Anesthesiology  2002 Apr;96(4):827-34 

Effects of dexamethasone on intravascular and extravascular fluid balance in
patients undergoing coronary bypass surgery with cardiopulmonary bypass.

von Spiegel T, Giannaris S, Wietasch GJ, Schroeder S, Buhre W, Schorn B, Hoeft
A.

Department of Anesthesiology and Intensive Care Medicine, University of Bonn,
Bonn, Germany.

BACKGROUND: Cardiac surgery with cardiopulmonary bypass is often associated with
postoperative hemodynamic instability. In this regard beneficial effects of
corticosteroids are known. The purpose of this study was to investigate whether
these effects are due mainly to a modification of the intravascular and
extravascular volume status or whether a more direct improvement of
cardiovascular performance by corticosteroids is the underlying mechanism.
METHODS: Twenty patients undergoing elective coronary bypass grafting were
included in this randomized double-blind study. Patients of the treatment group
received 1 mg/kg-1 dexamethasone after induction of anesthesia. In addition to
the use of standard monitors and detailed fluid balance assessments, the
transpulmonary double-indicator technique was used to measure extravascular lung
water, total blood volume, and intrathoracic blood volume. Measurements were
done after induction of anesthesia and 1 h, 6 h, and 20 h after the end of
surgery. RESULTS: After cardiopulmonary bypass, no relevant increase in
extravascular lung water was observed, despite highly positive fluid balances in
all patients. A significantly smaller increase in extravascular fluid content
was observed in the dexamethasone group. Total blood volume and intrathoracic
blood volume did not differ in the two groups. Patients pretreated with
dexamethasone had a decreased requirement for vasoactive substances and, in
contrast with the control group, no increase in pulmonary artery pressure.
CONCLUSIONS: Extravascular fluid but not extravascular lung water is increased
in patients after surgery with cardiopulmonary bypass. Pretreatment of adult
patients with 1 mg/kg-1 dexamethasone before coronary bypass grafting decreases
extravascular fluid gain and seems to improve postoperative cardiovascular
performance. This effect is not caused by a better intravascular volume status.

J Cardiothorac Vasc Anesth  2002 Apr;16(2):163-9 

Glucocorticoid effects on the inflammatory and clinical responses to cardiac
surgery.

Fillinger MP, Rassias AJ, Guyre PM, Sanders JH, Beach M, Pahl J, Watson RB,
Whalen PK, Yeo KT, Yeager MP.

Departments of Anesthesiology, Surgery, Physiology, and Pathology,
Dartmouth-Hitchcock Medical Center, Lebanon, NH.

OBJECTIVE: To measure the effects of glucocorticoids on the systemic
inflammatory response and clinical recovery after cardiac surgery. DESIGN:
Randomized, prospective, double-blind, placebo-controlled clinical trial with
concurrent comparison groups. SETTING: University medical center. PARTICIPANTS:
Patients scheduled for elective coronary artery bypass graft surgery using
normothermic cardiopulmonary bypass (CPB) and a standardized anesthetic.
INTERVENTIONS: Participants randomly received either methylprednisolone, 15
mg/kg intravenously 1 hour before surgery and 0.3 mg/kg intravenously every 6
hours x 4 doses, or placebo. Comparison groups included cardiac surgical
patients who received etomidate to lower endogenous cortisol during surgery and
healthy volunteers who received methylprednisolone only. Measurements and Main
Results: Patients who received methylprednisolone had a significant reduction in
circulating interleukin (IL)-6 at 60 minutes after CPB (p < 0.05) and on the
morning of the 1st (p < 0.01) and 3rd (p < 0.05) postoperative days and a
significant increase in circulating IL-10 at 60 minutes after CPB (p < 0.01)
compared with the placebo group. Etomidate, given to lower cortisol during
surgery, was associated with significantly decreased IL-6 and IL-10 responses to
surgery compared with the placebo group, whereas methylprednisolone alone, given
to healthy nonsurgical volunteers, had no effect on these cytokines. After
adjusting for age, there were no significant differences in postoperative length
of hospital stay between the methylprednisolone-treated (4.6 days) and placebo
(6.1 days) groups or in the duration of mechanical ventilation (9.9 hours and
15.6 hours). No patient treated with methylprednisolone had nausea and vomiting
on the 1st postoperative day compared with 33% of placebo-treated patients (p =
0.02). Glucose was significantly higher after methylprednisolone treatment at 1
hour after CPB (276 mg/dL v 210 mg/dL; p = 0.001) and at 2 hours (289 mg/dL v
213 mg/dL; p = 0.009) and 8 hours (247 mg/dL v 196 mg/dL; p = 0.02) after
surgery. There were no differences in pain scores and no significant intergroup
differences in lung peak expiratory flow rate or alveolar-arterial oxygen
gradients after surgery. CONCLUSION: This study shows significant effects of
glucocorticoids on the production of IL-6 and IL-10 in response to cardiac
surgery but only minor effects on clinical recovery. Copyright 2002, Elsevier
Science (USA). All rights reserved.

