Prothrombin Complex Concentrates in Pediatric Cardiac Surgery: The Current State and the Future.

Background: After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophilia patients, are safely and efficiently used off label for hemorrhage after bypass.

Coagulation Parameter Thresholds Associated with Non-Bleeding in the Eighth Hour of Adult Cardiac Surgical Post-Cardiotomy Extracorporeal Membrane Oxygenation.

Excessive bleeding and allogeneic transfusion during adult post-cardiotomy venoarterial extracorporeal membrane oxygenation (ECMO) are potentially harmful and expensive. Balancing the inhibition of clotting and distinguishing surgical from non-surgical bleeding in post-operative period is difficult. The sensitivity of coagulation tests including Thromboelastography(®) (TEG) to predict chest tube drainage in the early hours of ECMO was examined with the use of receiver-operating characteristics (ROC).

Transfusion errors: causes, incidence, and strategies for prevention.

Purpose Of Review: Miss-transfusion of blood has become one of the leading causes of death related to blood transfusion. New technology is able to better prevent miss-transfusions than older methods.

Recent Findings: New computer-based technology is available and is very effective in preventing miss-transfusion of blood.

Fontan conversion: identifying the high-risk patient.

Background: Patients with atriopulmonary Fontan tend to undergo conversion to total cavopulmonary connections secondary to arrhythmias or poor flow dynamics. However, the ideal candidate is unknown.

Methods: Between December 1994 and May 2011, 70 patients (40 males [57%]) underwent Fontan conversion.

The incidence of vasoplegia in adult patients with right-sided congenital heart defects undergoing cardiac surgery and the correlation with serum vasopressin concentrations.

Background: In adults with right-sided congenital heart disease, vasoplegia during and after cardiopulmonary bypass appears to be a frequent complication. The incidence of vasoplegia in the general adult and pediatric cardiac surgical population has been investigated, but the incidence in adult patients with right-sided congenital heart disease is unknown. Perioperative vasopressin levels during cardiac surgery have been studied in other cardiac surgical patients, but are not known in adults with right-sided congenital heart disease.

Dexamethasone levels predict cortisol response after infant cardiopulmonary bypass.

Objectives: We sought to evaluate whether there is variability in blood dexamethasone levels after a standard 1 mg/kg dose of dexamethasone administered before infant cardiopulmonary bypass. We hypothesized that postoperative dexamethasone drug levels are highly variable, and that the infant stress response is related inversely to the amount of dexamethasone measured in the blood.

Methods: Thirty-two infants (age, ≤365 days) received 1 mg/kg of dexamethasone before cardiopulmonary bypass (CPB) initiation.

Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors.

Objective: To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes.

Patients And Methods: Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010.

A prospective, randomized, blinded study of continuous ropivacaine infusion in the median sternotomy incision following cardiac surgery.

Objective: The aim of this prospective, randomized, double-blind, placebo controlled trial was to evaluate the safety and efficacy of continuous ropivacaine infusion of into the sternal wound.

Methods: We planned to enroll 200 patients scheduled for various cardiac surgical procedures into the study. Patients, in a double-blind randomized fashion, were given either normal saline or 0.

Outcomes of general anesthesia for noncardiac surgery in a series of patients with Fontan palliation.

Objectives: To describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery.

Background: The Fontan procedure was developed in 1971 to palliate patients with univentricular cardiac physiology leading to long-term survival of these patients, who may now present as adults for noncardiac surgery.

Methods: We retrospectively reviewed the medical records of Fontan patients 16 years and older who underwent general anesthesia for noncardiac surgery at Mayo Clinic in Rochester, Minnesota.

A prospective, randomized, double-blind trial of 3 regimens for sedation and analgesia after cardiac surgery.

Objective: The aim of this study was to evaluate cardiac risk as a consideration for selecting postoperative sedation and analgesia regimens used for cardiac surgical patients requiring cardiopulmonary bypass and early extubation.

Design: An observer-blind, randomized, controlled trial.

Setting: A tertiary referral medical center involving an intensive care unit.

Comparative safety and efficacy of topical hemostatic agents in a rat neurosurgical model.

Objective: Adequate hemostasis is extremely important in neurosurgery, commonly requiring the use of topical hemostatic agents. Apart from variable efficacy, the residual presence of these agents may cause foreign body reaction, infection, and delayed bone growth. This study compares the safety and efficacy of commonly used agents with a newly approved agent, Arista (microporous polysaccharide hemospheres; Medafor, Inc.

