Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate.

BACKGROUND: Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. OBJECTIVE: To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. METHODS: Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. RESULTS: Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. CONCLUSION: Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.

Certification in endovascular hemostasis for trauma surgeons: Possible and practical?

BACKGROUND: Endovascular hemostasis is commonplace with many practitioners providing services. Accruing sufficient experience during training could allow acute care surgeons (ACSs) to expand their practice. We quantified case load and training opportunities at our center, where dedicated dual-trained ACS/vascular surgery faculty perform these cases. Our aim was to assess whether ACS fellows could obtain sufficient experience in 6 months of their fellowship in order to certify in these techniques, per the requirements of other specialties. METHODS: We performed a retrospective case series where we reviewed 6 years (2013-2018) of endovascular activity at an academic, level I trauma center quantifying arterial access, angiography, embolization, stent and stent graft placement, and IVC filter procedures. This was compared with the certification requirements for interventional radiology, vascular surgery, cardiothoracic surgery, and interventional cardiology. RESULTS: Between 2013 and 2018, 1,179 patients with a mean ± SD Injury Severity Score of 22.47 ± 13.24, underwent 4960 procedures. Annual rates per procedure, expressed as median (interquartile range), were arterial access 193.5 (181-195.5), diagnostic angiography 352 (321.5-364.5), embolization 90.5 (89.25-93.25), stent placement 24 (13.5-29.25), and IVC filter procedures 16.5 (10-23.75). Our 6-month case volume exceeded or was within 85% of the required number of cases for vascular surgery and interventional radiology training, with the exception of stent-graft deployment for both specialties, and therapeutic procedures for vascular surgery. CONCLUSION: The case volume at a large trauma center with a dedicated endovascular trauma service is sufficient to satisfy the case requirements for endovascular certification. Our trainees are already acquiring this experience informally. An endovascular trauma curriculum should now be developed to support certification within ACS fellowship training.

Position of the French Working Group on Perioperative Haemostasis (GIHP) on viscoelastic tests: What role for which indication in bleeding situations?

PURPOSE: Viscoelastic tests (VETs), thromboelastography (TEG®) and thromboelastometry (ROTEM®) are global tests of coagulation performed on whole blood. They evaluate the mechanical strength of a clot as it builds and develops after coagulation itself. The time required to obtain haemostasis results remains a major problem for clinicians dealing with bleeding, although some teams have developed a rapid laboratory response strategy. Indeed, the value of rapid point-of-care diagnostic devices such as VETs has increased over the years. However, VETs are not standardised and there are few recommendations from the learned societies regarding their use. In 2014, the recommendations of the International Society of Thrombosis and Haemostasis (ISTH) only concerned haemophilia. The French Working Group on Perioperative haemostasis (GIHP) therefore proposes to summarise knowledge on the clinical use of these techniques in the setting of emergency and perioperative medicine. METHODS: A review of the literature. PRINCIPAL FINDINGS: The role of the VETs seems established in the management of severe trauma and in cardiac surgery, both adult and paediatric. In other situations, their role remains to be defined: hepatic transplantation, postpartum haemorrhage, and non-cardiac surgery. They must be part of the global management of haemostasis based on algorithms defined in each centre and for each population of patients. Their position at the bedside or in the laboratory is a matter of discussion between clinicians and biologists. CONCLUSION: VETs must be included in algorithms. In consultation with the biology laboratory, these devices should be situated according to the way each centre functions.

Thrombocytopenia and Neurosurgery: A Literature Review.

INTRODUCTION: The absence of evidence-based guidelines for platelet transfusion surrounding invasive neurosurgical procedures leads to uncertainty in management. Multiple studies have illuminated this lack of high quality data, and subsequent reliance on expert opinion. The generally accepted threshold for platelet transfusion has hovered around 100,000/µL. METHODS: We have conducted a review of available clinical literature to identify any evidence that may support or refute these general guidelines, in an attempt to clarify the need for platelet transfusion in the patient requiring neurosurgical intervention. RESULTS: The available evidence is sparse and of low quality, but suggests that a platelet count <100,000/µL is associated with increased risk of hemorrhagic complications. In addition, the acuity of thrombocytopenia, magnitude of decrease in platelet count, and responsiveness to platelet transfusions impact the risk of neurosurgical intervention, and should be taken into account when evaluating a patient's surgical candidacy. Higher quality, prospective studies on the subject are unlikely, given a general lack of clinical equipoise on the subject, and the ethical concerns such a study would present.

