Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study.

BACKGROUND: The management of perioperative iron deficiency is a component of the concept of patient blood management. The objective of this study was to update French data on the prevalence of iron deficiency in patients scheduled for major surgery. METHODS: The CARENFER PBM study was a prospective cross-sectional study in 46 centers specialized in orthopedic, cardiac, urologic/abdominal, or gynecological surgery. The primary end point was the prevalence of iron deficiency at the time of surgery (D-1/D0) defined as serum ferritin <100 µg/L and/or transferrin saturation (TSAT) <20%. RESULTS: A total of 1494 patients (mean age, 65.7 years; women, 49.3%) were included from July 20, 2021 to January 3, 2022. The prevalence of iron deficiency in the 1494 patients at D-1/D0 was 47.0% (95% confidence interval [CI], 44.5-49.5). At 30 days after surgery, the prevalence of iron deficiency was 45.0% (95% CI, 42.0-48.0) in the 1085 patients with available data. The percentage of patients with anemia and/or iron deficiency increased from 53.6% at D-1/D0 to 71.3% at D30 ( P < .0001), mainly due to the increase of patients with both anemia and iron deficiency (from 12.2% at D-1/D0 to 32.4% at D30; P < .0001). However, a treatment of anemia and/or iron deficiency was administered preoperatively to only 7.7% of patients and postoperatively to 21.7% (intravenous iron, 14.2%). CONCLUSIONS: Iron deficiency was present in half of patients scheduled for major surgery. However, few treatments to correct iron deficiency were implemented preoperatively or postoperatively. There is an urgent need for action to improve these outcomes, including better patient blood management.

Transfusion-Related Renal Dysfunction After Cardiac Surgery: The Role of Myeloid-Related Protein_14 in Neutrophil-Mediated Tubular Damage.

Transfusion is a specific cause of acute kidney injury (AKI) after cardiac surgery. Whether there is an association between the composition of blood products and the onset of AKI is unknown. The present study suggests that the transfusion of packed red blood cells containing a high amount of myeloid-related protein 14 (MRP_14) could increase the incidence of AKI after cardiac surgery. In a mouse model, MRP_14 increased the influx of neutrophils in the kidney after ischemia-reperfusion and their ability to damage tubular cells. Higher concentrations of MRP_14 were found in packed red blood cells from female donors or prepared by whole blood filtration.

Evaluation of the impact of HMS Plus on postoperative blood loss compared with ACT Plus in cardiac surgery.

BACKGROUND: The standardized management of anticoagulation during the cardiopulmonary bypass seems inaccurate because of patients and surgeries variability. This study evaluates if an individualized management of heparin and protamine guided by the HMS Plus system during cardiopulmonary bypass could reduce postoperative blood loss. METHODS: We conducted a prospective, controlled, unblinded, single-center study. One-hundred and eighthy-eight patients operated for cardiac surgery were included. Patients were divided in ACT Plus group (standardized approach) and HMS Plus group (individualized approach). The primary outcome was blood-loss volume during the first 24 postoperative hours. The main secondary outcomes were the need for allogeneic blood transfusions and the final protamine/heparin ratio. RESULTS: There was no difference between the two groups for baseline characteristics. Medium blood-loss volume in the ACT Plus group was 522±260 mL vs. 527±255 mL in the HMS Plus group (P=0.58). The final protamine/heparin ratio in the ACT Plus group was 0.94±0.1 vs. 0.58±0.1 in the HMS Plus group (P<0.0001). The transfusion rate during surgery in the ACT Plus group was 25% vs. 14% in the HMS Plus group (P=0.09). CONCLUSIONS: HMS Plus did not reduce the mean blood-loss volume during the first 24 postoperative hours compared with ACT Plus. Its utility for potential transfusion rate reduction remains to be proven.

Programmes for the management of preoperative anaemia: audit in ten European hospitals within the PaBloE (Patient Blood Management in Europe) Working Group.

BACKGROUND AND OBJECTIVES: Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce. MATERIALS AND METHODS: To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016. RESULTS: Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron. CONCLUSION: Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.

Cost-effectiveness of point-of-care viscoelastic haemostatic assays in the management of bleeding during cardiac surgery: protocol for a prospective multicentre pragmatic study with stepped-wedge cluster randomised controlled design and 1-year follow-up (the IMOTEC study).

