Crit Care Med  2003 Jan;31(1):28-33 

Risk factors for long intensive care unit stay after cardiopulmonary bypass in
children.

Brown KL, Ridout DA, Goldman AP, Hoskote A, Penny DJ.

OBJECTIVES 

To determine whether children who experience longer intensive care
unit (ICU) stays after open heart surgery may be identified at admission by
clinical criteria. To identify factors associated with longer ICU stays that are
potential targets for quality improvement.

SETTING Tertiary pediatric cardiac
surgical center.

DESIGN A retrospective review was performed of pre-, intra-, and
postoperative factors for children undergoing open heart surgery. All factors
were evaluated for strength of association with length of ICU stay (LOS) using a
negative binomial model. After multiple analysis, factors were deemed
significant if associated with a LOS with <.02.

PATIENTS A total of 355 pediatric
patients who had cardiac surgery with cardiopulmonary bypass in a 1-yr period
from April 1999 until March 2000.

MEASUREMENTS AND MAIN RESULTS Children who fell
above the 95th percentile for LOS in our institution occupied 30% of bed days
and had a three-fold greater mortality. Of all clinical factors considered,
those significantly associated with LOS were as follows: -mechanical
ventilation, neonatal status, medical problems, and transfer from abroad;
-higher operative complexity, increased cardiopulmonary bypass time or ischemic
time, and circulatory arrest; and -delayed sternal closure, sepsis, renal
failure, pulmonary hypertension, chylothorax, diaphragm paresis, and arrhythmia.
A model combining all factors identified preoperative mechanical ventilation,
neonatal status, major medical problems, operative complexity, cardiopulmonary
bypass time, and a postoperative complication score as independently associated
with LOS ( <.01).

CONCLUSIONS At the time of ICU admission after open heart
surgery, clinical criteria are evident that highlight a child's risk of longer
ICU stay. These pre- and intraoperative factors relate to LOS independent of
subsequent postoperative events. Those postoperative complications that are most
strongly associated with increased LOS are identified and, therefore, made
accessible to quality control.

J Urol  2003 Feb;169(2):435-444 

Surgical Techniques For Treating a Renal Neoplasm Invading The Inferior Vena
Cava.

Vaidya A, Ciancio G, Soloway M.

PURPOSE 

Historically inferior vena caval thrombus associated with renal cell
carcinoma was a deterrent to surgery. During the last 3 decades there has been
steady improvement in surgical techniques and perioperative care, which has
dramatically improved the ability to resect safely these tumors. We acknowledge
these improvements in chronological order.

MATERIALS AND METHODS A comprehensive
literature review of the different techniques used for resecting renal cell
carcinoma with inferior vena caval involvement was performed using MEDLINE. Data
focused on surgical techniques, including various incisions, exposures, adjuncts
to surgery and outcomes.

RESULTS Tumor thrombus associated with renal cell
carcinoma is no longer considered to have a detrimental impact on survival.
Patients who are acceptable surgical candidates have survival rates as high as
68%. Although there is a great deal of emphasis on the importance of an
aggressive surgical approach, a uniform operative strategy based on the level of
the tumor thrombus has not been established. Surgical techniques derived from
liver transplant surgery and cardiac arrest with cardiopulmonary bypass have
drastically decreased operative complications associated with extensive
involvement of the inferior vena cava with tumor thrombus.

CONCLUSIONS The only curative approach to renal cell carcinoma is surgery. An aggressive approach is
warranted when tumor involves the renal vein and inferior vena cava. Surgical
strategy depends on the level of the inferior vena caval thrombus. Patients with
extension of the thrombus above the diaphragm are a greater technical challenge.
Hypothermic circulatory arrest should be considered when treating vena
caval-atrial tumor thrombus. Surgeons familiar with liver mobilization can
greatly facilitate the exposure needed for safely operating in these cases.

Intensive Care Med  2003 Jan 22; [epub ahead of print] 

Base deficit in immediate postoperative period of coronary surgery with
cardiopulmonary bypass and length of stay in intensive care unit.

Hugot P, Sicsic JC, Schaffuser A, Sellin M, Corbineau H, Chaperon J, Ecoffey C.

Department of Anesthesiology and Intensive Care, CHU PontchaillouUniversite
Rennes 1, 2 rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.

OBJECTIVE. 