Starch-derived absorbable polysaccharide hemostat enhances bone healing via BMP-2 protein.

Surgical hemostasis is critical in reducing the likelihood of excessive bleeding and blood transfusion. In treating some cases, commonly used hemostatic agent showed limited efficacy and prolonged degradation and clearance, causing an inhibition of bone healing. Starch absorbable polysaccharide (SAPH) is a novel hemostatic agent made from a plant starch, which can be completely absorbed and achieve better hemostatic effects than many commonly used hemostatic agents. However, whether SAPH can induce a promotion of bone healing remains unknown. In this study, we used a model of rabbit parietal bone defect and a mouse osteoblast cell line MC3T3-E1 to evaluate the effects of SAPH on bone healing. We found that SAPH significantly decreased bone healing scores, reduced defective area of parietal bone, and increased the areas of bone trabeculae and cavitas medullaris. In addition, SAPH enhanced MC3T3-E1 osteoblasts proliferation, up-regulated the expressions of alkaline phosphatase (ALP) and osteocalcin and increased the level of bone morphogenetic protein 2 (BMP-2) in MC3T3-E1 osteoblasts. These SAPH-induced benefits in MC3T3-E1 osteoblasts were significantly abolished by the application of BMP-2-siRNA. These findings suggested that SAPH enhances bone healing, promotes the proliferation, differentiation and maturation of osteoblast by up-regulating BMP-2 expression in osteoblastic cells.

Quality Control Approach to Anticoagulants and Transfusion.

Quality can be defined by processes of care and by the characteristics of the care and its outcomes. In terms of blood loss and transfusion, otolaryngologists should be aware of available guidelines, standards for use of blood products, devices and hemostatic agents, outcomes metrics relevant to patients, and tools for implementing quality improvements. This article reviews the definition of health care quality, and discusses the data regarding anticoagulant medications (particularly new oral anticoagulants) and guidelines for blood product transfusion. A brief outline of quality tools is provided to help otolaryngologists create quality plans for themselves and their institutions/systems.

How do we transfuse blood components in cirrhotic patients undergoing gastrointestinal procedures?

The liver plays a pivotal role in hemostasis. Consequently, patients with cirrhosis frequently demonstrate abnormal coagulation profiles on routine laboratory tests. These tests mainly reflect decreased procoagulant proteins. However, in cirrhosis, complex changes also occur in anticoagulant and fibrinolytic pathways. Recent evidence demonstrates that patients with cirrhosis exist in a state of hemostatic rebalance. Accordingly, routine tests inadequately represent hemostatic alterations in these patients. Unfortunately, these tests are regularly used to guide the transfusion of blood components with the assumption that they will correct laboratory abnormalities and improve hemostasis in a bleeding patient or prevent excessive bleeding following a procedure. With an absence of both accurate laboratory testing to assess hemostasis and evidence-based guidelines to direct the transfusion of blood components, management of patients with cirrhosis poses a significant challenge to clinicians. Therefore, we developed multidisciplinary guidelines for the periprocedural transfusion of blood components in patients with cirrhosis based on concurrent evidence and personal experience at our medical center.

Encuesta sobre el manejo perioperatorio de la hemostasia y transfusión en el trasplante hepático / Survey of hemostasis management and transfusion in liver transplantation

Objetivo. Conocer el manejo de la hemostasia y la práctica transfusional entre los anestesiólogos españoles en el ámbito del trasplante hepático. Método. Se elaboró un cuestionario dirigido a los facultativos especialistas en anestesiología y reanimación de todos los centros que realizan trasplante hepático en España. Los datos requeridos hacían referencia a los 12 meses previos a su distribución, desde el 1 de enero al 31 de diciembre de 2011. Resultados. Se recogieron datos de los 24 centros. Solo el 46% respondieron disponer de protocolos o guías de actuación para el manejo de la hemostasia. El 83% de los centros respondieron conocer el porcentaje de pacientes transfundidos, pero solo el 57% conocía la media de hemoderivados. La mitad respondió estar nada satisfecho con el manejo realizado. La tromboelastometría fue utilizada como método adicional de monitorización en el preoperatorio solo en el 8% de los centros y en un tercio durante el intraoperatorio. El 46% de los centros realizó corrección preoperatoria de los déficits de coagulación basados en test convencionales. En cuanto al consumo de hemoderivados, en el 57% de los centros la media de transfusión de concentrados de hematíes fue ≤ 4. El consumo de plasma fresco congelado fue muy variable, mientras que en el 100% de los centros se consumieron menos de 4 pools de plaquetas por paciente. Conclusiones. Existe una amplia variabilidad en el manejo de la hemostasia y en la práctica transfusional entre los centros españoles. No existen guías de manejo perioperatorio o no son utilizadas ampliamente. Las medias de hemoderivados transfundidos siguen siendo elevadas. Se aprecia un descenso en los centros que utilizan los nuevos métodos de monitorización (AU)

