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Ketamine has no effect on oxygenation indices following elective coronary artery bypass grafting under cardiopulmonary bypass  [cached]
Parthasarathi Gayatri,Raman Suneel,Sinha Prabhat,Singha Subrata
Annals of Cardiac Anaesthesia , 2011,
Abstract: Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome and organ dysfunction. This can result in pulmonary dysfunction and deterioration of oxygenation after cardiac surgery and cardiopulmonary bypass. Previous studies have reported varying results on anti-inflammatory strategies and oxygenation after cardiopulmonary bypass. Ketamine administered as a single dose at induction has been shown to reduce the pro-inflammatory serum markers in patients undergoing cardiopulmonary bypass. Therefore we investigated if ketamine can result in better oxygenation in these patients. This was a prospective randomized blinded study. Eighty consecutive adult patients undergoing elective coronary artery bypass grafting under cardiopulmonary bypass were included in the study. Patients were divided into two groups. Patients in ketamine group received 1mg/kg of ketamine intravenously at induction of anesthesia. Control group patients received an equal volume of saline. All patients received standard anesthesia, operative and postoperative care.Paired t test and independent sample t test were used to compare the inter-group and between group oxygenation indices respectively. Oxygenation index and duration of ventilation were analyzed. Deterioration of oxygenation index was noted in both the groups after cardiopulmonary bypass. However, there was no significant difference in the oxygenation index at various time points after cardiopulmonary bypass or the duration of ventilation between the two groups. This study shows that the administered as a single dose at induction does not result in better oxygenation after cardiopulmonary bypass.
Statin prophylaxis and inflammatory mediators following cardiopulmonary bypass: a systematic review
Catherine Morgan, Michael Zappitelli, Peter Gill
Critical Care , 2009, DOI: 10.1186/cc8135
Abstract: We performed a systematic and comprehensive literature search for all randomized controlled trials (RCTs) of open heart surgery with CPB in adults or children who received prophylactic statin treatment prior to CPB, with reported outcomes which included markers of inflammation. Two authors independently identified eligible studies, extracted data, and assessed study quality using standardized instruments. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random effects model. Descriptive analysis was used when data could not be pooled.Eight RCTs were included in the review, with the number of trials for each inflammatory outcome being even more limited. Pooled data demonstrated benefit with the use of statin to attenuate the post-CPB increase in interleukins 6 and 8 (IL-6, IL-8), peak high sensitivity C-reactive protein (hsCRP), and tumor necrosis factor-alpha (TNF-α) post-CPB (WMD [95% confidence interval (CI)] -23.5 pg/ml [-36.6 to -10.5]; -23.4 pg/ml [-35.8 to -11.0]; -15.3 mg/L [CI -26.9 to -3.7]; -2.10 pg/ml [-3.83 to -0.37] respectively). Very limited RCT evidence suggests that prophylactic statin therapy may also decrease adhesion molecules following CPB including neutrophil CD11b and soluble P (sP)-selectin.Although the RCT evidence may suggest a reduction in post-CPB inflammation by statin therapy, the evidence is not definitive due to significant limitations. Several of the trials were not methodologically rigorous and statin intervention was highly variable in this small number of studies. This systematic review demonstrates that there is a significant gap that exists in the current literature in regards to the potential anti-inflammatory effect of statin therapy prior to CPB.The use of cardiopulmonary bypass (CPB) is necessary for many cardiac surgical procedures. However, it is clear that CPB can have deleterious effects, including initiation of cardiopulmonary dysfunction, renal dysfunction, and neurological inju
Pituitary intratumoral hemorrhage during radiation therapy following partial removal of giant pituitary adenoma: A case report  [PDF]
Junyang Liu, Yuichiro Yoneoka, Kensuke Tanaka, Hiraku Satou, Eisuke Abe, Naoto Watanabe, Yukihiko Fuji, Hitoshi Takahashi, Hidefumi Aoyama
Case Reports in Clinical Medicine (CRCM) , 2014, DOI: 10.4236/crcm.2014.31010

We report a rare case of intratumoral hemorrhage during postoperative radiotherapy for pituitary adenoma. A 57-year-old Asian male, complaining of long-standing eye strain, underwent a medical checkup of the brain. Magnetic resonance imaging showed a multicystic giant pituitary adenoma. The patient underwent an endoscopic endonasal transsphenoidal partial removal of the adenoma to provide optic pathway decompression and got relief from the visual symptoms. Just before completion of the postoperative radiotherapy for residual adenoma, the patient developed right hemiparesis, mild motor aphasia, and right oculomotor palsy. A cranial CT scan showed intratumoral hemorrhage into the intratumoral cyst. The patient therefore had to undergo three additional craniotomies for evacuation of cyst contents over the next 8 months. The follow-up MRI at 11 months after the initial hemorrhage showed that the new oozing of blood in the intratumoral cyst was still appearing. Intratumoral hemorrhage is a rare, albeit life-threatening, complication of pituitary adenoma. We reviewed relevant literature and suggested that the cystic component in pituitary adenoma could be a key pathogenesis of this rare complication. In conclusion, we suggest that it may be necessary to realize that cases which have cystic giant pituitary adenoma may cause hemorrhage by chance with the foreseeability.