INTRODUCTION: During cardiac surgery-associated bleeding, the early detection of coagulopathy is crucial. However, owing to time constraints or lack of suitable laboratory tests, transfusion of haemostatic products is often inappropriately triggered, either too late (exposing to prolonged bleeding and thus to avoidable administration of blood products) or blindly to the coagulation status (exposing to unnecessary haemostatic products administration in patients with no coagulopathy). Undue exposition to transfusion risks and additional healthcare costs may arise. With the perspective of secondary care-related costs, the IMOTEC study (Intérêt MédicO-économique de la Thrombo-Elastographie, dans le management transfusionnel des hémorragies péri-opératoires de chirurgies Cardiaques sous circulation extracorporelle) aims at assessing the cost-effectiveness of a point-of-care viscoelastic haemostatic assay (VHA: RoTem or TEG)-guided management of bleeding. Among several outcome measures, particular emphasis will be put on quality of life with a 1-year follow-up. METHODS AND ANALYSIS: This is a multicentre, prospective, pragmatic study with stepped-wedge cluster randomised controlled design. Over a 36-month period (24 months of enrolment and 12 months of follow-up), 1000 adult patients undergoing cardiac surgery with cardiopulmonary bypass will be included if a periprocedural significant bleeding occurs. The primary outcome is the cost-effectiveness of a VHA-guided algorithm over a 1-year follow-up, including patients' quality of life. Secondary outcomes are the cost-effectiveness of the VHA-guided algorithm with regard to the rate of surgical reexploration and 1-year mortality, its cost per-patient, its effectiveness with regard to haemorrhagic, infectious, renal, neurological, cardiac, circulatory, thrombotic, embolic complications, transfusion requirements, mechanical ventilation free-days, duration of intensive care unit and in-hospital stay and mortality. ETHICS AND DISSEMINATION: The study was registered at Clinicaltrials.gov and was approved by the Committee for the Protection of Persons of Nantes University Hospital, The French Advisory Board on Medical Research Data Processing and the French Personal Data Protection Authority. A publication of the results in a peer-reviewed journal is planned. TRIAL REGISTRATION NUMBER: NCT02972684; Pre-results.

Efficacy of artesunate-amodiaquine, dihydroartemisinin-piperaquine and artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria in Maradi, Niger.

BACKGROUND: Malaria endemic countries need to assess efficacy of anti-malarial treatments on a regular basis. Moreover, resistance to artemisinin that is established across mainland South-East Asia represents today a major threat to global health. Monitoring the efficacy of artemisinin-based combination therapies is of paramount importance to detect as early as possible the emergence of resistance in African countries that toll the highest burden of malaria morbidity and mortality. METHODS: A WHO standard protocol was used to assess efficacy of the combinations artesunate-amodiaquine (AS-AQ Winthrop®), dihydroartemisinin-piperaquine (DHA-PPQ, Eurartesim®) and artemether-lumefantrine (AM-LM, Coartem®) taken under supervision and respecting pharmaceutical recommendations. The study enrolled for each treatment arm 212 children aged 6-59 months living in Maradi (Niger) and suffering with uncomplicated falciparum malaria. The Kaplan-Meier 42-day PCR-adjusted cure rate was the primary outcome. A standardized parasite clearance estimator was used to assess delayed parasite clearance as surrogate maker of suspected artemisinin resistance. RESULTS: No early treatment failures were found in any of the study treatment arms. The day-42 PCR-adjusted cure rate estimates were 99.5, 98.4 and 99.0% in the AS-AQ, DHA-PPQ and AM-LM arms, respectively. The reinfection rate (expressed also as Kaplan-Meier estimates) was higher in the AM-LM arm (32.4%) than in the AS-AQ (13.8%) and the DHA-PPQ arm (24.9%). The parasite clearance rate constant was 0.27, 0.26 and 0.25 per hour for AS-AQ, DHA-PPQ and AM-LM, respectively. CONCLUSIONS: All the three treatments evaluated largely meet WHO criteria (at least 95% efficacy). AS-AQ and AL-LM may continue to be used and DHA-PPQ may be also recommended as first-line treatment for uncomplicated falciparum malaria in Maradi. The parasite clearance rate were consistent with reference values indicating no suspected artemisinin resistance. Nevertheless, the monitoring of anti-malarial drug efficacy should continue. Trial registration details Registry number at ClinicalTrial.gov: NCT01755559.

Fighting poor-quality medicines in low- and middle-income countries: the importance of advocacy and pedagogy.