Objective. To determine the management of haemostasis and transfusion practice in the field of liver transplantation in Spain. Methods. A questionnaire was developed for physicians in anaesthesiology of all centres performing liver transplantation in Spain. The information required made reference to the 12 months prior to its distribution, from January 1 to December 31, 2011. Results. Data were collected from 24 centres in which liver transplantation is performed in Spain. Only 46% reported that they had protocols or practice guidelines for the management of haemostasis, and 83% of hospitals responded that they knew the percentage of transfused patients, but only 57% knew the mean transfusion. Regarding the degree of satisfaction with the management of haemostasis/coagulation, 50% said they were not satisfied. Thromboelastometry was used as an additional method of preoperative monitoring in only 8% of the centres and intra-operatively in one-third. Less than half (46%) of the centres performed preoperative correction of coagulation deficits based on conventional tests. The mean number of packed red cells used was ≤ 4 in 57% of centres. Consumption of fresh frozen plasma was highly variable, while 100% of centres consumed less than 4 pools of platelets per patient. Conclusions. There is a wide variability in the management of haemostasis and transfusion practice among Spanish centres. There are no guidelines or they are not widely used. The mean use of transfused blood products remain high. There was a decrease in centres using new methods of monitoring (AU)

¿Mejora el torniquete la supervivencia del combatiente en zonas en conflicto? / Does the tourniquet improve the survival of the fighter in conflict zones?

ANTECEDENTES: El uso de los torniquetes ha estado presente en los conflictos bélicos como elemento terapéutico para el control de la hemorragia externa en miembros, no obstante, su empleo ha estado rodeado de controversias y supersticiones, a pesar de su probada utilidad. La presente revisión evalúa los beneficios que aporta el torniquete en la atención a los heridos en los modernos conflictos bélicos. El uso pre-hospitalario del torniquete es una medida generalizada y protocolizada en el contexto militar, y está fundamentada en estudios científicos y en una experiencia clínica correspondiente al uso de estos dispositivos en ZO. OBJETIVOS: Analizar mediante la revisión de las referencias encontradas los beneficios y los inconvenientes que ofertan estos dispositivos y si realmente mejoran la supervivencia del combatiente con hemorragia externa en miembros. MATERIAL Y MÉTODOS: Revisión bibliográfica de diversos estudios clínicos efectuados en diversas Zonas de Operaciones (ZO) de los últimos once años. RESULTADOS: el análisis de diversos estudios han demostrado que el uso precoz del torniquete en el campo de batalla, supone una mejora en los ratios de supervivencia y una disminución de la morbimortalidad, del consumo de hemoderivados y por lo tanto, de los costes económicos en el tratamiento de este tipo de heridos. Esta revisión bibliográfica pretende demostrar que el empleo precoz del torniquete en ZO aumenta la supervivencia de los heridos que presentan hemorragia externa en combate

BACKGROUND: The use of tourniquets has been in the wars as a therapeutic element to control the external bleeding, however, their use has been surrounded by controversy and superstitions, despite its proven utility. This review assesses the benefits of the tourniquet in care of the wounded soldiers in modern warfare. Pre-hospital use of the tourniquet is widespread and notarized as in the military context, and is based on scientific studies and clinical experience for the use of these devices in ZO. OBJECTIVES: To analyze by reviewing the references found the benefits and drawbacks that offer these devices and whether it improves survival fighterwith external bleeding members. Material and METHOD: Literature review of several clinical studies in various combat areas of the last eleven years. RESULTS: The analysis of several studies have shown that early use of the tourniquet on the battlefield, an improvementin survival rates and decreased morbidity and mortality, consumption of blood and therefore the economic costs treatment of such injuries. This literature review aims to demonstrate that early use of tourniquet ZO increases the survival of the casualty who have external bleeding in combat

Interstitial pregnancy: a 'road map' of surgical treatment based on a systematic review of the literature.