A preliminary study of a new tranexamic acid dosing schedule for cardiac surgery.

Objective(s): The authors have developed an alternative dosing schedule for tranexamic acid that incorporates the effects of renal function on tranexamic acid concentrations. The objectives of this study were to determine if this new dosing schedule can achieve the desired plasma concentration of tranexamic acid and reduce intra- and interpatient variability in tranexamic acid plasma concentrations relative to the current dosing schedule.

Design: A prospective randomized trial.

Aprotinin does not prolong the Sonoclot aprotinin-insensitive activated clotting time.

Study Objective: To determine whether a new Sonoclot-based, aprotinin-insensitive activated clotting time (aiACT) assay yields stable results over a broad range of aprotinin concentrations.

Design: Prospective trial conducted on in vitro blood samples.

Setting: Tertiary-care teaching medical center.

A comparison of fenoldopam with dopamine and sodium nitroprusside in patients undergoing cross-clamping of the abdominal aorta.

Fenoldopam, a selective dopamine-1-receptor agonist, decreases arterial blood pressure rapidly, with a brief duration of action similar to sodium nitroprusside (SNP), but in contrast to SNP, it increases renal blood flow. We compared the hemodynamic and renal effects of fenoldopam in patients undergoing abdominal aortic surgery requiring cross-clamping of the aorta with another therapeutic option, dopamine and SNP. Fenoldopam or 2 mcg x kg(-1) x min(-1) of dopamine and SNP was infused before incision in 60 randomly selected patients in a double-blind fashion.

Morbidity and mortality in the use of electroconvulsive therapy.

There are a few large studies of the morbidity and mortality of electroconvulsive therapy (ECT). To add data to this literature, we performed a retrospective review of all the patients who underwent ECT at our institution between January 1, 1988, through December 31, 2001. We identified 2,279 patients who were given 17,394 ECT treatments during their first series.

Hemofiltration but not steroids results in earlier tracheal extubation following cardiopulmonary bypass: a prospective, randomized double-blind trial.

Background: Activation of the inflammatory cascade is thought to account for some of the respiratory dysfunction and prolonged mechanical ventilation associated with cardiopulmonary bypass. The objective of this investigation was to identify whether perioperative steroids or hemofiltration during cardiopulmonary bypass, by their attenuation of inflammation, would reduce duration of mechanical ventilation after cardiac surgery.

Methods: After Institutional Review Board approval and informed consent, 192 patients scheduled to undergo elective primary coronary artery bypass grafting or valvular replacement or repair were randomized in a double-blind prospective study into three groups.

Variability of plasma aprotinin concentrations in pediatric patients undergoing cardiac surgery.

Objectives: Infants and children undergoing cardiopulmonary bypass for repair of congenital heart defects are at substantial risk for excessive bleeding, contributing greatly to morbidity and mortality. Aprotinin significantly reduces bleeding and transfusion requirements in adults but is of indeterminate value for pediatric patients. The aim of this study was to determine plasma aprotinin concentrations in these patients with a functional aprotinin assay.

A comparison of bleeding and transfusion in patients who undergo coronary artery bypass grafting via sternotomy with and without cardiopulmonary bypass.

Objective: To determine whether there is a difference between on-pump cardiopulmonary bypass (CABG) and off-pump coronary artery bypass grafting (OPCAB) without heparin reversal with regard to bleeding, transfusion requirements, and incidence of surgical re-exploration of the mediastinum.

Design: Retrospective chart review.

Setting: A large academic medical center.

Blood loss in infants and children for open heart operations: albumin 5% versus fresh-frozen plasma in the prime.

Background: Infants and children undergoing cardiopulmonary bypass become substantially hemodiluted secondary to the volume used to prime the oxygenator. Fresh-frozen plasma has been included in the prime to lessen dilution of clotting factors and correspondingly minimize blood loss and transfusions.

Methods: We prospectively randomized 56 patients weighing 10 kg or less who required cardiopulmonary bypass to receive either one unit of fresh-frozen plasma or 200 mL of albumin 5% in the prime.

Heparin-coated versus uncoated extracorporeal circuit in patients undergoing coronary artery bypass graft surgery.

Objective: To assess the effect of heparin-coated circuits on bleeding, transfusion, and platelet count in patients undergoing primary coronary artery bypass grafting with full heparinization.

Design: Randomized, double-blind study.

Setting: Tertiary-care academic medical center.