myocardial protection. The aim of the present study was to compare the beta-blocker technique to Buckberg's blood cardioplegia during coronary artery bypass grafting (CABG). METHODS: Sixty patients with coronary artery disease were randomly assigned to either the esmolol group (ES, n = 30) or the blood cardioplegia group (BC, n = 30). During aortic crossclamp ES patients received continuous normothermic coronary perfusion with esmolol-enriched blood. Hearts of the BC group were protected by antegrade cold blood cardioplegia according to Buckberg. We measured left ventricular (LV) contractility using TEE (fractional area of contraction, FAC) and hemodynamic parameters prior to cannulation for cardiopulmonary bypass (CPB), after decannulation, and 4 h postoperatively. Myocardial lactate release was measured prior to aortic cross-clamp, during cross-clamp, and after decannulation. LV biopsies for determination of heat-shock protein (HSP-70), actin pattern and intercellular adhesion-molecule (ICAM-I) as indicators for structural changes were collected prior CPB, at the end of the aortic cross-clamp period, and prior to weaning off CPB. RESULTS: There was no significant difference between both groups with respect to grafts and cross-clamp time. ES hearts did not release lactate during cross-clamp. In contrast, BC hearts released significant amounts of lactate. Post CPB FAC and hemodynamics under similar inotropic stimulation showed no difference between groups, whereas at 4 h post CPB measurements showed slightly better values in the ES group: cardiac index: ES: 2.9+/-0.1 (SEM) versus BC: 2.6+/-0.1 L/min per m2 (P < 0.05); FAC: ES: 55+/-3 versus BC: 48+/-3% (P < 0.05). HSP-70 and actin pattern showed no difference between groups; however, ICAM-I showed a significantly higher degree of structural changes in BC hearts: 18+/-2 versus ES: 11+/-1% (P < 0.05). CONCLUSION: Our data demonstrate that application of the beta-blocker technique during routine CABG was associated with slightly better functional recovery and less structural myocardial alteration as compared with intermittent cold blood cardioplegia, however, both techniques provided equivalent myocardial protection in terms of patient outcome. Future studies are required to investigate if myocardial ischemia minimization by use of the beta-blocker technique may be beneficial in compromized hearts.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Tramadol and beta-cyclodextrin piroxicam: effective multimodal balanced analgesia for the intra- and postoperative period.

BACKGROUND AND OBJECTIVES: This study was conducted to evaluate the analgesic efficacy of tramadol, an analgesic with both opioid and nonopioid actions (norepinephrine and serotonin pathways), with beta-cyclodextrin piroxicam, a nonsteroidal antiinflammatory drug, in the perioperative setting. METHODS: The study population consisted of 48 patients scheduled for minor abdominal procedures, who were assigned to one of four groups of 12 patients each. The premedication was either a placebo tablet or a 192.1-mg beta-cyclodextrin piroxicam tablet, administered orally 30-40 minutes before anesthesia induction. After intravenous administration of tramadol 1.5 mg/kg, anesthesia was induced with an intravenous loading dose of propofol. Anesthesia was maintained an intravenous infusion of propofol at 6-12 mg/kg/h plus either saline or tramadol at 1.2 mg/kg/h, atracurium, and a 2:1 nitrous oxide-oxygen mixture. The control group received a placebo tablet and an infusion of saline with propofol for anesthesia maintenance; the tramadol group received a placebo tablet and a continuous tramadol-propofol infusion; the beta-cyclodextrin piroxicam (BCP) group received a BCP tablet and a continuous saline-propofol infusion; and the beta-cyclodextrin piroxicam-tramadol (BCPT) group received beta-cyclodextrin piroxicam and a continuous tramadol-propofol infusion. RESULTS: The relative propofol consumption by the four groups was control = BCP (P > .05) >tramadol (P < .001) > B-CPT (P < .0002). The time for analgesic rescue decreased in the order BCPT > BCP (P < .0002) = tramadol > control (P < .001). The degree of sedation and the visual analog scores 10-cm scale at the time patients requested rescue analgesics were similar among the groups (P > .05). CONCLUSIONS: The combination of tramadol and beta-cyclodextrin piroxicam provided better perioperative analgesia than tramadol alone.

Abdomen↗