The Annals of thoracic surgery
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Erythropoietin was used in 10 patients undergoing elective cardiovascular operations who were compromised with anemia. Initially, their blood hemoglobin levels were less than 10 g/dL (range, 7.5 to 9.9 g/dL). Erythropoietin (600 to 700 units/kg per week) was administered intravenously or subcutaneously for about 2 to 12 weeks. ⋯ Although the causes of anemia were not specified in some of these patients, it was noteworthy that erythropoietin was effective even in a patient with hypoplastic bone marrow. Subcutaneous use was assumed to be especially favorable in managing anemic patients, in whom preoperative erythropoietin treatment could be continued for up to 82 days. We conclude that erythropoietin would be beneficial for the anemic population to secure homologous-blood-free operations.
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Case Reports
Lower extremity ischemia secondary to internal thoracic-coronary artery bypass grafting.
Vascular complications associated with the use of the internal thoracic artery as a conduit for coronary artery bypass are infrequent. However, acute limb-threatening ischemia can occur after the use of the internal thoracic artery for myocardial revascularization when this vessel forms an important collateral to an obstructed aortoiliac artery system. Although this is a rare complication, the consequences are devastating. Due to the risk of peripheral vascular insufficiency, we now perform simultaneous revascularization of the myocardium and the lower extremity when an internal thoracic artery that appears to be a major collateral to the ipsilateral aortoiliac system is used.
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Recent technological advances in cardiopulmonary bypass circuits achieving surface bonding with heparin have permitted prolonged extracorporeal life support (ECLS) in experimental studies without the use of systemic anticoagulation. Excessive bleeding and the need for massive transfusions after extended ECLS with systemic heparinization have often led to the development of sepsis and multisystem organ failure. The Carmeda bioactive surface circuit, along with a Bio-Medicus centrifugal pump (Bio-Pump) and the femoral veno-arterial route, were used successfully in 3 patients requiring ECLS between April 1992 and December 1992. ⋯ One patient received no heparin, and the other 2 patients received intermittent heparin infusion to maintain an average activated clotting time of 195 and 214 seconds. Multisystem organ dysfunction present before initiation of ECLS was rapidly reversed, and all patients were weaned successfully without any immediate major complications. The ability to conduct prolonged ECLS without systemic anticoagulation and without repeat sternotomy opens new avenues for the use of this procedure in profound heart failure.
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Randomized Controlled Trial Comparative Study Clinical Trial
Thoracic versus lumbar epidural fentanyl for postthoracotomy pain.
Thirty patients were prospectively randomized to receive either thoracic or lumbar epidural fentanyl infusion for postthoracotomy pain. Epidural catheters were inserted, and placement was confirmed with local anesthetic testing before operation. General anesthesia consisted of nitrous oxide, oxygen, isoflurane, intravenous fentanyl citrate (5 micrograms/kg), and vecuronium bromide. ⋯ The infusion rate needed to maintain a visual analogue scale score of less than 4 was lower in the thoracic group (1.55 +/- 0.13 micrograms.kg-1 x h-1) than in the lumbar group (2.06 +/- 0.19 microgram.kg-1 x h-1) during the first 4 hours after operation (p < or = 0.05). The epidural fentanyl infusion rates could be reduced at 4, 24, and 48 hours after operation without compromising pain relief. Four patients in the lumbar group required naloxone hydrochloride intravenously.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Renal dysfunction and intravascular coagulation with aprotinin and hypothermic circulatory arrest.
High-dose aprotinin was used in 20 patients undergoing primary or repeat operations on the thoracic or thoracoabdominal aorta using cardiopulmonary bypass and hypothermic circulatory arrest. The activated clotting times immediately before the establishment of hypothermic circulatory arrest exceeded 700 seconds in all but 1 patient. Three patients (15%) required reoperation for bleeding. ⋯ None of these 20 patients required reoperation for bleeding. Although aprotinin has been shown to reduce blood loss in patients having cardiac operations employing cardiopulmonary bypass, this benefit was not attained in this group of patients with thoracic aortic disease in whom hypothermic circulatory arrest was used. Use of aprotinin in elderly patients undergoing these procedures was associated with an increased risk of renal dysfunction and failure, and of myocardial infarction and death.