The Annals of thoracic surgery
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Practice Guideline Guideline
Practice guidelines in cardiothoracic surgery. Council of the Society of Thoracic Surgeons.
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Comparative Study
Cerebral lactate release after circulatory arrest but not after low flow in pediatric heart operations.
Arteriovenous (jugular bulb) differences in blood lactate were followed throughout the procedure and until 18 hours postoperatively in 17 children undergoing congenital heart operations during profound hypothermia. Transcranial Doppler sonography was used to monitor changes in blood flow velocity in the middle cerebral artery. Ten children had a period of total circulatory arrest (39 +/- 6 minutes) during profound hypothermia (arrest group). ⋯ Differences in blood lactate level were significantly less than zero (p < 0.05) from the start of rewarming until 3 hours after the end of cardiopulmonary bypass in the arrest group, whereas differences in blood lactate level remained close to zero in the low-flow group. We conclude that circulatory arrest during profound hypothermia is followed by a period with release of lactate from the brain, indicating anaerobic cerebral metabolism and possibly disturbed cerebral aerobic metabolism. This study argues for the avoidance of circulatory arrest whenever possible.
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The primary goal of monitoring cerebral blood flow and metabolism is to improve our understanding of the association with cardiopulmonary bypass and deep hypothermic circulatory arrest so that effective brain protection strategies can be developed and employed. A review of our cerebral blood flow/cardiopulmonary bypass database, presently totaling 275 neonates and infants, for the purposes of this publication, reveals certain trends and some conclusions that can be drawn. Deep hypothermic circulatory arrest continues to be a factor in the delayed recovery of cerebral blood flow and metabolism in these patients. ⋯ We have also examined in our series of 275 patients selective neuroprotection strategies for their potential for improving recovery of cerebral blood flow and cerebral metabolism. Duration of cooling on cardiopulmonary bypass correlates directly with suppression of metabolism due to hypothermia. Low-flow cardiopulmonary bypass instead of deep hypothermic circulatory arrest, and topical brain cooling with ice during deep hypothermic circulatory arrest, improve cerebral blood flow and cerebral metabolic recovery.
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The etiology and incidence of neurologic injury occurring after cardiac operations employing cardiopulmonary bypass is reviewed. Results of studies demonstrating the role of microemboli generated by pump oxygenators, and evidence for the efficacy of arterial line filtration to decrease delivery of emboli into the cerebral circulation and to decrease postoperative neuropsychological dysfunction, are similarly reviewed. The impact of different strategies for management of pH during moderate hypothermic cardiopulmonary bypass on cerebral blood flow and coupling of cerebral flow and metabolism, as well as their impact on the incidence of postoperative cognitive dysfunction, are also discussed, along with the results of studies examining the efficacy of various agents including thiopental, nimodipine, and nafamostat to decrease cognitive dysfunction subsequent to bypass.
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Comparative Study Clinical Trial
Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy.
One hundred thirty-eight consecutive, nonrandomized patients, with equivalent demographic and preoperative physiologic parameters, underwent either a video-assisted thoracic surgical (VATS) approach (n = 81) or a limited lateral thoracotomy (LLT) approach (n = 57) to accomplish pulmonary resection for peripheral lung lesions (< or = 3 cm in diameter). Wedge resection was done in 74 VATS patients and 19 LLT patients. Seven patients underwent VATS lobectomy and 38 patients had lobectomy performed through an LLT. ⋯ Shoulder girdle strength was equally impaired at day 3, but function was more improved in VATS patients at 3 weeks (p = 0.01). Patients undergoing wedge resection alone by LLT had greater impairment in early (day 3) pulmonary function (forced expiratory volume in 1 second) (p = 0.002); this difference from VATS was not sustained at 3 weeks. Video-assisted thoracic surgery is associated with reduced pain, shoulder dysfunction, and early pulmonary impairment compared with LLT for select patients requiring pulmonary resection.