Required volume for color flow injection test to confirm the intravascular placement of a peripheral venous catheter.

BACKGROUND: Confirmation of adequate peripheral intravenous catheter placement is essential before using venous catheters. The color flow injection test has been reported as a method with high sensitivity and specificity for this purpose. The technique involves administrating saline through the peripheral venous route to observe changes in the color flow pattern around the same vein at a more central location. However, the required volume of saline remains uncertain. This study aims to determine the appropriate dosage for conducting the test in pediatric patients and explore any potential correlations between dosage and patient characteristics. METHODS: A prospective study was conducted in children under 6 years of age with American Society of Anesthesiologists Physical Status 1-2 presenting for general anesthesia. After an intravenous cannula was placed in the forearm under general anesthesia, normal saline was injected at a speed of approximately 1 mL/s while the axillary artery and vein were observed with color flow Doppler imaging. The volume of normal saline required to induce a change in the color flow pattern around the vessels was measured. Measurements were performed twice and averaged for comparison with patient characteristics and other factors. RESULTS: The study cohort included 30 patients aged from 0.3 to 5.5 (2.6 ± 1.6) years. The change in color flow Doppler imaging was noted in all the patients, and the average volume was 1.40 ± 0.36 mL (95% confidence interval (CI), 1.27-1.54; p < 0.001), which was significantly correlated with age, with a correlation coefficient of 0.435 (95% CI, 0.09-0.69; p = 0.02). CONCLUSIONS: The required volume for the color flow injection test is small; therefore, the test is easy to perform and minimally invasive in pediatric patients.

One-lung ventilation and 3D image analysis in a case of tracheal bronchus with steeply angled branching of left main bronchus: a case report.

BACKGROUND: Establishing one-lung ventilation (OLV) in patients with tracheal bronchus (TB) may be challenging due to its unusual bronchial anatomy. We present a case of difficult OLV in a patient with right TB and steeply angled bifurcation of the left main bronchus. CASE PRESENTATION: A 79-year-old woman was scheduled to undergo video-assisted thoracic surgery left upper lobectomy. We planned right OLV with a bronchial blocker; however, it was difficult to place the blocker in the left main bronchus due to a steep bifurcation angle. Therefore, we changed the entry angle of the lumen tip by advancing the tracheal tube to just above the tracheal bifurcation, allowing successful placement of the bronchial blocker into the bronchus. CONCLUSION: For airway management in patients with TB, especially for OLV, it is essential to understand the anatomy of the trachea, bronchus, and TB and to select the appropriate device for each case.

Changes in cerebral and renal oxygenation during laparoscopic pyloromyotomy.

Although a laparoscopic approach may be preferred over open procedures for abdominal surgery, there are limited data on the effect of laparoscopic procedures on cerebral and renal oxygenation in neonates and young infants. Here, we evaluated the effect in neonates and infants. In this two-center prospective observational study, we evaluated changes in cerebral and renal regional oxygen saturation (rSO2) in infants during laparoscopic pyloromyotomy. Intraoperative hemodynamic and respiratory parameters and rSO2 were recorded. For the primary outcome, these parameters were compared at incision and at the end of pneumoperitoneum. The study cohort included 25 infants with a mean age of 40 ± 10 days and weight of 4.0 ± 0.6 kg. IAP at the beginning of laparoscopy was 10 ± 2 mmHg (range 7-15 mmHg). Although both cerebral and renal rSO2 decreased from incision compared to the end of laparoscopy, the decrease reached statistical significance only for cerebral rSO2 (81 ± 12 to 76 ± 16, p = 0.033). Similarly, the increase in fractional tissue oxygen extraction (FTOE) was only statistically significant for cerebral FTOE (0.18 ± 0.12 to 0.23 ± 0.16, p = 0.037). No change in hemodynamic or respiratory parameters was found. Although there was a decrease in cerebral rSO2 and increase in cerebral FTOE during pneumoperitoneum, the values did not decrease below those noted before anesthetic induction.

Intracuff pressure during one-lung ventilation in infants and children.