An electronic search concerning the surgical approach in cases of interstitial pregnancy from January 2000 to May 2013 has been carried out. Fifty three studies have been retrieved and included for statistical analysis. Conservative and radical surgical treatments in 354 cases of interstitial pregnancy are extensively described. Hemostatic techniques have been reported as well as clinical criteria for the medical approach. Surgical outcome in conservative versus radical treatment were similar. When hemostatic techniques were used, lower blood losses and lower operative times were recorded. Conversion to laparotomy involved difficulties in hemostasis and the presence of persistent or multiple adhesions. Laparoscopic injection of vasopressin into the myometrium below the cornual mass was the preferred approach.

Influencia de las técnicas de hemostasia quirúrgica y la neuromonitorización intraoperatoria en la incidencia de eventos adversos en cirugía de tiroides / Hemostasis and neuromonitoring as patient safety measures in thyroid surgery

Introducción. Los efectos adversos más frecuentes tras la tiroidectomía son: la hemorragia, la parálisis del nervio laríngeo recurrente (NLR), el hipoparatiroidismo y las complicaciones de la vía aérea. Objetivos. Evaluar si las acciones de mejora introducidas han disminuido los eventos adversos centinela monitorizados tras cirugía de la glándula tiroides. Método. Estudio retrospectivo de 954 pacientes sometidos a tiroidectomía durante el periodo 1997–2011. Para la hemostasia se empleó la técnica convencional mediante ligadura con hilos y electrocoagulación mono o bipolar en el periodo A (durante los años 1997–2006); en los periodos B (durante los años 2006–2010) y C (en el año 2011) se empleó exclusivamente la tecnología Harmonic Ultracision®. La localización del NLR, en los periodos A y B se realizó mediante localización visual y en el periodo C además se utilizó neuromonitorización intraoperatoria. Resultados. Comparados los periodos A y B+C, ha resultado una reducción significativa de la incidencia de hemorragia del 1,92 al 0,24% (p = 0,007) y de las complicaciones postoperatorias en la vía aérea que precisaron traqueotomía del 1,28 al 0% (p = 0,012). La reducción de la incidencia de parálisis del NLR (del 1,32 al 0,8%; p = 0,45) y la de hipoparatiroidismo (del 1,1 al 0,6%; p = 0,42) no fueron estadísticamente significativas. El número de eventos anuales se redujo desde el periodo A (odds ratio = 3,51) hasta el C (odds ratio = 0,39). Conclusiones. Las mejoras técnicas en la hemostasia intraoperatoria y en la identificación del NLR mediante neuromonitorización incrementan la seguridad del paciente en cirugía tiroidea(AU)

Introduction. The most frequent adverse effects after thyroidectomy are hemorrhage, recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, and airway complications. Objectives. To evaluate if improvement actions introduced in thyroidectomy have an influence on monitored sentinel events after surgery of thyroid gland. Method. A retrospective study of 954 patients subjected to thyroidectomy during the period 1997 to 2011. The hemostasis techniques used were, conventional ligature and mono or bipolar electrocoagulation in period A (1997–2006), and the Harmonic Ultracision® technology was used exclusively during periods B (2006–2010) and C (2011). The identification the RLN was performed visually in periods A-B and by intraoperative neuromonitoring in period C. Results. On comparing periods A and B + C, there was a significant reduction in the incidence of bleeding from 1.92% to 0.24% (P=.007), and postoperative complications in the airway that required tracheotomy from 1.28% to 0% (P=.012). The reductions in the incidence of RLN paralysis (from 1.32% to 0.8%, P=.45) and hypoparathyroidism (from 1.1% to 0.6%, P=.42) were not statistically significant. The number of annual events decreased from period A (odds ratio=3.51) to C (odds ratio=0.39). Conclusions. Technical improvements in hemostasis, and identification of RLN, increase patient safety in thyroid surgery(AU)

[Use of ischemia in total knee arthroplasty. Is there a difference?]. / Uso de isquemia en la artroplastía total de rodilla. ¿Existe diferencia?

