Seminars in cardiothoracic and vascular anesthesia
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Semin Cardiothorac Vasc Anesth · Jun 2009
Lessons learned in antifibrinolytic therapy: The BART trial.
Despite nearly 2 decades of published reports and clinical trials demonstrating the relative safety and efficacy of aprotinin in adult cardiac surgical patients at increased risk of bleeding-culminating in an official endorsement of the usage of aprotinin in such patients from both cardiac surgery and anesthesiology subspecialty committees-several more recent studies have raised profound concerns regarding the safety of aprotinin in these same patients. These studies and the implications thereof have ultimately resulted in the withdrawal of aprotinin from clinical usage internationally. This article will briefly review these developments with the hope of understanding how this abrupt turnabout took place and will attempt to understand how such events can be avoided in the future.
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From the first description of the "systemic inflammatory response" in the early 1990s, it has been recognized that this is a multifaceted response of the body to the combined insult of cardiothoracic surgery with bypass, involving causation by "activation of complement, coagulation, fibrinolytic, and kallikrein cascades, activation of neutrophils with degranulation and protease enzyme release, oxygen radical production, and the synthesis of various cytokines from mononuclear cells." Yet the intervening 15 years have seen a narrowing of research into individual systems and interventions naively targeted at single pathways without achieving clinically meaningful benefits. The time has come to redefine the systemic inflammatory response so that research can be more productively focused on objectively measuring and interdicting this multisystem disorder. ⋯ Triggers might be inadvertently provided by transient episodes of ischemia/malperfusion to vulnerable organs or handling trauma to major vessels. Future research should be directed at suppressing systemic activation with combinations of drugs and improved circuit coating, whereas changes in clinical practice and continuous monitoring of perfusion parameters can help eliminate localized triggering events.
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Semin Cardiothorac Vasc Anesth · Jun 2009
What was hot and what was not in 2007?: a literature review.
While the number of publications each year in cardiac anesthesia is enormous there are a select group of interesting articles highlighting controversies in current practice or new techniques, medications, procedures which may change practice down the road. The purpose of this article is to review some of these articles. While by no means a systematic review, this article highlights some of the more interesting papers from the cardiac anesthesia and surgical literature from 2007. The articles focus on areas such as: methods to reduce both cerebral dysfunction and renal dysfunction, myocardial protection inhaled volatile anesthetic agents, and methods to reduce atrial fibrillation.
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Semin Cardiothorac Vasc Anesth · Jun 2009
Suction, salvage, sutures, and potions: blood management post-aprotinin.
Hemostasis management of the cardiac surgical patient has changed following the withdrawal of aprotinin for use in cardiac surgical patients. The challenge to minimize blood loss and reduce exposure of cardiac surgical patients to blood products continues to grow with patients presenting being older and sicker and more complex procedures being performed. The cardiac surgery team has many options available for it to consider; although current recommendations strongly support the use of cell salvage as one process to assist in this challenge, other options need to be equally critically evaluated.
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Blood has been described as the most precious and personal substance in the world. Current directions in cardiac surgery are moving away from transfusing donor "Allogeneic" blood products, and towards improving methods of saving and preserving the patient's own "autologous" blood. Nothing else comes close to the natural healing abilities and homeostasis that one's own whole blood offers. ⋯ Admission to discharge hemovigilance requires a concerted multidisciplinary team effort with multimodal tools available in the coagulation armamentarium to effectively avoid this form of organ transplant. Improving outcomes and reducing morbidity and mortality in cardiac surgery takes place at the microcirculatory capillary level and with control of Hemostasis. Cardiac teams need to effectively communicate and minimize blood loss and hemodilution and reverse it, for state of the art blood management in Cardiac surgery.