The Annals of thoracic surgery
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Almost one-third of 24 adult patients undergoing hypothermic cardiopulmonary bypass (CPB) for elective cardiac operation were found to have upper extremity skin and muscle temperatures of 30.0 degrees C or less at termination of CPB despite the return of nasopharyngeal temperature to normal values. Within 45 minutes, the mean nasopharyngeal temperature of these patients fell spontaneously from 37.1 degrees +/- 0.3 degrees C (+/- standard deviation) to 35.1 degrees +/- 0.4 degrees C, a significantly greater fall (p less than 0.005) than was observed for patients with extremity temperatures greater than 30.0 degrees C. Persistent hypothermia of the upper extremities correlated statistically with large body mass; it appears that these patients incur disproportionately large caloric debts during hypothermic CPB. Inadvertent hypothermia after CPB can be minimized if both core and extremity temperatures are utilized to provide an assessment of the adequacy of warming prior to return to spontaneous circulation.
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Four instances of severe anaphylactoid reaction occurring subsequent to cardiopulmonary bypass are described. These catastrophic reactions, from which 2 patients died, took place approximately an hour following administration of protamine and were characterized by marked peripheral vasodilatation, loss of capillary membrane integrity, and fulminant noncardiogenic pulmonary edema. ⋯ Differential diagnosis from other causes of acute cardiorespiratory dysfunction depended on early assessment of pulmonary artery and left ventricular filling pressures, cardiac output, respiratory mechanics, and arterial blood gases. Therapy was difficult; success in 1 of the patients seemed to have been effected in part by prompt administration of high-dose corticosteroids and maintenance of peripheral vascular tone with an alpha-adrenergic agonist.
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Today, surgeons are able to manage both blunt and penetrating wounds of the heart with increasing success, including those with associated intracardiac injuries. After diagnosis by cardiac catheterization, substantial intracardiac lesions are repaired using cardiopulmonary bypass. Among more than 300 patients treated for cardiac wounds in our city-county hospital in recent years, 15 were found to have marded intracardiac defects. ⋯ Thirteen of the 15 patients required repair of the intracardiac defects. One was repaired acutely and 12 were repaired electively. All 15 patients were alive and asymptomatic at the time of writing.
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From 1968 to 1978, 14 patients were treated for major tracheal or bronchial injury. Five injuries resulted from blunt trauma and nine from penetrating injury. Of the 5 patients with injury due to blunt trauma, three had avulsions of the right main bronchus from the trachea. ⋯ Three patients with partial transections of the cervical or upper mediastinal trachea were treated by primary closure. The other 2 patients had gunshot wounds to the distal right lateral trachea, which were treated by right thoracotomy and primary closure. There were no deaths, and the subsequent course was generally good in all patients.
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Activated coagulation time (ACT) for protamine reversal was monitored in 28 consecutive patients (Group 1) and a standard heparin-protamine protocol was used for an earlier series of 28 patients (Group 2). Although Group 1 received a significantly higher total heparin dose than Group 2 (p less than 0.01), the protamine dose for reversal was significantly less for the ACT group than for the controls (p less than 0.0005). ⋯ This study shows that the ACT test did not reduce postoperative bleeding significantly when compared with our standard protocol. It also indicates that there is wide individual sensitivity to heparin and that significantly less protamine is required for reversal.