Am Surg  2002 Apr;68(4):359-63; discussion 364 

Continuing experience with liver resection and vena cava reconstruction using
cardiopulmonary bypass and hypothermic circulatory arrest.

Sener SF, Winchester DJ, Votapka TV, McGuire MS, O'Connor B, Szokol JW.

Division of General Surgery of the Department of Surgery, Evanston Northwestern
Healthcare, Illinois, USA.

When the suprahepatic vena cava or the hepatic vein confluence with the inferior
vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the
liver, cross-clamping the IVC during liver or retroperitoneal resection is
hazardous. This report describes a 10-year experience with ten patients who had
liver (seven) or retroperitoneal (three) resections with vena cava
reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest.
There were no perioperative deaths. Morbidity consisted of prolonged bile leak
(one), pulmonary embolism (one), and stroke (one). Control of the liver was
secured in six of seven patients who had a liver resection. There were three
significant advantages to this technique. First, the median sternotomy provided
superior exposure to the suprahepatic IVC. Second, the bypass technique avoided
the risks of hemodynamic instability and prevented air embolism and sudden
uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third,
hypothermia provided a method of protection for residual liver function
especially in the face of chronic liver disease induced by infection or
chemotherapy.

Crit Care Med  2002 Apr;30(4):827-32 
Myocardial inflammatory activation in children with congenital heart disease.

Mou SS, Haudek SB, Lequier L, Pena O, Leonard S, Nikaidoh H, Giroir BP,
Stromberg D.

Department of Pediatrics (SSM, SBH, LL, OP, BPG), University of Texas
Southwestern Medical School, Dallas, TX; and the Division of Pediatric
Cardiothoracic Surgery (SL, HN) and Division of Pediatric Cardiology (DS),
Children's Medical Center, Dallas.

OBJECTIVE: In several cardiac-related diseases, there is a strong association
between systemic endotoxemia, myocardial cytokine production, and cardiac
failure. Because pre- and postoperative endotoxemia recently was reported in
children with congenital heart disease, we sought direct evidence of myocardial
inflammatory activation in a cohort of children undergoing congenital heart
surgery on cardiopulmonary bypass. Inflammatory activation was prospectively
defined as the presence of nuclear factor-kappaB nuclear translocation in
myocardial tissue samples. DESIGN: Prospective observational study. SETTING:
Tertiary care pediatric intensive care unit. PATIENTS: Fifteen children with
congenital heart disease undergoing operative repair on cardiopulmonary bypass.
INTERVENTIONS: All patients underwent operative repair of congenital heart
disease on cardiopulmonary bypass and had plasma samples obtained for endotoxin
and tumor necrosis factor-alpha, both pre- and postoperatively. Myocardial
tissue samples were obtained intraoperatively, both before and during
cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Elevated plasma endotoxin
concentrations were documented in all 15 patients during the study period. In 12
patients, plasma endotoxin was elevated before cardiopulmonary bypass. The
median preoperative tumor necrosis factor-alpha concentration was 16.4 pg/mL,
which is higher than concentrations reported in adults with New York Heart
Association class III congestive heart failure. Examination of myocardial tissue
samples revealed nuclear factor-kappaB nuclear translocation (predominantly
p50/p65 heterodimers) in nine of 15 patients (60%). Four of these nine patients
had nuclear factor-kappaB nuclear translocation before initiation of
cardiopulmonary bypass, with p50/p50 homodimers present in two of the four.
CONCLUSIONS: These data provide the first evidence of nuclear factor-kappaB
activation in children with congenital heart disease and the first evidence of
myocardial nuclear factor-kappaB translocation in human hearts before explant
for transplantation. Furthermore, these data suggest that, similar to adults
with advanced congestive heart failure, the myocardial inflammatory cascade may
contribute to the pathophysiology of congenital heart disease in infants and
children.

Crit Care Med  2002 Apr;30(4):787-91 

Very early extubation in children after cardiac surgery*.

Kloth RL, Baum VC.

Departments of Anesthesiology (RLK, VCB) and Pediatrics (VCB), and the
Cardiovascular Research Center (VCB), University of Virginia School of Medicine,
Charlottesville, VA.