OBJECTIVE: We prospectively evaluated intracuff pressure (IP) during one-lung ventilation (OLV) to characterize potential risk associated with overinflation of the cuff used for OLV. DESIGN: Prospective observational study over a 2-year period, in infants and children undergoing thoracic surgery. The IPs of the tracheal and bronchial balloon were measured using a manometer and compared to a previously recommended threshold of 30 cmH2O. Data were compared by the device type used to achieve OLV. SETTING: Freestanding tertiary-care pediatric hospital. PARTICIPANTS: Patients ≤18 years of age undergoing thoracic procedures requiring OLV. INTERVENTIONS: Measurement of IP. MEASUREMENTS AND MAIN RESULTS: Thirty patients were enrolled (age 5 months-18 years) with a median weight of 28 kg. Median tracheal and bronchial IPs were 32 cmH2O (range: 11, 90) and 44 cmH2O (range: 10, 100), respectively. The tracheal and bronchial IPs exceeded 30 cmH2O in 13 of 20 patients (65%) and 21 of 30 patients (70%), respectively. CONCLUSIONS: IP was high and in excess of recommended levels in most children undergoing OLV. Continuous monitoring of IP may be indicated during OLV to address the risks involved and ensure the prevention of complications related to high IP. TYPE OF STUDY: Prospective comparative study. LEVEL OF EVIDENCE: Level II.

Use of remifentanil in general anesthesia for neonatal non-cardiac surgery: a case series.

OBJECTIVE: This case series aimed to summarize our experience in usage of remifentanil in neonates undergoing non-cardiac surgery. BACKGROUND: Physiology of neonates and infants is different from that of adults. Immaturity of their vital organ systems narrows a safety margin of perioperative management including anesthesia. Remifentanil has favorable characteristics for pediatrics such as short duration of action and rapid elimination. Although remifentanil was introduced into clinical practice since 1996, its application to neonatal anesthesia has not been validated yet. METHODS: This is a 14-month retrospective case series of neonates receiving remifentanil during non-cardiac surgery at a tertiary care pediatric hospital in Japan. Patients' characteristics, intraoperative data, and complications were retrieved from medical records. RESULTS: A total of 68 neonates underwent non-cardiac surgery under general anesthesia, of whom 48 received remifentanil. Infusion rate was 0.14 (0.04-0.35) mcg/kg/min (median, range). No intractable adverse events including postoperative apnea were detected. CONCLUSION: Remifentanil is generally feasible to neonatal surgical population.

Perioperative care in an adolescent patient with heparin-induced thrombocytopenia for placement of a cardiac assist device and heart transplantation: case report and literature review.

Heparin-induced thrombocytopenia (HIT) can cause life-threatening complications following the administration of heparin. Discontinuation of all sources of heparin exposure and the use of alternative agents for anticoagulation are necessary when HIT is suspected or diagnosed. We present the successful use of bivalirudin anticoagulation in an adolescent patient during cardiopulmonary bypass who underwent both placement of a left ventricular assist device and subsequent heart transplantation within a 36-hour period. The pathophysiology and diagnosis of HIT are reviewed, previous reports of the use of direct thrombin inhibitors for cardiac surgery are presented, and potential dosing regimens for bivalirudin are discussed.

An In Vitro Assessment of the Efficacy of Various IV Cannulas for the Rapid IV Fluid Administration.

OBJECTIVES: The current study prospectively evaluates the administration of fluid through commonly used vascular cannulas of various length and diameter. DESIGN: Observational, in vitro experiment. SETTING: Not applicable. SUBJECTS: No human subjects. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fluid (500 mL) was administered via gravity flow and with pressure assistance (pressure bag set at 300 mm Hg) through various vascular cannulas including peripheral IV catheters (22 gauge, 1 inch; 20 gauge, 1.16 and 1.88 inch; and 18 gauge, 1.16 and 1.88 inch), 3-Fr central line lumens (lengths 50, 80, and 120 mm), and a 4-Fr, 10 cm Micropuncture catheter (Cook Medical, Bloomington, IN). During gravity flow, drain time decreased by approximately 50% when moving from a 22 to 20 to 18 gauge cannula and increased by approximately 20% as the catheter length increased from 50 to 80 to 120 cm. Flow rates were highest with the Micropuncture catheter, which achieved a drain time of 2.7 minutes for the 500 mL bag when infused with pressure assistance. CONCLUSIONS: In general, the delivery of crystalloid solutions through commonly used vascular cannulas was fastest with larger diameter and shorter length cannulas. Pressure-assisted flow was able to partially compensate for the increased resistance with smaller and longer catheters. The unique design of the tip of the Micropuncture catheter compensated for the increased length and allowed for rapid fluid delivery. This design may compensate for the increased length when longer catheters are needed for ultrasound-guided placement.

