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Adverse effects of postoperative infusion of shed mediastinal blood
LITERATURE REVIEW
Oe M, Asou T, Morita S, et ah Protamine-induced hypotension in heart operations: Application of the concept of ventricular-arterial coupling. J Thorac Cardiovasc Surg 112:462-471, 1996 End-systolic pressure-volume relationship was examined by measurement of instantaneous left ventricular pressure and aortic flow in 35 patients undergoing cardiac surgery during protamine infusion (3 mg/kg into the central venous line over 3 minutes at a constant rate). Mean arterial pressure decreased more than 10 mmHg with protamine infusion in 80% of patients. Decreases in mean arterial pressure and effective arterial elastance always preceded the depression of endsystolic elastance. Afterload reduction by protamine-related vasodilation explained the initiation of hypotension. A delayed decrease in inotropy was observed.
Meldrum DR, Cleveland Jr JC, Sheridan BC, et al: Cardiac preconditioning with calcium: Clinically accessible myocardial protection. J Thorac Cardiovasc Surg 112:778-786, 1996 Calcium chloride (5 nmol/min for 2 minutes) was administered to isolated perfused rat hearts 10 minutes before a 20-minute ischemia and 40-minute reperfusion insult. Preischemic calcium chloride administration improved myocardial functional recovery determined by enhanced developed pressure, improved coronary flow, reduced end-diastolic pressure, and decreased creatine kinase leakage during reperfusion. Concurrent protein kinase C inhibition (chelerythrin at 20 retool/L/2 min) eliminated the beneficial effects of calcium chloride. Activation of the alpha isoform of protein kinase C by calcium chloride administration was shown by immunohistochemical staining.
Vertrees RA, Conti VR, Lick FD, et al: Adverse effects of postoperative infusion of shed mediastinal blood. Ann Thorac Surg 62:717-723, 1996 In a prospective, randomized study, reinfusion of shed mediastinal blood increased fibrin split product, D-dimer, and'plasma-free hemoglobin values in this patient group (n = 20) as compared with those for controls (n = 20). All other coagulation variables, platelet count, and hemoglobin levels after the reinfusion period were similar in the two groups. There were no significant differences between mediastinal drainage and red blood cell transfusion requirements between the two groups. Assay of collected mediastinal blood showed this infusate to have low fihrinogen level (8 to 10 mg/dL), clotting factor activities, platelet count (36 to 44 x 106/mL), and hematocrit (9% to 10%) values. Elevated fibrin split product and D-dimer levels were measured in collected rnediastinal blood.
Reddy VM, Liddicoat JR, Fineman JR, et ah Fetal model of single ventricle physiology: Hemodynamic effects of oxygen, nitric oxide, carbon dioxide, and hypoxia in the early post-natal period. J Thorac Cardiovasc Surg 112:437-449, 1996 The authors describe a reproducible model of single ventricle physiology created in utero. A 10-ram Damus-Kaye Stansel anrtopulmonary anastomosis was created in fetal sheep (n = 14) with pulmonary blood flow provided through a 5-mm aortopulmonary shunt after Iigation of the main pulmonary artery distally. Lambs underwent sternotomy and 30 minutes of deep hypothermic circulatory arrest 2 to 3 days after delivery at term. Nitric oxide (80 ppm) and oxygen (100%) caused a decrease in pulmonary vascular resistance and an increase in
257
pulmonary/systemic blood flow ratio before and after bypass. Hypoxia (10% oxygen) and 5% carbon dioxide increased pulmonary vascular resistance and decreased the ratio of pulmonary-to-systemic blood flow.
Riordan C J, Randsbaek F, Storey JH, et al: Effects of oxygen, positive end-expiratory pressure, and carbon dioxide on oxygen delivery in an animal model of the univentricular heart. J Thorac Cardiovasc Surg 112:644-654, 1996 Another univentricular heart model was created in 1- to 2-week-old neonatal pigs (wide atrial septal defect, incompetent mitral valve, occlusion of right ventricular outflow tract, and 6-ram polytetrafluoroethylene innominate-to-pulmonary artery graft). Using this model, reductions in inspired oxygen tension were directly related to decreases of pulmonary-to-systemic flow ratio. Addition of 5% carbon dioxide to the inspired gas did not significantly decrease pulmonary-to-systemic flow ratio. Systemic oxygen delivery was optimal when pulmonary-tosystemic flow ratio was 1 to 0.7. When the initial ratio was greater than 0.7, interventions that decreased the ratio increased oxygen delivery. Interventions decreasing the ratio when the initial pulmonary/systemic flow ratio was less than 0.7 were detrimental to systemic oxygen delivery.