The globalization of pharmaceutical production has not been accompanied by a strengthening and harmonization of the regulatory systems worldwide. Thus, the global market is characterized today by a situation of multiple standards, and patients in low- and middle-income countries are exposed to the risk of receiving poor-quality medicines. Among those who first raised the alarm on this problem, there were pioneering humanitarian groups, who were in a privileged position to witness the gap in quality of medicines between high-income countries and low- and middle-income countries. Despite an increasing awareness of the problem and the launch of some positive initiatives, the divide in pharmaceutical quality between the North and the South remains important, and insufficiently addressed. More advocacy is needed for universal access to quality-assured medicines. It should target all those who are strongly "involved" with medicines: regulators, international organizations, journalists, purchasers, prescribers, program managers, policy makers, public health actors and the patients. Advocacy should be based on evidence from research and monitoring programs, and technical concepts should be translated in lay language through communication tools that address all the stakeholders. The fight to ensure universal access to quality medicines needs the participation of all, and can only be successful if grounded in common understanding.

Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study.

RATIONALE: Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence. OBJECTIVES: To determine whether early HVHF decreases all-cause mortality 30 days after randomization. METHODS: This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury. MEASUREMENTS AND MAIN RESULTS: On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia. CONCLUSIONS: For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

Propofol Infusion syndrome during refractory status epilepticus in a young adult: successful ECMO resuscitation.

BACKGROUND: Propofol infusion syndrome (PRIS) is a rare but serious complication of propofol administration consisting of metabolic disorder with acidosis, often leading to fatal cardiovascular collapse. METHODS: A case of PRIS is described in a 17-year-old female with refractory status epilepticus (RSE) who was receiving high-dose propofol for seizure control and sedation. RESULTS: Metabolic syndrome was observed with renal failure, severe metabolic acidosis, and rhabdomyolysis after 58 h of propofol infusion at a maximum dose of 8.8 mg/kg/h. It was not initially associated with circulatory failure. Propofol was stopped immediately, and brief bradycardia was observed. The patient was started on continuous hemofiltration resulting in correction of the metabolic disorder. However, cardiocirculatory failure occurred a few hours later. Her clinical evolution and biological assessments were typical of PRIS. Extracorporeal membrane oxygenation (ECMO) was initiated despite the presence of cardiocirculatory arrest. Cardiocirculatory function improved rapidly, and the patient was weaned off ECMO after 5 days. No severe neurologic effects were observed, and she left the intensive care unit after 36 days, returning home after 2 months. CONCLUSIONS: Careful consideration should be given before prescribing propofol as first-line therapy for RSE, and this drug should be avoided altogether if high doses are required. Close biochemical monitoring is needed if propofol is used for more than a few hours, so that PRIS can be recognized promptly. Immediate discontinuation of propofol is essential, and early hemofiltration should be initiated. ECMO should be considered in cases of cardiocirculatory failure.

The effect of age on skin color and color heterogeneity in four ethnic groups.

BACKGROUND: Few comparative data are available on age-related changes in skin color among different ethnic groups. The aim of the study was to measure and analyze the skin color and color heterogeneity in four different ethnic groups living in the same local environment and to determine the effects of age on these skin color characteristics. METHODS: Female volunteers (385) from four ethnic populations (African-American, Caucasian, Chinese and Mexicans) living in the same city were enrolled after informed consent. Skin color was measured on two facial areas, forehead and cheek. The subjects were further divided into six age ranges: 19-30, 31-40, 41-50, 51-60, 61-70 and 71-87 years to determine any age-related effects on the skin color and color heterogeneity in both areas. RESULTS: According to the L(*)a(*)b(*) CIE system, clarity (fairness/lightness) was found to be lower in the African-American group whereas the hue was lower in Caucasians, which means more red skin. A clear, statistically significant darkening of the skin with age was observed in all ethnic groups, while evidence of yellowing of the skin was shown in the Chinese volunteers. Overall, the skin color of the face of African-Americans was more heterogeneous than in the other ethnic groups, but showed the least increase with age. CONCLUSION: Our study revealed interesting differences in skin color and color heterogeneity with respect to ethnicity and age-related alterations. Data obtained are very useful in improving our knowledge about the skin of people of different origins and helps in the development of specific cosmetic products that are well adapted to all these populations.

Skin from various ethnic origins and aging: an in vivo cross-sectional multimodality imaging study.