Preoperative prediction of pediatric patients with effusions and edema following cardiopulmonary bypass surgery by serological and routine laboratory data
József Bocsi, J?rg Hambsch, Pavel Osmancik, Peter Schneider, Günter Valet, Attila Tárnok
Critical Care , 2002, DOI: 10.1186/cc1494
Abstract: One-day preoperative serum levels of immunoglobulins, complement, cytokines and chemokines, soluble adhesion molecules and receptors as well as clinical chemistry parameters such as differential counts, creatinine, blood coagulation status (altogether 56 parameters) were analyzed in peripheral blood samples of 75 children (aged 3–18 years) undergoing cardiopulmonary bypass surgery (29 with postoperative effusions and edema within the first postoperative week).Preoperative elevation of the serum level of C3 and C5 complement components, tumor necrosis factor-α, percentage of leukocytes that are neutrophils, body weight and decreased percentage of lymphocytes (all P < 0.03) occurred in children developing postoperative effusions and edema. While single parameters did not predict individual outcome, >86% of the patients with postoperative effusions and oedema were correctly predicted using two different classification algorithms. Data mining by both methods selected nine partially overlapping parameters. The prediction quality was independent of the congenital heart defect.Indicators of inflammation were selected as risk indicators by explorative data analysis. This suggests that preoperative differences in the immune system and capillary permeability status exist in patients at risk for postoperative effusions. These differences are suitable for preoperative risk assessment and may be used for the benefit of the patient and to improve cost effectiveness.Patients undergoing cardiopulmonary bypass (CPB) surgery frequently develop systematic inflammatory response syndrome, ranging from mild to severe complications such as pericardial, pleural and/or abdominal effusion, liver enlargement and edema. These complications are characterized by increased capillary permeability, a shift of fluid and protein from the intravascular to the interstitial space and may further progress into hypovolemia, massive generalized edema, acute respiratory distress syndrome, or even capillary
Cardiopulmonary Bypass
Luc Rondelez, Philippe Linden
Critical Care , 2010, DOI: 10.1186/cc8900
Abstract: This 207-pages work includes 15 chapters, is well illustrated and contains a lot of tables and interesting diagrams. The first chapters present the equipment and the preparation of the cardiopulmonary bypass (CPB) circuit, the conduct of the bypass and the process of weaning from mechanical to physiological circulation. Two chapters describe the management of the hemostatic and metabolic consequences of the CPB circuit. One chapter is dedicated to myocardial protection. The effects of extracorporeal circulation on the body are described, with particular attention to the brain and the kidney, two organs at high risk of complication after CPB. Mechanical circulatory support, deep hypothermic circulatory arrest and extracorporeal membrane oxygenation are described in specific chapters. The last chapter describes CPB in noncardiac procedures, such as thoracic aortic surgery, pulmonary embolism, hepatic and pulmonary transplantation, major oncologic surgery, and trauma. The editors and authors are UK and US anesthetists, perfusionists and surgeons with recognized expertise in the field of CPB.This book covers most of the topics related to the management of CPB - in adults. Unfortunately, there is no chapter dealing specifically with pediatric CPB.The information provided in this book is relatively basic, and is less complete than in many textbooks on the subject. Several chapters refer to relatively old concepts of perfusion that have been challenged since (that is, the use of crystalloids as the priming fluid, management of the on-bypass hematocrit on bypass, overview of the coagulation cascade, and so forth). Little information is provided about new perfusion approaches such as the Heart Port? technique, the mini-bypass technique, the different coating options of the bypass circuitry, the different mechanical circulatory support devices, and so forth. In this field, the more recent strategies are not described.Each chapter ends with suggested further reading that most