To assess the relationship between the base deficit value in the
immediate postoperative period of coronary surgery for cardiopulmonary bypass
and the length of stay in the ICU. 

DESIGN AND SETTING. Prospective descriptive
study in the department of anesthesia and cardiovascular surgery of a university
hospital. 

PATIENTS. 185 consecutive patients. 

INTERVENTIONS. Coronary artery
bypass graft with cardiopulmonary by pass. 

MEASUREMENTS AND RESULTS. Thirty
variables were determined during the pre-, intra-, and postoperative periods; a
statistical univariate analysis was performed differentiating patients whose
length of stay in the ICU was 2 days or less and those whose stay was more than
2 days. Secondly, a logistic regression model was performed on the variables
shown to have a statistically significant difference in univariate analysis,
with determination of the odd ratio. Fourteen variables had a statistically
significant difference in univariate analysis and three of them highlighted by
the logistic regression model: administration of catecholamines, base deficit
value in the 1st h postoperatively, and age with odd ratios, respectively, of
3.15, 1.51, and 1.07). 

CONCLUSIONS. The value of base deficit measured during
the 1st h after coronary surgery for cardiopulmonary bypass is correlated with
the length of stay in ICU.

J Thorac Cardiovasc Surg  2003 Jan;125(1):184-90 

Does aprotinin influence the inflammatory response to cardiopulmonary bypass in
patients?

Schmartz D, Tabardel Y, Preiser JC, Barvais L, D'Hollander A, Duchateau J,
Vincent JL.

Departments of Anesthesiology, Intensive Care Medicine, and Anesthesiology,
Erasme University Hospital, and the Department of Immunology, Brugmann
University Hospital, Brussels, Belgium.

OBJECTIVES: 

Aprotinin has been shown to have anti-inflammatory properties, but
its effects on the inflammatory reaction to cardiopulmonary bypass remain
controversial. This prospective, randomized, double-blind study evaluated the
influence of aprotinin on various blood markers of inflammation during and after
cardiopulmonary bypass. 

METHODS: Sixty male patients underwent coronary artery
bypass grafting. The patients were randomized into 3 groups: a placebo group, a
second group receiving 2,000,000 KIU of aprotinin followed by an infusion of
500,000 KIU/h and 2,000,000 KIU in the pump prime, and a third group receiving
half this dosage. Measurements of tumor necrosis factor, interleukin 6,
interleukin 8, interleukin 10, endotoxin, histamine, complement factors,
prekallikrein, and prostaglandin D(2) were obtained at baseline, 30 minutes
after study drug loading, 10 minutes after the beginning of cardiopulmonary
bypass, before the end of bypass, 4 hours after bypass, and on the first and
second postoperative days. 

RESULTS: Aprotinin had no significant effect on any
of these parameters. As expected, aprotinin reduced early blood loss in both
treated groups. 

CONCLUSIONS: These results indicate that aprotinin at doses
currently used to reduce blood loss has no significant influence on the systemic
inflammatory response during moderate hypothermic cardiopulmonary bypass in
human subjects, as assessed by the mediators measured in this study.

J Thorac Cardiovasc Surg  2003 Jan;125(1):121-5 

Continuous retrograde blood cardioplegia is associated with lower hospital
mortality after heart valve surgery.

Flameng WJ, Herijgers P, Dewilde S, Lesaffre E.

Cardiac Surgery and Biostatistical Centre, Katholieke Universiteit Leuven,
Belgium.

OBJECTIVE: 

Myocardial preservation studies comparing blood and crystalloid
cardioplegia techniques were almost exclusively performed on patients undergoing
coronary bypass, and they were unable to show a difference in hospital
mortality. We investigated possible factors, including cardioplegia techniques,
influencing hospital mortality in patients undergoing cardiac valve surgery.


METHODS: We evaluated hospital mortality in 1098 consecutive patients undergoing
cardiac valve surgery by using a multivariate logistic regression with
propensity score balancing of the groups. In 25% of the patients, multiple valve
or Bentall procedures were performed, and in 46% of all patients, coronary
bypass grafting was associated with valve surgery. A first cohort of 504
consecutive patients were operated on by using single-shot antegrade cold
crystalloid cardioplegia, and a second cohort of 594 patients were operated on
by using continuous retrograde cold blood cardioplegia. 