BACKGROUND: Ethnic differences in skin structural features have not been thoroughly investigated, and the few reported studies are contradictory. Thus, we have carried out a set of in vivo measurements on the skin of about 400 volunteers from various ethnic origins living in the same environment. METHODS: Female subjects were distributed into four ethnic groups: African Americans, Mexicans, Caucasians, and Chinese. Inter- and intra-ethnic skin structural differences, according to age and anatomic site, were investigated using three non-invasive skin-imaging methods: ultrasound (US) at 25 and 150 MHz, and optical coherence tomography (OCT). RESULTS: The thickness of the skin is higher on the cheek compared with the dorsal and ventral forearm, with no ethnic or age-related specificity. We confirm that the sub-epidermal non-echogenic band is a sensitive marker of skin aging, and reveal for the first time that it is less pronounced in African Americans. From OCT images, we bring out evidence that the thickness of the dermal-epidermal junction (DEJ) decreased with age, and was higher in African Americans than in Caucasians. Finally, by comparing US images at 150 MHz with OCT images, we show that papillary dermis thickness can be measured and appears to be quite constant irrespective of age or ethnic group. CONCLUSION: Our study confirms that skin imaging is very attractive to further our knowledge of the morphology of skin from various ethnic origins. Regarding age effects, quantitative parameters have shown that they would be delayed in African Americans compared with all other ethnic populations.

CardioWest (Jarvik) total artificial heart: a single-center experience with 42 patients.

BACKGROUND: When implanted in patients with biventricular failure, the CardioWest total artificial heart has asserted itself over time as a reliable bridge-to-transplant device that as yet is used by only a few international teams. The aim of this single-center retrospective study is to assess both the comorbidity and survival of patients awaiting heart transplants while receiving circulatory support with a CardioWest total artificial heart. METHODS: From 1990 to December 2006, 42 patients received a CardioWest total artificial heart at our center. Mean age at the time of implantation was 45.7 +/- 9.5 years, and 40 patients (95%) were men. Idiopathic or dilated cardiomyopathy was diagnosed in 45.2% (n = 19) of the patients and ischemic cardiomyopathy in 42.8% (n = 18). Average body surface area was 1.9 +/- 0.22 m(2). RESULTS: Duration of support was 1 to 292 days (mean, 101 +/- 86 days). Twelve patients died (28.5%) while receiving device support, and 30 patients (71.5%) underwent transplantation. Actuarial survival rates for the transplanted patients were 90% (n = 25), 81% (n = 14), and 76% (n = 10) at 1, 5, and 10 years, respectively. Causes of death during device support included multiorgan failure in 6 (50%), sepsis in 2, acute respiratory distress syndrome in 2, alveolar hemorrhage in 1, and other cause in 1. There were no device malfunctions that led to patient death. Adverse events included stroke in 3 patients (7%) and infections in 35 patients (85%) during support. CONCLUSIONS: The CardioWest total artificial heart is an excellent bridge-to-transplant device for patients with biventricular failure. Our study demonstrates excellent safety, reliability, and efficiency. Exceptional outcome after transplantation underlines its capacity to aid in end-organ recovery.

Aspergillus fumigatus endocarditis of the mitral valve in a heart transplant recipient: a case report.

Aspergillus endocarditis is a rare event after heart transplantation. We report a case of Aspergillus fumigatus endocarditis after orthotopic heart transplantation. The patient was treated with a combination of voriconazole and caspofungin without valve replacement and survived for 168 days after the diagnosis. Previously reported cases are reviewed.

Comparative study of the hydration of the stratum corneum between four ethnic groups: influence of age.

BACKGROUND: Several recent overviews have reported that significant work remains to be performed to understand and quantify the ethnic differences in skin properties. In this way, we have carried out a set of in vivo biophysical experiments on the skin of American women from different ethnic populations living in the same environment. Inter- and intraethnic skin micro relief results were already published, skin hydration differences are now reported here. METHODS: The skin water content was evaluated taking advantage of the new skin capacitance imaging technique which allows to study stratum corneum hydration without suffering of the influence of the skin micro-relief and hair on the measurement. Three hundred and eleven American women from four ethnic groups were enrolled in this study. The investigation was performed during the summer season of 2004 on the major relatively distinct ethnic groups of Chicago, which is to say: African American, Chinese, Caucasian and Mexican. The hydration of the skin was investigated on the dorsal and ventral forearm sites as a function of ethnicity and age. RESULTS: Skin dryness is higher on sun exposed sites for lighter skin tones, such as in Chinese and Caucasian women, than on sites that are primarily out of the sun; while, no skin dryness differences are seen on either site for African American and Mexican women whose skin is darker. The skin dryness does not change as a function of ethnicity for the younger group for either the ventral and dorsal site of the forearm. With age, however, the dryness of the skin is higher for African American and Caucasian women than for the two other ethnic groups, with a higher percentage increase in Caucasian women. CONCLUSIONS: This study has revealed that the hydration of the skin is different according to ethnicity and that the age effects are influenced by ethnicity, suggesting anatomical or physiological property differences in ethnic skin. This study has also pointed out that the SkinChip seems to be a convenient and fast way to investigate both the micro relief as previously published and the dryness of the skin on a large number of subjects, and in this way will be very useful to improve our knowledge about skin of people from different ethnic groups and helping to develop specific products that are customized to all these populations.

