The Annals of thoracic surgery
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To summarize this rather wide-ranging study, let us review the high points. The future practice of thoracic surgery will be increasingly affected by governmental factors and will have even greater technological dimensions. To do this work, we must continue to attract high-caliber individuals, and this is best accomplished by the early and continuing involvement in the educational process of strong role models from our field. ⋯ Likewise, although the accreditation process must protect the resident from exploitation, it must not be so restrictive that it does not allow for educational innovation and justifiable differences among programs. These are the thoughtful opinions of our colleagues. They deserve serious consideration.
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Randomized Controlled Trial Clinical Trial
Effect of low-dose aprotinin on coagulation and fibrinolysis in cardiopulmonary bypass.
To study the effect of low-dose aprotinin on hemostasis in patients undergoing cardiopulmonary bypass (CPB) for coronary artery bypass operations and to elucidate the mechanism of aprotinin action, we randomized 14 of 27 patients to receive 30,000 KIU/kg aprotinin in the CPB priming volume and 7,500 KIU/kg aprotinin intravenously each hour during CPB (1 patient was excluded from the aprotinin group because of protamine shock). Intraoperative and postoperative blood loss was significantly reduced in the aprotinin group. Antithrombin III level was significantly decreased, and the levels of thrombin-antithrombin III complexes were significantly increased during CPB in both groups, indicating activation of the clotting system. ⋯ A marked decrease in the platelet count was observed during CPB similarly in both groups. These findings demonstrated that low-dose aprotinin administration was effective in reducing intraoperative and postoperative blood loss and that activation of the clotting system during CPB was not followed by hyperfibrinolysis in aprotinin-treated patients. The improved hemostasis is mainly attributable to the prevention of hyperfibrinolysis during CPB.
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Rupture of cardiac chambers after nonpenetrating blunt thoracic trauma is being recognized with increasing frequency. Despite a high mortality rate, survival after repair of a single-chamber rupture is widely reported. Bichamber cardiac rupture is less frequent, and we report a patient who survived this injury.
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Gastrointestinal damage occurs in 0.6% to 2% of patients after cardiopulmonary bypass (CPB), and carries a mortality of 12% to 67%. The incidence of subclinical gastrointestinal damage may be much greater. We examined the effects of nonpulsatile, hypothermic CPB on intestinal absorption and permeability in 41 patients. ⋯ The permeation of 3-O-methyl-D-glucose and D-xylose returned to normal levels 5 days after CPB, but that of L-rhamnose remained significantly below pre-CPB values at 6.6% +/- 0.5% (p = 0.004). However, the permeation of lactulose increased after CPB (from 0.35% +/- 0.04% to 0.59% +/- 0.1%; p = 0.018), and the lactulose/L-rhamnose gut permeability ratio increased markedly (from 0.045 +/- 0.04 to 0.36 +/- 0.08; normal = 0.06 to 0.08; p = 0.004). Patients who had a CPB time of 100 minutes or more had a greater increase in gut permeability (p = 0.049).(ABSTRACT TRUNCATED AT 250 WORDS)
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Transport of critically ill neonates in need of extracorporeal membrane oxygenation can be risky. Their extreme cardiorespiratory instability may delay or even preclude conventional transport to an extracorporeal membrane oxygenation center. We report the use of a UH-1 helicopter specially adapted for mobile extracorporeal membrane oxygenation support to transport a critically ill neonate.