RESULTS: After correction for patient-related and operative risk factors, lower hospital
mortality was found in patients who received retrograde blood cardioplegia (P
=.020). The odds ratio of in-hospital death when using blood cardioplegia was
0.44 (95% confidence interval, 0.22-0.88). Further predictors of hospital
mortality were age, advanced New York Heart Association functional class,
cardiopulmonary bypass time, reoperation, active endocarditis, and renal
failure. 

CONCLUSIONS: This study shows that continuous retrograde blood
cardioplegia is associated with lower hospital mortality in heart valve
operations.

Anesth Analg  2003 Feb;96(2):344-50 

Patients with a History of Type II Heparin-Induced Thrombocytopenia with
Thrombosis Requiring Cardiac Surgery with Cardiopulmonary Bypass: A Prospective
Observational Case Series.

Nuttall GA, Oliver WC Jr, Santrach PJ, McBane RD, Erpelding DB, Marver CL, Zehr
KJ.

Department of Anesthesiology and. Laboratory Medicine, Division of Hematology,
and. Division of Cardiovascular Surgery, ||Mayo Clinic, Rochester, Minnesota.

Heparin-induced thrombocytopenia with thrombosis (HITT) type II is a
life-threatening complication of heparin therapy that most often occurs after
5-10 days of exposure to heparin. Anticoagulation is a significant concern for
patients with HITT type II being prepared for cardiac surgery requiring
cardiopulmonary bypass (CPB). We report a case series of 12 patients with a
history HITT type II who underwent CPB and cardiac surgery. Six patients did not
express the antibody that mediates HITT type II immediately before surgery.
Heparin was used as the anticoagulant for the duration of CPB only, and all
these patients did well without thrombotic complications. Six patients expressed
the antibody that mediates HITT type II immediately before surgery. Hirudin was
used as the anticoagulant for CPB in these patients. The ecarin clotting time
was used to guide hirudin therapy during CPB. The patients receiving hirudin did
well, but they had a large amount of bleeding, required transfusions of multiple
allogeneic blood products, and had a frequent rate of reexploration of the
mediastinum after CPB. IMPLICATIONS: We report a case series of 12 patients with
a clinical history of type II heparin-induced thrombocytopenia and describe
their hematologic management during cardiac surgery with cardiopulmonary bypass.

Ann Thorac Surg  2003 Jan;75(1):17-22 

Comparison of bovine and porcine heparin in heparin antibody formation after
cardiac surgery.

Francis JL, Palmer GJ 3rd, Moroose R, Drexler A.

Center for Hemostasis and Thrombosis, Department of Thoracic Cardiovascular
Surgery, Florida Hospital, 2501 N. Orange Ave, Suite 786, Orlando, FL 32804,
USA. john.francis@flhosp.org

BACKGROUND: 

Heparin-induced thrombocytopenia (HIT) is a potentially devastating
complication of heparin therapy. The incidence of clinical HIT after
cardiovascular surgery is less than 2%, although asymptomatic antibodies to
heparin-platelet factor 4 (PF4) occur more frequently. Bovine heparin is thought
to cause more HIT than porcine heparin, although this has never been established
for heparin use during coronary artery bypass grafting. We therefore undertook a
randomized, prospective study of heparin-PF4 antibody formation in patients
undergoing first-time CABG given intraoperative bovine or porcine heparin.


METHODS: Two hundred seven patients (108 porcine, 99 bovine) completed the
study. Heparin given pre- or postoperatively was always porcine. Platelet counts
and heparin-PF4 antibody tests (enzyme-linked immunosorbent assays) were
performed preoperatively and daily until postoperative day 7 or discharge if
earlier. 

RESULTS: The overall incidence of heparin-PF4 antibody formation was
42%. Six patients (2.9%) were positive preoperatively, of which, 1 developed
clinical HIT. When these were excluded, seroconversion rates were 44 of 99
(44.4%) and 33 of 108 (30.6%) for bovine and porcine heparin, respectively (p =
0.041). Among patients who produced antibodies, most (90% bovine, 85% porcine)
seroconverted after postoperative day 2. There were no differences in
postoperative platelet counts; only 1 patient developed thrombosis associated
with seroconversion, but without developing thrombocytopenia. The seroconversion
rates for patients having cardiopulmonary bypass or off-pump surgery were not
significantly different. 

