Effect of aprotinin on postoperative blood loss in off-pump coronary artery bypass surgery.

BACKGROUND AND AIM OF THE STUDY: Off-pump coronary artery bypass (OPCAB) enables a reduction in postoperative complications, particularly bleeding and transfusion. Nevertheless, a significant percentage of patients still needs transfusion. The effect of antifibrinolytic therapy on postoperative bleeding as part of OPCAB is still not widely described. The purpose of this study was to investigate the potential benefit of aprotinin in OPCAB. METHODS: We conducted a retrospective comparative study with a historical control group. Consecutive patients undergoing off-pump coronary bypass were divided in two groups: 40 patients were operated without any antifibinolytic drug (group C); 40 patients received aprotinin (group A) during surgery. Patients in group A received a bolus of 2 x 10(6) KIU during 30 minutes, followed by a continuous infusion of 0.5 x 10(6) KIU per hour until the end of surgery. The same protocol was used during the whole study period. RESULTS: Preoperative data of the two groups did not differ except for the number of grafts performed, which was higher in group A. Prothrombin time and activated clotting time increased in both groups after surgery. The use of packed red blood cells or fresh frozen plasma was not significantly different between both groups. Postoperative blood loss was significantly reduced in the aprotinin group (540 mL +/- 320 vs. 770 mL +/- 390, p = 0.006). No increase in postoperative troponin values was found in group A. CONCLUSIONS: Aprotinin significantly reduced postoperative blood loss without reducing the transfusion rate. Aprotinin was not associated with any increase in postoperative complications.

[Continuous infusion of remifentanil and target-controlled infusion of propofol for coronary surgery in elderly patients: comparison with continuous infusion of remifentanil and propofol]. / Perfusion continue de rémifentanil et propofol en anesthésie intraveineuse à objectif de concentration au cours de la chirurgie coronaire du sujet âgé: comparaison avec l'alfentanil et le propofol en perfusion continue.

OBJECTIVES: Comparison of the length of mechanical ventilation and postoperative complications after coronary surgery in elderly patients anaesthetised with propofol associated with either alfentanil or remifentanil. STUDY DESIGN: Retrospective study with an historic control group. PATIENTS: Three hundred thirty-eight consecutive patients (75-year-old or more) undergoing isolated coronary surgery. One hundred and fifty seven patients operated between January 1998 and June 2000 received alfentanil (1 microg/kg/minute) with a manually control infusion of propofol, 181 operated between July 2000 and 2002, remifentanil 0.25 microg/kg/minute with target controlled infusion of propofol (target blood concentration: 1.5 to 2 microg/ml). METHODS: The two groups were compared for preoperative and surgical data. The length of mechanical ventilation, stay in ICU and the main postoperative complications were compared between the two groups. RESULTS: Length of mechanical ventilation was significantly reduced in the remifentanil group (6 +/- 9 h vs. 13 +/- 63 h ; p <0.0001), 70% of the patients were extubated before the 6th postoperative hours against 53% in the alfentanil group (p =0.0023). This was not associated with a reduction of stay in ICU or postoperative complications. During surgery, an increased used of vasopressor was observed in the remifentanil group (40.2% vs 2.4% ; p <0.0001) with a postoperative elevation of blood concentration of CKMb (35.7 +/- 38.2 microg/l, vs. 27.7 +/- 31.9 microg/l, p =0.02). CONCLUSION: Elderly patients undergoing coronary surgery were extubated earlier with remifentanil. However, this had no effect on duration of ICU stay but was associated with an increased used of vasopressor.

Inhaled nitric oxide: effects on hemodynamics, myocardial contractility, and regional blood flow in dogs with mechanically induced pulmonary artery hypertension.

