The Annals of thoracic surgery
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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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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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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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Lidocaine addition to crystalloid cardioplegic solution for prevention of reperfusion ventricular fibrillation after the release of the aortic cross-clamp was studied in 50 patients undergoing coronary artery bypass grafting and in 30 patients undergoing mitral or aortic valve replacement. Twenty-six of the patients undergoing coronary artery bypass grafting received lidocaine, 100 mg/L of cardioplegia, whereas a control group of 24 patients received cardioplegia without lidocaine. ⋯ In the valve group, lidocaine cardioplegia also reduced significantly the incidence of reperfusion ventricular fibrillation from 93% to 42%. In both groups, lidocaine cardioplegia decreased the number of direct-current countershocks required to defibrillate the heart, with no significant increase in the incidence of high-grade atrioventricular block.