CONCLUSIONS: This study confirms the high frequency of
heparin-PF4 antibodies after coronary artery bypass grafting and demonstrates a
significantly higher incidence after bovine heparin. However, because some
patients may seroconvert after discharge, our study may underestimate the true
incidence.

J Pediatr  2003 Jan;142(1):26-30 

Effect of cardiopulmonary bypass on urea cycle intermediates and nitric oxide
levels after congenital heart surgery.

Barr FE, Beverley H, Vanhook K, Cermak E, Christian K, Drinkwater D, Dyer K,
Raggio NT, Moore JH, Christman B, Summar M.

Departments of Pediatrics, Cardiothoracic Surgery, and Medicine and the Program
in Human Genetics, Vanderbilt University School of Medicine, Nashville,
Tennessee.

OBJECTIVE: 

To test the hypothesis that cardiopulmonary bypass used for repair of
ventricular septal defects and atrioventricular septal defects would decrease
availability of urea cycle intermediates including arginine and subsequent
nitric oxide availability. Study design Consecutive infants (n = 26) undergoing
cardiopulmonary bypass for repair of an unrestrictive ventricular septal defect
or atrioventricular septal defect were studied. Blood samples were collected
immediately before surgery, immediately after surgery, and 12 hours, 24 hours,
and 48 hours after surgery. Urea cycle intermediates, including citrulline,
arginine, and ornithine, were measured by amino acid analysis. Nitric oxide
metabolites were measured by means of the modified Griess reaction. 

RESULTS:
Cardiopulmonary bypass caused a significant decrease in the urea cycle
intermediates arginine, citrulline, and ornithine at all postoperative time
points compared with preoperative levels. The ratio of ornithine to citrulline,
a marker of urea cycle function, was elevated at all postoperative time points
compared with preoperative values, indicating decreased urea cycle function.
Nitric oxide metabolites were significantly decreased at all postoperative time
points except for 48 hours, compared with preoperative levels. 

CONCLUSIONS:
Cardiopulmonary bypass significantly decreases availability of arginine,
citrulline, and nitric oxide metabolites in the postoperative period. Decreased
availability of nitric oxide precursors may contribute to the increased risk of
postoperative pulmonary hypertension.

J Urol  2003 Jan;169(1):75-8; discussion 78 

Experience with an elective vacuum assisted cardiopulmonary bypass in the
surgical treatment of renal neoplasms extending into the right atrium.

Tasca A, Abatangelo G, Ferrarese P, Piccin C, Fabbri A, Musi L.

Department of Urology, S Bortolo Hospital, Vicenza, Italy.

PURPOSE: 

We evaluate the results of an elective cardiopulmonary bypass conceived
to minimize the surgical risk related to its use with temporary circulatory
arrest and deep hypothermia in the treatment of patients with renal tumor
extending into the right atrium. 

MATERIALS AND METHODS: From July 1996 to
December 2000, 19 patients with renal neoplasm and venous involvement were
admitted to our department. Three patients 4, 57 and 58 years old with a right
(2) and left (1) renal tumor extending into the right atrium underwent radical
nephrectomy and tumor thrombus removal using a normothermic cardiopulmonary
bypass. The bypass circuit was connected with a vacuum assisted venous drainage
giving a negative pressure of 20 to 40 mm. Hg. Neither circulatory arrest nor
hypothermia was used. Tumor thrombus was extracted through a longitudinal
"cavotomy" and removed along with the kidney. 

RESULTS: Total cardiopulmonary
bypass time was 14, 19 and 22 minutes, respectively. No intraoperative or
postoperative complications due to surgical technique occurred. No significant
bleeding was observed at the time of cavotomy and all neoplastic tissue was
removed. Pathological examination documented renal cell carcinoma in 2 cases and
Wilms tumor in 1. All the patients are alive 30, 42 and 15 months, respectively,
after the operation. 

CONCLUSIONS: Normothermic cardiopulmonary bypass with
vacuum assisted venous drainage makes circulatory arrest and hypothermia
unnecessary and avoids the potential complications associated with these
procedures. With respect to veno-venous shunts this technique guarantees
complete surgical control of the thrombus and avoids the need for extensive
dissection of the retrohepatic vena cava and Pringle maneuver.