OBJECTIVE: Very early extubation of children after cardiac surgery has been
suggested as a safe alternative to prolonged postoperative intubation but is
still not common practice. Studies of early extubation in children may not have
described reasons for failure to extubate, or have included nonbypass or only
low-risk repairs. We present our experience with very early extubation in an
inclusive group of children after cardiac surgery. DESIGN: Retrospective chart
review. SETTING: University hospital operating room and pediatric intensive care
unit (ICU). PATIENTS: A total of 102 consecutive children (age <18 yrs)
undergoing cardiac surgery requiring cardiopulmonary bypass. MAIN RESULTS:
Forty-eight patients were extubated early (88% in the operating room, 12% on
arrival in ICU). Patients extubated late were younger (13.8 +/- 26.2 vs. 47.6
+/- 44.5 months), smaller (8.1 +/- 10.7 vs.17.5 +/- 14.2 kg), and had higher ASA
scores than patients extubated early (p <.001 for all). The youngest patient
extubated early was 2 months old (range, 2-192 months). Paco2 on ICU arrival was
higher in the early extubation group (52.4 +/- 6.9 vs. 41.2 +/- 14.7 mm Hg [7.0
+/- 0.9 vs. 5.5 +/- 2.0 kPa], p <.001), and pH was lower (7.27 +/- 0.04 vs. 7.37
+/- 0.16, p <.001). Use of subarachnoid morphine did not affect ability to
extubate early. No patients in the early extubation group required special
airway support, reintubation, or increased inotropic support after ICU
admission. CONCLUSIONS: Successful early extubation of even young children is
possible and easily accomplished in most children undergoing cardiopulmonary
bypass, even with complex procedures, but advantages of extubation in the
operating room vs. immediate ICU extubation remain unclear. Transient
mild-to-moderate mixed acidosis is common and requires no treatment. Full
implementation requires acceptance by surgical and ICU staffs.

Can J Surg  2002 Apr;45(2):95-103 

An expanding role for cardiopulmonary bypass in trauma.

Chughtai TS, Gilardino MS, Fleiszer DM, Evans DC, Brown RA, Mulder DS.

Division of General Surgery, McGill University, Montreal, Que.

OBJECTIVES: To analyze experience at the McGill University Health Centre with
cardiopulmonary bypass (CPB) in trauma, complemented by a review of the
literature to define its role globally and outline indications for its expanded
use in trauma management. DATA SOURCES: All available published English-language
articles from peer reviewed journals, located using the MEDLINE database.
Chapters from relevant, current textbooks were also utilized. STUDY SELECTION:
Nine relevant case reports, original articles or reviews pertaining to the use
of CPB in trauma. DATA EXTRACTION: Original data as well as authors' opinions
pertinent to the application of CPB to trauma were extracted, incorporated and
appropriately referenced in our review. DATA SYNTHESIS: Overall mortality in the
selected series of CPB used in the trauma setting was 44.4%. Four of 5 survivors
had CPB instituted early (first procedure in operative management) whereas 3 of
4 deaths involved late institution of CPB. CONCLUSIONS: Although CPB has
traditionally been used in the setting of cardiac trauma alone, a better
understanding of its potential benefit in noncardiac injuries will likely make
for improved outcomes in the increasingly diverse number of severely injured
patients seen in trauma centres today. Further studies by other trauma centres
will allow for standardized indications for the use of CPB in trauma.

Eur J Cardiothorac Surg  2002 Apr;21(4):716-20 

Stage I palliation for hypoplastic left heart syndrome in low birth weight
neonates: can we justify it?

Pizarro C, Davis DA, Galantowicz ME, Munro H, Gidding SS, Norwood WI.

Nemours Cardiac Center - Orlando, Arnold Palmer Hospital for Children and Women,
82 West Miller St, 32806, Orlando, FL, USA

Objective: Although the outcome of cardiac surgery in neonates with low birth
weight (LBW) has improved, LBW remains a risk factor for surgical palliation.
Few surgical series of LBW patients include those with hypoplastic left heart
syndrome (HLHS). To identify variables associated with poor outcome in this
group, we reviewed our experience with patients with HLHS and LBW who underwent
Stage I Norwood palliation. Methods: Between January 1998 and December 2000, 20
consecutive LBW (<2500g) neonates with HLHS (n=13) or HLHS variant (n=7)
underwent surgical palliation. Retrospective review of all patient data and
analysis to identify risk factors was performed. Results: Mean age at surgery
was 5.1+/-4.6 days (range 1-17), mean weight was 1.98+/-0.44kg (range 1.1-2.5),
including nine patients under 2kg. Ten patients were born at <35 weeks
gestation. Anatomic diagnosis included HLHS in 13 patients (10 with aortic
atresia), unbalanced atrioventricular canal defect in two, double outlet right
ventricle in two and other variants in three. Mean ascending aortic size was
4.0+/-1.8mm (range 1.5-8). Associated cardiac defects were present in three
patients, and a genetic syndrome and/or congenital anomaly was present in four
of them. Mean circulatory arrest time was 60+/-10min. Extracorporeal support was
used perioperatively in 10 patients. Early mortality was 9/20 (45%). At a mean
follow up at 22+/-10 months (range 8-38), six patients underwent stage II, and
are awaiting stage III; four patients have completed their Fontan. Anatomic
variant, ascending aortic size, prematurity, age at surgery, weight, duration of
circulatory arrest, cardiopulmonary bypass time and associated non-cardiac
anomalies were not risk factors for poor outcome whereas restrictive pulmonary
venous drainage and coronary artery anomalies were associated with decreased
survival. Conclusion: LBW newborns with HLHS and physiologic variants have an
increased early surgical risk but have acceptable intermediate survival rates
for subsequent palliation including Fontan. LBW and prematurity should not be
contraindications to early surgical palliation.