In Mexico, aging has become the daily routine of millions. Total Knee Arthroplasty is a procedure that is doing more and more with satisfactory results and survival of the implant up to 20 years in 90%. The tourniquet is a useful tool to the orthopedic surgeons to minimize blood loss and make the placement of implants easier, because it enhances the vision of the surgical field. We report the results of 75 total knee arthroplasties performed in January 2007 to January 2010, in terms of bleeding, duration of procedure and Haemoglobin levels with and without tourniquet, the patients were distributed in 3 different groups, In group 1 the tourniquet was kept inflated until the placement of the femoral and tibial components, in group 2 the tourniquet was kept inflated until the wound dressing and finally in group 3 we did not use tourniquet. We performed hematic biometry 24 hours after surgery and if the patient's hemoglobin was less than 9.0 g/dl or the patient had low cardiac output symptoms, regardless of hemoglobin level, blood transfusion was indicated. The results demonstrate that there significant differences between the amount of blood loss among the 3 groups (1:1.157 ml, 2:709 ml, 3:1.493 ml) and surgical time (1:100, 2:110, 3:135). So that demonstrates that tourniquet use has a direct relation to blood loss and surgical time.

[Prevention of complications after surgery in patients with upper limbs' lymphedema].

The results of surgical treatment of patients with the fourth stage of the upper limbs' lymphedema was studied. Of all 170 patients with lymphedema, 16 (9.4%) had the fourth stage of the disease. The debulking procedures were performed in 15 patients (8 had standart operations, 7 - simultaneous rwo-stage operations). Beeing a preliminary stage of the radical surgical excision of lymphoedematously changed tissues, the liposuction allows a more precisional hemostasis for the accurate vessel visualization. It led to the 4,4 times decrease of the postoperative morbidity rate and shortened the time of the operation.

Evaluation of tenoxicam on prevention of arachnoiditis in rat laminectomy model.

Post laminectomy arachnoiditis has been shown by experiments with rats and post operative radiological imaging in humans. The purpose of this experimental study was to determine the efficacy of tenoxicam in preventing arachnoiditis in rats. Twenty-four Wistar rats were divided into two groups, and L3 laminectomy was performed. In the tenoxicam group, 0.5 mg/kg tenoxicam was applied intraperitoneally. Normal saline was applied intraperitoneally in the control group. Later, the rats were killed at weeks 3 and 6, and the laminectomy sites were evaluated pathologically for arachnoiditis. The results showed that 6 weeks after surgery, the tenoxicam group showed lowest arachnoiditis grades. However, statistically significant difference was not found in arachnoiditis between the control group and the tenoxicam group. Based on these findings it is concluded that application of the tenoxicam after lumbar laminectomy did not effectively reduce arachnoiditis. Performing the most effective surgical technique without damage around tissue in a small surgical wound and having meticulous hemostasis in surgery seem to be the key for preventing arachnoiditis effectively.

[Surgical strategy for iatrogenic injuries of the spleen].

A retrospective investigation of 1226 case histories of patients operated on the stomach and duodenum was made. Organ-saving operations using laser technique were assessed. The main cause of injuries to the spleen during operation was traction of the stomach when mobilizing it. The performance of organ-saving operations for such injuries using laser technique is possible in 76% of cases.

Understanding of intra-operative tourniquets amongst orthopaedic surgeons and theatre staff--a questionnaire study.

INTRODUCTION: Pneumatic tourniquets are used frequently in orthopaedic theatres to provide a bloodless field whilst operating on the extremities. Their use has given rise to complications and preventable damage due to over-pressurisation and prolonged application. We designed a questionnaire to assess the knowledge on tourniquet use among operating department assistants (ODAs) and specialist registrars (SpRs) in orthopaedic surgery. SUBJECTS AND METHODS: A questionnaire was constructed using set guidelines from the Association of periOperative Registered Nurses (AORN) for recommended practice of tourniquet application. This was distributed to orthopaedic registrars with varying levels of experience and ODAs from five different NHS hospitals. The unpaired, two tailed t-test was used to test for statistical significance of results. RESULTS: A total of 54 completed questionnaires were collected for analysis. The study population included 29 orthopaedic SpRs and 25 ODAs. The mean score for the orthopaedic SpRs as a group was 41.3% (SD 6.85; range, 29.0-54.8%). The mean score for the ODAs was 46.7% (SD 9.64; range, 23.3-62.9%) with a P-value of 0.024. CONCLUSIONS: Most surgeons are taught how to use pneumatic tourniquets by their senior colleagues as no formal teaching is given. Most of the complications are infrequent and preventable. However, their consequences can be devastating to the patient with medicolegal implications. Our results show suboptimal knowledge of tourniquets and their use among SpRs and ODAs. This study highlights the need for amendments in training to improve the knowledge and awareness of medical practitioners on the application and use of tourniquets to prevent adverse events and improve patient safety.