General anesthesia with a native airway for patients with mucopolysaccharidosis type III.

BACKGROUND: Mucopolysaccharidosis type III is a progressive disease with worsening airway, pulmonary, and cardiac involvement that may complicate anesthetic care. AIM: To prospectively evaluate the incidence of airway issues and complications during magnetic resonance imaging (MRI) and lumbar puncture (LP) during general anesthesia with a native airway for patients with mucopolysaccharidosis type III. METHOD: The study was a part of the natural history study. Anesthesia was induced with sevoflurane, which was discontinued after intravenous access was obtained. General anesthesia with a native airway was provided by dexmedetomidine and propofol. Dexmedetomidine (0.5 µg·kg-1 ) was administered over 5 min followed by a continuous infusion at 0.5 µg·kg-1 ·h-1 . A continuous infusion of propofol was started at 150 µg·kg-1 ·min-1 . A bolus dose of propofol (1 mg·kg-1 ) was administered and the propofol infusion was increased as needed. Airway management and vital signs were recorded for the entire procedure until discharge. RESULTS: Twenty-five patients (6.9 ± 3.1 years) received total of 43 MRI and LP procedures in the cohort. No patient failed sedation. Although mask induction with sevoflurane was not clinically problematic, upper airway obstruction was noted during 14 procedures (33%). This required the application of continuous positive airway pressure, temporary oral airway placement, jaw thrust, or shoulder roll. Airway dynamics improved once the anesthesia was transitioned to intravenous anesthetic agents. Although a small shoulder roll was needed to improve airway patency for 11 cases (26%), a large shoulder roll tended to make the upper airway obstruction worse. Oxygen desaturation (≤90%) was noted during MRI in three cases (7%). CONCLUSION: A combination of dexmedetomidine and propofol provided effective general anesthesia with a native airway during the procedures. Although upper airway obstruction was noted, it resolved with simple airway maneuvers without further airway intervention.

The Effect of Transesophageal Echocardiography Probe Placement on Intracuff Pressure of an Endotracheal Tube in Infants and Children.

OBJECTIVES: To evaluate the effects of transesophageal echocardiography (TEE) probe insertion on the endotracheal cuff pressure (CP). DESIGN: Prospective observational study. SETTING: Single standing, not-for-profit pediatric hospital. PARTICIPANTS: A total of 80 pediatric patients (aged 6 days to 18.4 years) who underwent cardiac surgery and intraoperative TEE. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Following anesthesia induction and endotracheal intubation, the CP was recorded at 4 points: before the insertion of the TEE (P1), at TEE insertion (P2), during TEE examination (P3), and after the probe was advanced into the stomach (P4). Twenty patients were enrolled in each of the following age groups:<1 year of age; 1-4 years of age; 5-8 years of age; and 9-18 years of age. CP was compared between pairs of time points using paired t-tests, and differences in CP over time were compared among age groups using repeated-measures analysis of variance. CP at P1, P2, P3, and P4 was 18.7±11.6, 26.7±14.4, 22.3±12.4, and 20.6±12.6 cmH2O, respectively. Although CP significantly increased from P1 to P2 (p<0.001), there was no significant difference between P1 and P4 (95% CI; -0.3 to 4.1; p = 0.083). There was no significant difference in CP change based on the age of the patient. CONCLUSION: Following a transient increase in CP with TEE probe insertion, the CP returned to baseline after the tip of the TEE probe was advanced into the stomach. There was no variation among age groups in the magnitude of the CP change during the study.

The effect of esophagogastroduodenoscopy probe insertion on the intracuff pressure of airway devices in children during general anesthesia.