Can J Anaesth  2002 Apr;49(4):402-408 

Multidisciplinary management of a Jehovah's Witness patient for the removal of a
renal cell carcinoma extending into the right atrium.

Moskowitz DM, Perelman SI, Cousineau KM, Klein JJ, Shander A, Margolis EJ, Katz
SA, Bennett HL, Lebowitz NE, Ergin MA.

Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Critical
Care Medicine, Pain Management and Hyperbaric Medicine, the Department of
Cardiothoracic Surgery, the Department of Urology, and the Division of
Cardiology and Department of Internal Medicine, Englewood Hospital and Medical
Center, Englewood, New Jersey, USA.

PURPOSE: To highlight the management of a Jehovah's witness surgical patient
presenting for cardiopulmonary bypass (CPB) and deep hypothermic circulatory
arrest. Clinical features: A 47-yr-old male, Jehovah's Witness, with renal cell
carcinoma was admitted for left radical nephrectomy and excision of tumour
thrombus extending into the junction of the inferior vena cava (IVC) and right
atrium (RA). The preoperative goals were to maximize red blood cell mass,
delineate the extent of tumour extension and develop a surgical plan
incorporating blood conservation strategies to minimize blood loss. A midline
abdominal incision was made to optimize removal of the non-caval portion of the
tumour from the intra-abdominal region. CPB and deep hypothermic circulatory
arrest were instituted to aid in removing the tumour from the IVC and RA.
Intraoperative blood conservation strategies included the use of acute
normovolemic hemodilution, antifibrinolytics, cell salvage, point-of-care
monitoring of heparin and protamine blood concentrations, leukocyte-depleting
filter, and meticulous surgical techniques. The patient was successfully weaned
from CPB and was transported to the cardiothoracic intensive care unit without
complication. The patient was discharged home one week after the operation with
a hemoglobin of 10.2 g*dL(-1) and a hematocrit of 31.2%. CONCLUSION: Multiple
blood conservation techniques were employed to manage this Jehovah's Witness
patient through complex cardiac surgery, which was previously denied to him at
other institutions. The successful outcome of this patient, while respecting the
right to refuse allogeneic blood products, is a result of a multidisciplinary
collaboration as well as the application of established blood conservation
techniques.

J Neurosurg Anesthesiol  2002 Apr;14(2):137-40 

Aprotinin and deep hypothermic cardiopulmonary bypass with or without
circulatory arrest for craniotomy.

Grady RE, Oliver Jr WC, Abel MD, Meyer FB.

Private practice of R. E. Grady, M.D., Sioux Valley Hospital, Sioux Falls, South
Dakota; and Departments of Anesthesiology and Neurosurgery, Mayo Clinic and Mayo
Foundation, Rochester, Minnesota.

SUMMARY: Deep hypothermic cardiopulmonary bypass with or without circulatory
arrest has been used to facilitate the surgical repair of complex
cerebrovascular lesions. The advantages of deep hypothermia have been tempered
by the occurrence of coagulopathy that is associated with substantial morbidity
and mortality. This study analyzed retrospectively the records of 13 patients
who underwent cerebrovascular neurosurgery using deep hypothermic
cardiopulmonary bypass with or without circulatory arrest during the period 1993
through 1999. All patients received the serine protease inhibitor aprotinin in
an effort to avoid the development of a coagulopathy, defined as hemorrhage
requiring reoperation. No patients developed postoperative intracranial
hemorrhage. There was also no evidence of renal dysfunction, deep venous
thrombosis, myocardial infarction, or pulmonary embolism. In conclusion, this
study suggests that aprotinin may be beneficial to avoid the coagulopathy that
is more likely to occur if deep hypothermic cardiopulmonary bypass with or
without circulatory arrest is used for craniotomy without adverse effects on
renal function or apparent thrombotic complications.