BACKGROUND: Pulmonary artery hypertension with right ventricular failure is a frequent complication that occurs immediately after heart transplantation in which the use of inhaled nitric oxide may be effective. METHODS: The effects of pulmonary artery hypertension and nitric oxide on myocardial function and on pulmonary and systemic hemodynamic parameters were evaluated in eight anesthetized dogs. Pulmonary artery hypertension was induced by successive microbead injections into the pulmonary circulation. RESULTS: Microbead injections resulted in overt pulmonary artery hypertension (pulmonary artery pressure, + 190%; pulmonary vascular resistance, + 389%; ratio of pulmonary vascular resistance to systemic vascular resistance, 0.41). RESULTS: The end-diastolic length of the right ventricular outflow tract increased significantly along with an increase in right ventricular contractility (peak first derivative of left ventricular pressure as a function of time, + 100%; outflow tract systolic shortening, + 19%). Despite this compensatory mechanism, the increased pulmonary barrier resulted in a decrease in stroke volume (-31%). Systemic effects were observed, such as an increase in heart rate that maintained the cardiac output despite a decrease in left ventricular end-diastolic length (end-diastolic length in region of left anterior descending artery, - 9%). Right myocardial and septal blood flows were also significantly increased. CONCLUSIONS: Nitric oxide administration restored the stroke volume with a decrease in pulmonary artery hypertension and an improvement of the pulmonary vascular resistance to systemic vascular resistance ratio. Systemic blood pressure and coronary perfusion remained unaffected. This selective effect on the pulmonary circulation should be considered a major advantage of nitric oxide inhalation in the treatment of right ventricular dysfunction in acute pulmonary hypertension.

[Prediction of respiratory complications after surgery of the abdominal aorta]. / Prédiction des complications respiratoires après chirurgie de l'aorte abdominale.

The most frequent type of complication in patients undergoing aortic surgery is respiratory. Preoperative lung function (PFT) and arterial blood gas measurement (ABG) are often carried out to assess the risk more precisely. The aim of the present retrospective study was to determine which value of lung function test could identify patients who developed such complications. "Receiver Operating Characteristic" (ROC) curves and the area beneath the curve for the diagnosis of respiratory complications were calculated for each variable of PFT and ABG. The greatest Youden index for each variable was chosen as indicative pulmonary function criterion of increased risk of pulmonary complications. One hundred and ninety-five patients (age: 65 +/- 10 years) were included. Respiratory complications occurred in 15% of patients. Respiratory complications increased from 12% if the vital capacity (VC) was > or = 77% of the predicted value to 35% if the VC was < 77% (P = 0.002), and from 10% if the FEV1 was > 76% to 34% if the FEV1 was > or = 76% (P = 0.0005). A decreased PaO2 or increased PaCO2 was not correlated with an increased incidence of respiratory complications. Length of stay in ICU or in hospital were increased when VC or FEV1 were low. Frequency of pulmonary complications was 9% in patients without PFT abnormalities, 16% in patients with either diminished VC or FEV1 and 35% in patients with both lowered VC and FEV1. However, all the areas under the ROC curves were < 0.7 and the sensitivity of the different variables was low. It is concluded that routine preoperative PFT and ABG cannot predict respiratory complications after abdominal aortic surgery.

Pulmonary function tests predict outcome after cardiac surgery.

The aim of this study was to examine the value of systematic preoperative pulmonary function tests (PFTs) in order to reliably predict prolonged stay in I.C.U., prolonged mechanical ventilation and mortality in elective cardiac surgical patients. 149 consecutive adult patients (valvular replacement or coronary bypass graft) were studied retrospectively. We examined the preoperative respiratory data: vital capacity (VC), first second forced expired volume (FEV1), PaCO2 and PO2. Length of stay in I.C.U. (LICU), duration of mechanical ventilation (DMV), incidence of reintubation and survival rate were used as indices of respiratory morbidity. The results of the present study clearly indicate that patients with impaired airway flow rates had a prolonged postoperative recovery following cardiac surgery. Mortality, ICV and DMV increased when FEV1 was less than 1.5 L, VC was less than 2.5 L, or PaO2 was less than 8.5 kPa. Reintubation was associated with impaired flow rates. Pulmonary function tests appeared effective in predicting postoperative complications and the need for prolonged ventilatory support.

[Nature, frequency and variability of health counseling by 7 pediatric physicians ]. / Nature, fréquence et variabilité des conseils de santé chez 7 pédiatres praticiens.