A case report and brief review of the literature on bilateral retinal infarction following cardiopulmonary bypass for coronary artery bypass grafting
Brian A Trethowan, Helen Gilliland, Aron F Popov, Barathi Varadarajan, Sally-Anne Phillips, Louise McWhirter, Robert Ghent
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-154
Abstract: A 36 year-old Caucasian male (59 kg, BMI 23.8 kg.m-2) presented for urgent coronary artery bypass grafting 4 weeks after admission to the coronary care unit with a non-ST elevation myocardial infarction. He had episodic chest pain for 1 year increasing in frequency over six weeks prior to admission. On admission to hospital he was commenced on medication including acetylsalicylic acid, Clopidogrel, Elantan LA, Bisoprolol, Ramipril, Ezetimibe and Enoxaparin and he remained as an inpatient until his scheduled surgical procedure without requiring heparin, GTN infusion or inotropes. Urgent coronary angiography revealed a critical lesion of the left main stem artery, 70% stenosis of the proximal circumflex and 70% stenosis of the origin of the posterior descending artery and moderate impairment of left ventricular function with inferoposterior hypokinesis. This impairment in left ventricular was confirmed by transthoracic echocardiography. On arrival in the anaesthetic room his initial blood pressure was recorded as 90/50 mmHg and this had no apparent effect on pre-operative organ function considering all blood tests were within normal range and urine output was >1 ml.kg-1.hr-1. General anaesthesia was induced and was further maintained with propofol target-controlled infusion (1.5μg.ml-1), remifentanil (0.34μg.kg-1.min-1) and isoflurane/oxygen/air mix at FiO2 of 0.4 and end-tidal isoflurane 0.4-0.6%. Peri-operative transoesophageal echocardiography was used as part of monitoring in this case and epi-aortic ultrasound scanning was not utilised. As the left internal mammary artery was being taken down a dose of 250 mg (4.3 mg/kg) of heparin was given with a subsequent ACT of 559s. During CPB mean arterial pressure was maintained between 50-60 mmHg using boluses of phenylephrine and subsequently an infusion of noradrenaline. The lowest recorded mean arterial pressure was 45 mmHg immediately post institution of CPB. The infusion of noradrenaline ran at doses from 0.05-0.075
Relative adrenal insufficiency and hemodynamic status in cardiopulmonary bypass surgery patients. A prospective cohort study
José L Iribarren, Juan J Jiménez, Domingo Hernández, Lisset Lorenzo, Maitane Brouard, Antonio Milena, María L Mora, Rafael Martínez
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-26
Abstract: Prospective cohort study on cardiopulmonary bypass patients who received etomidate or not during anesthetic induction. Relative adrenal insufficiency was defined as a rise in serum cortisol ≤ 9 μg/dl after the administration of 250 μg of consyntropin. Plasma cortisol levels were measured preoperatively, immediately before, 30, 60, and 90 minutes after the administration of cosyntropin, and at 24 hours after surgery.120 elective cardiopulmonary bypass patients were included. Relative adrenal insufficiency (Δcortisol ≤9 μg/dl) incidence was 77.5%. 78 patients received etomidate and 69 (88%) of them developed relative adrenal insufficiency, (P < 0.001). Controlling for clinical characteristics with a propensity analysis, etomidate was the only independent risk factor associated with relative adrenal insufficiency (OR 6.55, CI 95%: 2.47-17.4; P < 0.001). Relative adrenal insufficiency patients showed more vasopressor requirements just after surgery (P = 0.04), and at 4 hours after surgery (P = 0.01). Pre and post-test plasma cortisol levels were inversely associated with maximum norepinephrine dose (ρ = -0.22, P = 0.02; ρ = -0.18, P = 0.05; ρ = -0.21, P = 0.02; and ρ = -0.22, P = 0.02, respectively).Relative adrenal insufficiency in elective cardiopulmonary bypass patients may induce postoperative vasopressor dependency. Use of etomidate in these patients is a modifiable risk factor for the development of relative adrenal insufficiency that should be avoided.Hypothalamic-pituitary-adrenal axis activation is an essential component of the general adaptation to illness and stress and contributes to the maintenance of cellular and organ homeostasis. Relative adrenal insufficiency (RAI) is frequently diagnosed in critically ill patients [1-3], and its presence is related to poorer prognosis in patients with sepsis. This has led to recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients [4]. However, the clinical impac