Halm EA, Browner WS, Tubau JF, et al: Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Ann Intern Med 125:433-441, 1996 Consecutive men (n : 339) with known or suspected coronary artery disease scheduled for major noncardiac surgery underwent preoperative evaluation including transthoracic echocardiography to assess ejection fraction, wall motion abnormalities, and left ventricular hypertrophy. Postoperative ischemic events occurred in 3% of patients, congestive heart failure occurred in 8%, and ventricular tachycardia occurred in 8%. No echocardiographic measurements were associated with ischemic events. In multivariable analyses, ejection fraction <40% and wall motion score were predictors of all outcomes combined but not of a specific morbid outcome. Adding echocardiographic information to predictive models that contain known clinical risk factors did not alter sensitivity, specificity, or predictive values in clinically significant ways.
Connors Jr AF, Speroff T, Dawson NV, et al: The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 276:889897, 1996 The therapeutic value of pulmonary artery catheterization is questioned in this observational study of critically ill nonsurgical adult patients in five US teaching hospitals between 1989 and 1994. More than 5,700 patients with acute respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, cirrhosis, nontranmatic coma, metastatic colon cancer, non-small-cell lung cancer, and multiorgan system failure with malignancy or sepsis were studied. Pulmonary artery catheter (PAC)-managed patients were matched to non-PACtreated patients on the basis of disease category and propensity score (score based on covariables determining selection of pulmonary artery catheterization and characterizing severity of illness). By case-matching analysis, patients with pulmonary artery catheterization had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03 to 1.49). The mean cost per hospital stay was $49,300 with PAC
Oe M, Asou T, Morita S, et ah Protamine-induced hypotension in heart operations: Application of the concept of ventricular-arterial coupling. J Thorac Cardiovasc Surg 112:462-471, 1996 End-systolic pressure-volume relationship was examined by measurement of instantaneous left ventricular pressure and aortic flow in 35 patients undergoing cardiac surgery during protamine infusion (3 mg/kg into the central venous line over 3 minutes at a constant rate). Mean arterial pressure decreased more than 10 mmHg with protamine infusion in 80% of patients. Decreases in mean arterial pressure and effective arterial elastance always preceded the depression of endsystolic elastance. Afterload reduction by protamine-related vasodilation explained the initiation of hypotension. A delayed decrease in inotropy was observed.
Meldrum DR, Cleveland Jr JC, Sheridan BC, et al: Cardiac preconditioning with calcium: Clinically accessible myocardial protection. J Thorac Cardiovasc Surg 112:778-786, 1996 Calcium chloride (5 nmol/min for 2 minutes) was administered to isolated perfused rat hearts 10 minutes before a 20-minute ischemia and 40-minute reperfusion insult. Preischemic calcium chloride administration improved myocardial functional recovery determined by enhanced developed pressure, improved coronary flow, reduced end-diastolic pressure, and decreased creatine kinase leakage during reperfusion. Concurrent protein kinase C inhibition (chelerythrin at 20 retool/L/2 min) eliminated the beneficial effects of calcium chloride. Activation of the alpha isoform of protein kinase C by calcium chloride administration was shown by immunohistochemical staining.
Vertrees RA, Conti VR, Lick FD, et al: Adverse effects of postoperative infusion of shed mediastinal blood. Ann Thorac Surg 62:717-723, 1996 In a prospective, randomized study, reinfusion of shed mediastinal blood increased fibrin split product, D-dimer, and'plasma-free hemoglobin values in this patient group (n = 20) as compared with those for controls (n = 20). All other coagulation variables, platelet count, and hemoglobin levels after the reinfusion period were similar in the two groups. There were no significant differences between mediastinal drainage and red blood cell transfusion requirements between the two groups. Assay of collected mediastinal blood showed this infusate to have low fihrinogen level (8 to 10 mg/dL), clotting factor activities, platelet count (36 to 44 x 106/mL), and hematocrit (9% to 10%) values. Elevated fibrin split product and D-dimer levels were measured in collected rnediastinal blood.