Development and validation of a new Skin Color Chart.

BACKGROUND: Age-induced skin color variations are of great importance and incite increasing demand for cosmetic products to improve the appearance. The evaluation by clinicians or estheticians of the efficacy of skin care products is particularly difficult and requires the help of color charts. PURPOSE: To standardize this kind of evaluation, we have developed a new Skin Color Chart. In contrast to other color charts, this new one represents true skin color without metamerism and covers almost all skin colors encountered around the world. This new instrument has been validated for both Asian and Caucasian skin complexion and sun spot color. METHOD: The new device used to record skin color, the Chromasphere, developed by L'Oréal, is briefly presented. All skin color measurements and the validation of each selected Color were performed under identical conditions, and then, absorption spectra of both skin and chart were compared using severe criteria. The first use and the validation of this Skin Color Chart were performed by dermatologists (two in China and one in France) in groups of about 40 women on sunspots and complexion color. RESULTS: Regarding repeatability (intraobserver agreement), the new Skin Color Chart showed very good statistical validation on complexion and sunspot color. The agreement between dermatologists, the reproducibility criterion, although not as good remained high. An example of the evaluation of the efficacy of a whitening product is given in order to illustrate the 'sensitivity' of this new device to evaluate very weak color variations. CONCLUSIONS: The new Skin Color Chart appears to be very useful and easy to use even by clinicians without training in color evaluation.

Silicon avalanche photodiodes for direct detection of X-rays.

Silicon avalanche photodiodes (APDs) are discussed as fast X-ray detectors for synchrotron radiation. The emphasis is on ;direct' detection, where the X-ray is absorbed within the silicon APD itself, and, therefore, on use with medium-energy X-rays, <30 keV. The impact of APD structure on device performance is examined, and representative data from many different commercial devices are presented. Specific areas discussed include signal shapes, high-rate behavior, time resolution and pulse-height response. Data from several APD arrays are also presented, as is a detailed description of an integrated package system. Tables are included comparing commercially available devices, including arrays.

Propofol and sufentanil titration with the bispectral index to provide anesthesia for coronary artery surgery.

BACKGROUND: To provide anesthesia for cardiac surgery, hypnotics and opioids are frequently titrated on variables such as mean arterial pressure and heart rate. In this study conducted in patients scheduled to undergo coronary artery bypass grafting, propofol and sufentanil, both administered by computer-controlled infusion, were titrated on the Bispectral Index (BIS) values using a predefined algorithm. METHODS: After written informed consent, 110 patients, 95 men and 15 women aged 61 (9) yr [mean (SD)], were randomly allocated to receive predicted sufentanil effect site concentrations (Ce) of 0.5, 0.75, 1, 1.25, and 1.5 ng/ml, decreased by a third after sternotomy (groups 1-5). Target induction propofol concentration was 1.5 microg/ml and subsequently adjusted on BIS values. The following parameters were recorded: BIS values, predicted propofol Ce, the number of changes of propofol target, mean arterial pressure, heart rate, the number of bolus injection and doses of vasoconstrictor and vasodilator drugs, time to tracheal extubation, postoperative awareness and satisfaction scores, and cumulative morphine doses for the first postoperative day. RESULTS: One patient randomized to group 1 required 0.75 ng/ml sufentanil Ce instead of 0.5 ng/ml for increased BIS values on tracheal intubation. BIS values were similar in the five groups. The predicted propofol Ce values were different (P < 0.05; analysis of variance) among the five groups: 1.59 (0.47) to 1.23 (0.25) microg/ml in group 1 and group 4, respectively. Significantly fewer changes of propofol target were required in group 4 as compared to group 1. There were no differences among the five groups for mean arterial pressure, heart rate, time to tracheal extubation, awareness, satisfaction scores, and morphine requirements. CONCLUSION: These results suggest the BIS, as part of an algorithm that uses both the absolute BIS value and its increase following tracheal intubation, can be used to effectively titrate both propofol and sufentanil. A predicted sufentanil Ce of 1.25 ng/ml before and 0.8 ng/ml after sternotomy was associated with the lowest predicted propofol Ce and fewer changes of propofol target. Lower sufentanil concentrations required higher propofol concentrations and more frequent changes of the target propofol concentration and were associated with similar hemodynamic tolerance.