The Response of Hemostatic Marker Levels to Activated Factor VII in a Neonate following Cardiopulmonary Bypass
Michael J. Eisses,Michael Richards,Denise Joffe,Jeremy M. Geiduschek,Wayne L. Chandler
Case Reports in Medicine , 2009, DOI: 10.1155/2009/420152
Abstract: The primary function of recombinant activated factor VII (rFVIIa) is to increase thrombin formation which leads to increased fibrin and less “bleeding.” As a result, most of literature utilizes “bleeding” as the outcome measure with respect to rFVIIa. However, we report the actual effect of rFVIIa on changes in hemostatic markers such as prothrombin activation peptide F1.2, thrombin antithrombin complex (TAT), D-dimer, tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI) in a neonate after cardiopulmonary bypass. A single dose of rFVIIa caused a 5.5-fold increase in F1.2, 3.5-fold increase in TAT, and a small increase in d-dimer compared to only a 1.5-fold increase, no increase, and a decrease, respectively, in two neonates undergoing the same procedure having not received rFVIIa. The patterns of change for tPA and PAI were similar.
Lepirudin as an alternative to "heparin allergy" during cardiopulmonary bypass
Haralabos Parissis
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-44
Abstract: This report indicates that r-hirudin provides effective anticoagulation, however unless ECT is monitoring, post operative hemorrhage is encountered. Therefore this case is unique not only because of its rarity but also by the fact that it presents the caveats encountered when ECT is not available.Traditionally in our effort to maintain optimal cardiopulmonary bypass during cardiac surgery, high dose unfractionated heparin is being used; however there are conditions that the use of heparin is contraindicated. Various thrombin inhibitors could theoretically being used instead, with the favor being Hirudin and lately bivalirudinHirudin is a potent natural direct thrombin inhibitor that is derived from the salivary glands of the medicinal leech, Hirudo medicinalis [1]. It is a 65-amino-acid polypeptide that forms a tight, irreversible 1:1 complex with thrombin (1 molecule of hirudin binds with 1 molecule of thrombin).Hirudin shows both direct anti-Xa activity as well as activation of antithrombin III [2]. It is the most potent and specific thrombin inhibitor known. Uunlike heparin, it is not inactivated by Platelet Factor 4 (PF4), and also can inhibit thrombin bound within the clot [3]. Hirudin is now produced, by using recombinant technology (r-hirudin). Two r-hirudins have been commercially produced (lepirudin and desirudin); however, lepirudin has been more extensively studied and is the focus of this review.Lepirudin is an anti-thrombotic recombinant DNA form of hirudin derived from yeast cells. Each vial of Refludan contains 50 mg of lepirudin. It is normally used in adult patients requiring anticoagulation who have Heparin Induced Thrombocytopenia (HIT) type II [4].Two binding sites are present on the thrombin molecule: the active site that catalyzes the majority of the functions of thrombin, and the -brinogen-binding site that mediates binding of thrombin to -brinogen.Hirudin (lepirudin) binds irreversibly to both the active site and the -brinogen-binding site. T
Cardiopulmonary bypass in Jehovah's Witnesses
K Frimpong-Boateng, E Aniteye, LA Sereboe, VOS Amuzu
West African Journal of Medicine , 2003,
Abstract: Jehovah's Witnesses do not accept heterologous blood transfusion for religious reasons. Autologous transfusions are also rejected if there is no continuous contact between the circulation and the autologous blood. There is, therefore , the need to adopt methods which will avoid transfusion of heterologous blood in elective cases as far as Jehovah's Witnesses are concerned. We report two cases where pre-operatively administration of nutritional supplements, haematenics, erythropoietin, antimalarials and the modification of the extra-corporeal circulation bypass circuit allowed successful open-heart surgery using cardiopulmonary bypass.
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