Given the size of the esophagogastroduodenoscopy (EGD) probe and the compressibility of the pediatric airway, the EGD probe may increase the intracuff pressure (IP) of an airway device. The current study evaluated IP changes during EGD examination under general anesthesia in pediatric patients. Following the induction of anesthesia, a laryngeal mask airway (LMA) or endotracheal tube (ETT) was placed without neuromuscular blockade. The IP was measured at baseline, during EGD probe insertion, while the EGD probe was in place, and after probe removal. The study cohort included 101 patients (mean age 11.3 years). The airway was secured with an LMA and an ETT in 88 and 13 patients, respectively. The IP increased from 27 ± 15 cmH2O at baseline to 34 ± 17 cmH2O during probe insertion (p < 0.001), remained at 33 ± 16 cmH2O while the probe was in place, and decreased to 26 ± 14 cmH2O after probe removal. The IP of the LMA or ETT increased during EGD probe insertion and remained elevated while the probe was in place. High IP may compromise mucosal perfusion resulting in a sore throat when using an LMA or the potential for airway damage if an ETT is used. Removal of air from the cuff and titration of the IP should be considered after EGD insertion.

A Retrospective Analysis of the Influence of Ventricular Morphology on the Perioperative Outcomes After Fontan Surgery.

OBJECTIVES: The objectives of this study were to evaluate the effect of ventricular morphology on perioperative outcomes during Fontan surgery. DESIGN: Retrospective cohort study. SETTING: Single standing, not-for-profit pediatric hospital. PARTICIPANTS: A total of 72 patients who underwent Fontan surgery using cardiopulmonary bypass without aortic cross-clamp between January 1, 2009 and December 31, 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The patients were divided into 3 categories depending on their single-ventricle lesions: (1) LV group (n = 20): left dominant and hypoplastic right ventricle; (2) RV group (n = 37): right dominant and hypoplastic left ventricle; and (3) BV group (n = 15): biventricular or indeterminate dominance. Perioperative major adverse events were collected based on the Society of Thoracic Surgeons database. The need for perioperative allogeneic blood transfusions also was determined. The mean age was 3.3±1.7 years and the mean weight was 13.6±4.0 kg. All patients had extracardiac lateral tunnel or conduit Fontan procedures. Sixty-nine of the patients (96%) underwent tracheal extubation in the operating room. Anesthesia, surgery, and CPB times were 326±68, 239±73, and 70±41 minutes, respectively. Eleven patients (15%) required allogeneic blood products intraoperatively, while 30 patients (42%) required allogeneic blood products during the perioperative period. Length of cardiac intensive care unit stay and hospital stay (median [IQR]) were 1 [1,2] and 12 [9,18] days, respectively. There was no mortality and no significant differences between groups in major postoperative complications, anesthetic or surgical variables. CONCLUSIONS: No difference in the immediate perioperative outcomes was noted based on ventricular morphology.

Residual volume in the cuff of the endotracheal tube when the pilot balloon is torn off instead of deflated using a syringe.

BACKGROUND: In recent years, there has been a shift in airway management with the use of cuffed endotracheal tubes (ETT) in pediatric patients. While the use of a syringe to deflate the cuff is generally recommended, anecdotal observations suggest that some healthcare practitioners tear off the pilot balloon from ETT to deflate the cuff. This study was conducted to estimate the residual volume in the cuff when the pilot balloon is torn off for deflation. METHOD: The in vitro study was conducted in three phases. In phases 1 and 2, various sized cuffed ETTs (3.0, 4.0, and 5.0 mm) were inflated to achieve an intracuff pressure of 20-30 cmH2O in open atmosphere (phase 1) or inside a tube to simulate external pressure from the tracheal wall (phase 2). The pilot balloons were ripped off and the residual volume in the cuff was measured. The process was repeated using 10 ETTs of each of the 3 sizes. In phase 3, the same process was repeated using ten, size 7.0 cuffed ETTs inflated in an intubating mannequin. RESULTS: In phase 1, the percentage of the remaining residual volume was 60.7, 72.8, and 69.5% in 3.0, 4.0, and 5.0 mm ETTs respectively. Although the percentage of residual volume in phases 2 and 3 was less than phase 1, the residual volume in phases 2 and 3 still averaged approximately 60-70% of the volume required for cuff inflation. In one case, the pilot balloon tube was completely occluded and the residual volume in the cuff could not be expelled even with external pressure. CONCLUSION: Since significant percentage of the volume remained in the cuff after tearing off the pilot balloon tube with one being completely occluded, we would not recommend this method for cuff deflation.