Evaluation of a commercial vascular clip: risk factors and predictors of failure from in vitro studies.

OBJECTIVE: To assess risk factors and predictors of failure of the Hem-o-lok(TM) vascular clip (Weck Closure Systems, Research Triangle Park, NC, USA) using vessels harvested from a porcine model. MATERIALS AND METHODS: Vessels of various diameters were harvested from a porcine model, clipped at 90 degrees or 45 degrees using the Hem-o-lok clip and then cut either flush or with a 1-mm cuff. The vessels were then connected to a burst-pressure device and pressures required to burst the clip or to cause it to leak were measured. RESULTS: The Hem-o-lok clip leaked or burst when the vessel to which it was applied was cut flush. The clip became even more likely to fail if the angle of application of the clip was not at 90 degrees to the vessel surface. CONCLUSION: The Hem-o-lok vascular clip is safe if it is applied at 90 degrees to the vessel surface and, more importantly, if a 1-mm cuff is left between the clip and the point at which the vessel is divided. We would therefore discourage the practice of not leaving this cuff of tissue, in an attempt to maximize vessel length during laparoscopic donor nephrectomy.

Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians.

OBJECTIVE: To determine the incidence and risk factors for neurological events complicating cardiac surgery, and the implications for operative outcome in octogenarians. METHODS: Of 6791 who underwent primary on-pump CABG and/or valve surgery from 1998 through 2006, 383 were aged > or =80 years. Neurological complications, classified as reversible or permanent, were investigated by head CT scan in patients who did not recover soon after an event. RESULTS: There were more females (47% vs 26%, p<0.0001) among octogenarians (n=383, median age 82 years) than among younger patients (n=6408, median age 66 years). Controlled heart failure, NYHA class III/IV and chronic obstructive pulmonary disease were more prevalent in octogenarians while preoperative myocardial infarction was predominant in younger patients. Octogenarians were at higher operative risk (median EuroScore 6 vs 2, p<0.0001). Operative procedures differed between octogenarians and younger patients (p<0.0001); respective frequencies were 45% vs 77% for CABG, 26% vs 10% for AVR, and 23% vs 6% for AVR+CABG. Mortality was higher for octogenarians (8.9% vs 2.1, p<0.0001). Early neurological complications observed in 3.9% of the entire study population were mostly reversible (3.2%). Age > or =80 years (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.89-4.21, p<0.0001), prior cerebrovascular disease (OR 2.23, 95% CI 1.56-3.18, p<0.0001), AVR+CABG (OR 2.92, 95% CI 1.60-5.33, p<0.0001) and MVR+CABG (OR 4.77, 95% CI 2.10-10.85, p<0.0001) were predictive of neurological complications. More octogenarians experienced neurological events (p<0.0001): overall 12.8% vs 3.4%, reversible 11.5% vs 2.8%, permanent 1.3% vs 0.6%. Among octogenarians, neurological complication was associated with elevated operative mortality (18% vs 8% for those without neurological complication, p=0.03), and prolonged ventilation, intensive care stay and hospitalisation. Predictors of neurological complications in octogenarians were blood and/or blood product transfusion (OR 3.60, 95% CI 1.56-8.32, p=0.003) and NYHA class III/IV (OR 7.6, 95% CI 1.47-39.70, p=0.02). CONCLUSION: Octogenarians undergoing on-pump CABG and/or valve repair/replacement are at higher risk of neurological dysfunction, from which the majority recover fully. The adverse implications for operative mortality and morbidity, however, are profound. Blood product transfusion which has a powerful correlation with neurological complication should be reduced by rigorous haemostasis with parsimonious use of sealants when appropriate.