The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · May 1993
Blood activation during neonatal extracorporeal life support.
Cardiopulmonary bypass for heart operations is associated with a whole body inflammatory reaction. The main factors involved in this reaction are the contact system and the complement system. The activation of the contact system is considered mainly responsible for impaired hemostasis because it affects platelet function. ⋯ The complement activation and leukocyte inflammatory reaction during the initial period are able to cause a capillary leak syndrome and might therefore explain the frequently observed temporary compromised lung function in extracorporeal life support. This reaction, as in cardiopulmonary bypass, might be reduced by the use of specific drugs or heparin coating also in extracorporeal life support. The cause of the second period of activation during extracorporeal life support requires further studies before adequate measures can be recommended.
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J. Thorac. Cardiovasc. Surg. · May 1993
Plasma fentanyl levels in infants undergoing extracorporeal membrane oxygenation.
Plasma levels of fentanyl were analyzed in 12 infants undergoing extracorporeal membrane oxygenation who received a fentanyl bolus (5 to 10 micrograms/kg) followed by infusion at 1 to 6.3 micrograms/kg/hr. Fentanyl levels, averaging 11 samples/infant, were measured by radioimmunoassay (mean 19.7 +/- 35.7 ng/ml; n = 140). Eight of the infants, all with a primary diagnosis other than congenital diaphragmatic hernia, survived with relatively short (< 7 days) courses on extracorporeal membrane oxygenation; this group of infants did not develop tolerance to fentanyl and could be maintained on infusion rates of < 5 micrograms/kg/hr throughout. ⋯ The fentanyl infusion dose and plasma level were higher in the congenital diaphragmatic hernia nonsurvivors who did not receive lorazepam (p < 0.001). A decrease in fentanyl clearance correlated with renal dysfunction (p < 0.01). A bolus of fentanyl followed by infusion of relatively low doses (1 to 5 micrograms/kg/hr) provides adequate analgesia for infants on extracorporeal membrane oxygenation, particularly when it is supplemented with intravenous lorazepam whenever needed to control infant movement.
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J. Thorac. Cardiovasc. Surg. · May 1993
Anatomic repair of transposition of great arteries with ventricular septal defect and aortic arch obstruction. One-stage versus two-stage procedure.
Between September 1, 1982, and March 1, 1992, 40 patients underwent anatomic repair of transposition of the great arteries, ventricular septal defect, and aortic arch obstruction. In group I, 26 patients (65%) underwent repair in a two-stage procedure, phases A and B. Phase A included repair of the aortic arch obstruction with (16 patients) or without (10 patients) pulmonary artery banding through a left thoracotomy (mean age 18.7 +/- 23.4 days). ⋯ The one-stage procedure allowed complete repair in neonates without the need for multiple operations. We believe that it may decrease early mortality rates (14.2% versus 30.7%), reduce the reoperation rate and cumulative stay in the intensive care unit (11.7 days versus 24.7 days, p = Not significant), and significantly decrease the overall rate of morbidity (p < 0.01). However, requirements for surgical intervention with a one-stage or a two-stage procedure must include accurate assessments of intracardiac and aortic arch anatomy.
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J. Thorac. Cardiovasc. Surg. · Apr 1993
Randomized Controlled Trial Comparative Study Clinical TrialComparison of two aprotinin dosage regimens in pediatric patients having cardiac operations. Influence on platelet function and blood loss.
Only a few studies have reported on the effects of aprotinin in pediatric cardiac surgery, and the correct dose is controversial. In a prospective, randomized study, three groups of children weighing less than 20 kg were investigated. In group 1 (n = 14): aprotinin 20,000 U/kg was given after induction of anesthesia, 20,000 U/kg was added to the prime, and another 20,000 U/kg was given every hour of cardiopulmonary bypass (low-dose regimen). ⋯ Blood loss was similar for all three groups and added up to approximately 28 ml/kg until the first postoperative day. The use of packed red cells was also comparable for the three groups, whereas the use of fresh frozen plasma was highest in group 1 (1680 ml until the first postoperative day). We conclude from this study that aprotinin did not improve platelet function and did nor reduce blood loss or the need for homologous blood transfusion in pediatric cardiac surgery, regardless of whether a low-dose or a high-dose regimen was used.
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J. Thorac. Cardiovasc. Surg. · Apr 1993
Comparative StudyHemostatic activation during cardiopulmonary bypass with different aprotinin dosages in pediatric patients having cardiac operations.
The effect of high-dose aprotinin treatment on hemostatic activation during cardiopulmonary bypass in pediatric patients having cardiac operations was investigated. Sixty patients weighing less than 10 kg undergoing cardiac operations for different types of congenital heart diseases were studied: 20 patients were treated with aprotinin 2 x 15,000 KIU/kg, 20 patients with 2 x 30,000 KIU/kg, and 20 patients without aprotinin treatment served as the control group. Different split products of fibrinogen and/or fibrin and the fibrinolytic activity on fibrin plates were measured to assess fibrinolytic activation. ⋯ These observations suggest an attenuation of hemostatic activation during cardiopulmonary bypass with less plasmin formation and, because of inhibition of contact activation, less thrombin generation with aprotinin treatment. Thus the thrombotic-thrombolytic equilibrium is kept more balanced after cardiopulmonary bypass. High-dose aprotinin treatment is recommended for pediatric patients undergoing cardiac operations.