Journal of cardiothoracic and vascular anesthesia
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J. Cardiothorac. Vasc. Anesth. · Apr 1998
Randomized Controlled Trial Comparative Study Clinical TrialA comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery.
To compare the efficacy of thoracic epidural analgesia (TEA) and intrapleural analgesia (IPA) after minimally invasive direct coronary artery bypass (MIDCAB) surgery with regard to quality of analgesia and complications. ⋯ IPA is a safe and effective technique for postoperative analgesia after MIDCAB surgery and has a low complication rate compared with TEA. Careful positioning, chest tube clamping, and anchoring of the catheter are mandatory for IPA to be effective.
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J. Cardiothorac. Vasc. Anesth. · Apr 1998
ReviewResolved: A pulmonary artery catheter should be used in the management of the critically ill patient. Pro.
Selected studies showing both positive and negative outcomes with the use of pulmonary artery catheters (PACs) are reviewed. Indications for use of a PAC are controversial, although clearly the "red cap syndrome" is an indication for its insertion. There are sufficient data as well as personal experience to suggest that PACs do make a difference in the management of critically ill patients. ⋯ Studies are reviewed that addressed physician level of expertise related to PAC insertion, complications, data and waveform interpretation, and management. User knowledge clearly is suboptimal. Before attempting to draw conclusions from outcome studies, criteria for appropriate use need to be developed and clinician knowledge needs to be significantly improved.
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J. Cardiothorac. Vasc. Anesth. · Apr 1998
Epidural anesthesia in cardiac surgery: is there an increased risk?
To assess the risk of hemorrhagic complications associated with epidural anesthesia in patients undergoing coronary artery bypass grafting. ⋯ By following certain guidelines, the risk for the development of epidural hematoma is not increased in patients undergoing epidural anesthesia during cardiac surgery.
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J. Cardiothorac. Vasc. Anesth. · Apr 1998
ReviewSafety issues in heparin and protamine administration for extracorporeal circulation.
This article reviews past approaches to heparin and protamine dosing and summarizes current practice. The author elucidates his experience with the Celite activated coagulation time (ACT), with attention to his adoption of a value of 400 seconds for this time; the adoption of an ACT of 480 seconds by Bull et al (J Thorac Cardiovasc Surg 69:674-684, 1975) and Young et al (Ann Thorac Surg 26:231-240, 1978); the proposed use of heparin response curves by Bull et al; the author's experience with a unitized dosing system to individualize dosing of heparin; and the use for this purpose by Despotis et al (J Thorac Cardiovasc Surg 110:46-54, 1995) of a system based on protamine titration. In more than 270 adult cardiac surgery patients, the unitized dosing system identified patients with high sensitivity or resistance to heparin and facilitated exact individualized doses to be given to produce the desired effect. ⋯ Aprotinin is not a procoagulant during cardiopulmonary bypass. Emerging studies suggest that graft patency is not affected by aprotinin use. The Celite ACT should not be used to monitor heparin effect and safety when using aprotinin; the kaolin ACT should be used instead.
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J. Cardiothorac. Vasc. Anesth. · Apr 1998
ReviewCardiopulmonary bypass-induced inflammation: is it important?
The systemic endotoxemia that occurs with the institution of cardiopulmonary bypass (CPB) is a potent stimulus for the release of proinflammatory cytokines, including tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), and IL-6. Raised IL-6 levels have been reported to correlate with post-CPB left ventricular wall-motion abnormalities and myocardial ischemic episodes. Neutrophil-endothelial adhesion is strongly implicated in the inflammation and reperfusion injury that may follow a period of CPB, and organ injury is thought to be, in part, neutrophil mediated. ⋯ Recent data suggest that administration of the serine protease inhibitor aprotinin to patients undergoing myocardial revascularization with CPB can reduce TNF-alpha blood levels and blunt neutrophil CD11b upregulation. Preliminary data suggest that aprotinin can inhibit cytokine-induced nitric oxide synthase expression and subsequent NO production by murine bronchial epithelial cells. These effects may explain some of the reported antiinflammatory effects of the serine protease inhibitors.