Reddy VM, Liddicoat JR, Fineman JR, et ah Fetal model of single ventricle physiology: Hemodynamic effects of oxygen, nitric oxide, carbon dioxide, and hypoxia in the early post-natal period. J Thorac Cardiovasc Surg 112:437-449, 1996 The authors describe a reproducible model of single ventricle physiology created in utero. A 10-ram Damus-Kaye Stansel anrtopulmonary anastomosis was created in fetal sheep (n = 14) with pulmonary blood flow provided through a 5-mm aortopulmonary shunt after Iigation of the main pulmonary artery distally. Lambs underwent sternotomy and 30 minutes of deep hypothermic circulatory arrest 2 to 3 days after delivery at term. Nitric oxide (80 ppm) and oxygen (100%) caused a decrease in pulmonary vascular resistance and an increase in
257
pulmonary/systemic blood flow ratio before and after bypass. Hypoxia (10% oxygen) and 5% carbon dioxide increased pulmonary vascular resistance and decreased the ratio of pulmonary-to-systemic blood flow.
Riordan C J, Randsbaek F, Storey JH, et al: Effects of oxygen, positive end-expiratory pressure, and carbon dioxide on oxygen delivery in an animal model of the univentricular heart. J Thorac Cardiovasc Surg 112:644-654, 1996 Another univentricular heart model was created in 1- to 2-week-old neonatal pigs (wide atrial septal defect, incompetent mitral valve, occlusion of right ventricular outflow tract, and 6-ram polytetrafluoroethylene innominate-to-pulmonary artery graft). Using this model, reductions in inspired oxygen tension were directly related to decreases of pulmonary-to-systemic flow ratio. Addition of 5% carbon dioxide to the inspired gas did not significantly decrease pulmonary-to-systemic flow ratio. Systemic oxygen delivery was optimal when pulmonary-tosystemic flow ratio was 1 to 0.7. When the initial ratio was greater than 0.7, interventions that decreased the ratio increased oxygen delivery. Interventions decreasing the ratio when the initial pulmonary/systemic flow ratio was less than 0.7 were detrimental to systemic oxygen delivery.
Halm EA, Browner WS, Tubau JF, et al: Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Ann Intern Med 125:433-441, 1996 Consecutive men (n : 339) with known or suspected coronary artery disease scheduled for major noncardiac surgery underwent preoperative evaluation including transthoracic echocardiography to assess ejection fraction, wall motion abnormalities, and left ventricular hypertrophy. Postoperative ischemic events occurred in 3% of patients, congestive heart failure occurred in 8%, and ventricular tachycardia occurred in 8%. No echocardiographic measurements were associated with ischemic events. In multivariable analyses, ejection fraction <40% and wall motion score were predictors of all outcomes combined but not of a specific morbid outcome. Adding echocardiographic information to predictive models that contain known clinical risk factors did not alter sensitivity, specificity, or predictive values in clinically significant ways.
Connors Jr AF, Speroff T, Dawson NV, et al: The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 276:889897, 1996 The therapeutic value of pulmonary artery catheterization is questioned in this observational study of critically ill nonsurgical adult patients in five US teaching hospitals between 1989 and 1994. More than 5,700 patients with acute respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, cirrhosis, nontranmatic coma, metastatic colon cancer, non-small-cell lung cancer, and multiorgan system failure with malignancy or sepsis were studied. Pulmonary artery catheter (PAC)-managed patients were matched to non-PACtreated patients on the basis of disease category and propensity score (score based on covariables determining selection of pulmonary artery catheterization and characterizing severity of illness). By case-matching analysis, patients with pulmonary artery catheterization had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03 to 1.49). The mean cost per hospital stay was $49,300 with PAC