Remifentanil: applications in neonates.

Remifentanil is a synthetic opioid derivative that was introduced into clinical practice in the United States in 1996. The unique modification of its chemical structure to include a methyl-ester ring allows its hydrolysis by non-specific plasma and tissue esterases. This molecular configuration results in its rapid metabolism thereby providing a rapid onset, easy titration by continuous infusion, and a short context-sensitive half-life with rapid elimination. These principles are stable and consistent across all age groups regardless of the infusion characteristics. Owing to these pharmacokinetic characteristics, it is an effective agent in the neonatal population allowing the provision of intense analgesia and anesthesia with a rapid recovery profile in various clinical scenarios. Here, we review the pharmacokinetics of remifentanil in neonates, discuss its clinical applications including intraoperative administration for anesthetic care, unique applications for procedural sedation including endotracheal intubation, and its potential use for sedation in the Intensive Care Unit setting during mechanical ventilation.

[Laparoscopi Surgery and Anesthetic Management for Infants and Children].

The advantages of laparoscopic surgery resulting in quicker recovery from surgery, decreased postopera- tive pain, shorter hospital stay, and an: improved cos- metic outcome compared to open surgery have led to the expansion of its applications. This expansion includes its use for new surgical procedures as well as indications in younger patients even neonates. The majority of surgical procedures in children are at- tempted under laparoscopy, ranging from short pro- cedures such as day surgeries to even longer case such as congenital biliary atresia. The anesthetic man- agement of laparoscopic surgery in pediatric population has unique features and pitfalls. This chapter de- scribes : (i) the application of laparoscopic surgery for pediatrics ; (ii) the physiological effects of pneumo- peritoneum on respiratory, cardiovascular, renal sys- tems and intracranial pressure ; and (iii) actual anes- thesia management To accomplish safe anesthetic management of the pediatric patients for laparoscopic surgery, anesthesiologists should be familiar with the basic tenets of pediatric anesthesia as well as the potential physiological changes that result from in- creased intra-abdominal pressure due to insufflated CO2, the absorbed CO2, and patient positioning.

Perioperative care of infants with pyloric stenosis.

Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.

An in vitro and in vivo validation of a novel color-coded syringe device for measuring the intracuff pressure in cuffed endotracheal tubes.

BACKGROUND: The clinical practice of pediatric anesthesiology has changed with a transition to the use of cuffed endotracheal tubes (ETTs) in infants and children. The monitoring of intracuff pressure has been suggested as one means to limit the potential for damage to the tracheal mucosa. The current study evaluates the accuracy of a novel, color-coded syringe device which provides three zones (green, clear, and red) to estimate the intracuff pressure. METHOD: The study was conducted in two phases. Phase 1 was an in vitro study where cuffed ETTs of sizes 4.0 mm, 5.0 mm and 6.0 mm ID were placed into polyvinylchloride tubing of appropriate sizes. A manometer and the syringe device were simultaneously attached to measure the intracuff pressure at the middle of the 3 different zones on the device (red, clear, and green). Phase 2 was an in vivo study where the syringe device and the manometer were simultaneously attached to the pilot balloon to measure the intracuff pressure and the corresponding zone on the color-coded syringe following endotracheal intubation. Statistical analysis included a descriptive reporting of the mean ± SD, median, range, and 95% confidence intervals (CI) of the actual intracuff pressure readings at the three zones of the syringe device during both its in vitro and in vivo use. RESULTS: For phase 1 of the study, the 95% CI for the green, clear, and red zones were 21.5-21.8, 29.2-29.5, and 46.5-47.4 cmH2O respectively. This correlated well with the manufacturer reported values of 20-30, 30-40, and 40-60 cmH2O for the 3 zones (green, clear, and red respectively). Phase 2 of the study included 200 patients ranging in age from 0.1 to 21.8 years (6.7 ± 5.1 years) and in weight from 4.0 to 129.1 kilograms (29.4 ± 23.3 kgs). The size of the ETTs ranged from 3.0 to 7.0 mm ID. The intracuff pressure measured by the manometer ranged from 4 to 65 cmH2O (27.6 ± 9.7 cmH2O). The 95% CI for the green, clear, and red zones were 20.5-21.7, 27.7-29.1, and 41.2-46.5 cmH2O respectively. There was no significant differences noted when comparing different patient ages or sizes of ETT. CONCLUSION: The current study demonstrates a clinically acceptable correlation between the zones on this novel, color-coded syringe device and the actual measurement of the intracuff pressure obtained by a manometer for both in vitro and in vivo use. This device is a simple, reliable, portable and affordable method to monitor intracuff pressure.