A prospective study of health counseling was conducted in 7 private pediatric ambulatory settings. The frequency, duration, differences and contents of these advices are given. These latter were classified as systematic (given by the pediatrician), given (occasional), requested, preventive, or therapeutic, for statistical analysis. 1,703 counsels were registered during 1,503 consultations. 828 of them health counsels (HC) and will be reported here. Educational HC were the most frequent, followed by those concerning therapy, hygiene, immunization and nutrition. The mean counsel duration was 2 minutes. Their frequency and contents varied greatly among the 7 pediatricians. The content of the immunization counsels only was homogeneous. 22% of the HC were systematic, when 47% were requested. A better teaching of health counseling would further improve the credibility and efficacy of health counseling in pediatric practice.

[Consumption coagulopathies following peritoneojugular bypass. Prevention by a heparin-antithrombin III combination]. / Les coagulopathies de consommation après dérivations péritonéo-jugulaires. Prévention par l'association héparine-antithrombine III.

Consumption coagulopathy (CIVD) is a frequent complication of peritoneojugular bypass operation. Preventive treatment applied involves low-dose heparin (1.5 mg/kg/d) to maintain an antithrombin III concentration of at least 65%. Results are evaluated in 6 patients treated by 7 bypass operations. A biologic CIVD developed in 2 cases (29%) but no clinical coagulopathy was observed. This incidence is less than that usually reported, a literature review indicating a biologic coagulopathy in 65% of cases, with clinical evidence in 12.5%. Furthermore, patients with spontaneously elevated AT III levels did not develop CIVD while, in contrast, sufficiently high concentrations of AT III could not be maintained in the 2 patients with coagulopathy. These findings suggest the interest of prevention of a CIVD by the use of this procedure.

[Secondary rupture of the spleen after external cardiac massage]. / Rupture secondaire de rate après massage cardiaque externe.

A case of delayed splenic rupture occurring 18 days after external cardiac massage is reported. A 30 year old woman underwent mitral valve replacement. Two cardiac arrests in the immediate postoperative period were successfully treated by external cardiac massage. Recovery was uneventful until the 18th day, when the patient began to suffer from dizziness. Haemodynamic and biological data suggested hypovolaemia by dehydration. The day after, her abdomen became painful and anaemia was discovered. Splenic rupture was diagnosed by abdominal ultrasonography and splenectomy was carried out; no other lesion was found. In spite of the widespread practice of external cardiac massage, splenic rupture without any other lesion is unusual. It is suggested that abdominal ultrasonography should follow all cardiac massages.

[Rare complication of frontal sinusitis in children: gas gangrene of the scalp. Apropos of a case]. / Une complication rare des sinusites frontales de l'enfant: la gangrène gazeuse du scalp. A propos d'une observation.

An 11-year-old child developed an infection of the scalp due to anaerobic germs following an acute attack of frontal sinusitis. The mechanism and therapy of this rare complication are discussed. The favorable outcome in this case suggests the need for revision of the generally poor prognosis of this complication, on the condition that adequate treatment be applied under the control of a multidisciplinary team.

[Fentanyl-oxygen-pancuronium anaesthesia in cardiac surgery (author's transl)]. / Anesthésie au fentanyl-oxygène-pancuronium en chirurgie cardiaque.

A retrospective study of the anaesthetic records in cardiac surgical patients was undertaken: massive doses of fentanyl were used according to Stanley (29). The rate of drug administration was fentanyl 150 micrograms/kg for induction and 15 to 25 micrograms/kg/hour for maintenance, pancuronium bromide 0,1 mg/kg for induction and 0,015 mg/kg/hour for maintenance. Myocardial oxygen consumption (estimated by rate-pressure-product) during induction period remains constant. The oesophago-rectal temperature gradient is smaller than with other anaesthetic techniques, showing a very good perfusion homogeneity without the need of vasodilatator drugs. The temperature after-drop in the post bypass period is also reduced (less than 1,2 degrees C). The incidence of hemodynamic and rhythmic disturbances during operations and during the first post-operative day is lowered. Delayed respiratory autonomy appears to be the major drawback of this method (group 1: 25,30 h +/- 7,30 h; 30,20 h +/- 12,25 h; group 3: 21,15 h +/- 6,25 h).