Thoracic epidural infusion with chloroprocaine for postoperative analgesia following epicardial pacemaker placement in an infant.

In critically ill neonates and infants, major interventions, including thoracotomy, may result in significant postoperative respiratory insufficiency and pain leading to the need for postoperative mechanical ventilation. Although there are many potential options for providing postoperative analgesia, there continues to be expanding use of regional anesthesia in this population. One of the many reported advantages is the provision of postoperative analgesia while avoiding the deleterious effects on respiratory function that may be seen with systemic opioids. We report the use of thoracic epidural anesthesia using a continuous infusion of chloroprocaine to provide analgesia following thoracotomy and epicardial pacemaker placement in an infant. The perioperative plan was complicated by comorbid conditions including congenital complete heart block, recent rhinovirus infection with residual respiratory involvement, and prematurity.

[Anesthetic management of a patient with Fontan circulation with pacemaker failure].

We describe the anesthetic management of a 23-year-old female patient with severe bradycardia due to pacemaker lead disconnection. The pacemaker had been placed due to complete AV block following an extracardiac Fontan operation. She was scheduled for lead repair under general anesthesia. The preoperative HR was only 37 beats x min(-1) of idioventricular rhythm. As further bradycardia was a major concern, we prepared a percutaneous cardiac pacemaker and the catheterization laboratory for transatrial cardiac pacing. After placement of transcutaneous cardiac pacing pads on the chest, we administered isoproterenol at 0.01 microg x kg(-1) x min(-1). We confirmed an increase in HR to 50 beats x min(-1) and induced anesthesia, after which isoproterenol was administered at 0.015 microg x kg(-1) x min(-1). No bradycardia was observed perioperatively. Transvenous cardiac pacing, part of the last step in the ACLS bradycardia algorithm, is inappropriate except in patients with anatomic Fontan circulation. Furthermore, in the case of bradycardia, percutaneous or transesophageal cardiac pacing can be used; however, these are not always effective. Transatrial cardiac pacemakers are probably most effective for bradycardia with Fontan circulation but they should be placed by a catheter specialist, and emergency placement can be difficult. As described here, a special management protocol is necessary to control bradycardia in the face of Fontan circulation.

[Anesthetic management of Jehovah's Witnesses patients undergoing open heart surgery with cardiopulmonary bypass].

BACKGROUND: The anesthetic management of Jehovah's Witnesses (JW) patients undergoing open heart surgery with cardiopulmonary bypass (CPB) is associated with a major risk of anemic hypoxia. METHODS: Fifteen patients from the community of JW underwent open heart surgery. The surgical procedures undertaken were aortic valve replacement in 7 patients, mitral valve plasty or replacement in 5 patients, repair of congenital heart diseases in 2 patients, and removal of left atrial myxoma in one patient. Hemoglobin values, cardiac output, and oxygen delivery (Do2) as well as consumption (Vo2) were evaluated during and after surgery. RESULTS: After CPB, the mean hemoglobin (Hb) value decreased to 8.2 g x dl(-1) from the baseline level of 11.6 g x dl(-1) (P = 0.0007); however, it increased to 10.5 g x dl(-1) at the end of surgery Cardiac index remained unchanged. Oxygen delivery (Do2) decreased after CPB from its baseline level, whereas oxygen consumption remained unchanged. Twenty-four hours after surgery, Do2 recovered to its baseline level because of an increase in cardiac output with the Hb value of 10.7 g x dl(-1) . CONCLUSIONS: The decrease in Hb level is unavoidable in cardiac surgery with CPB in these JW patients. This survey showed that the decrease in Hb level may be compensated by conserved cardiac output avoiding the decrease of Do2 to its critical level when hypoxia occurs.