[The process of integrating oncology nurse navigators into joint (hospital-community) local teams]. / Processus d'implantation d'infirmières pivots en oncologie au sein d'equipes locales conjointes (Centre hospitalier-Communauté).

Implementing oncology nurse navigators or IPOs (which stands for "infirmière pivot en oncologie") is a key element of the Québec Cancer Control Program in order to improve the continuity of care. This qualitative study describes the process of implementing IPOs in teams working both in hospitals and in the community. Several groups of stakeholders (IPOs, physicians, nurses, various health workers, administrators, people with cancer and their families) described how they perceive the functions and effects related to this implementation. After putting results into perspective, we recommend developing measures promoting the dissemination of the role and integration of IPOs in formally defined health teams. We strongly advocate for the continuation of joint efforts in order to define and clarify this complex role.

Preoperative autologous blood donation reduces the need for allogeneic blood products: a prospective randomized study.

OBJECTIVE: We sought to assess the efficacy of preoperative autologous blood donation in reducing patient exposure to allogeneic blood products following elective cardiac surgery. METHODS: We included 48 patients in a prospective study and randomly assigned them into the control or treatment group. We excluded patients with aortic stenosis, main trunk stenosis and unstable angina. Group A (n=23; coronary disease n=21 and valvular disease n=2) was the control group, and group B (n=25; coronary disease n=21, valvular disease n=4) received preoperative autologous blood donation. All patients had cardiopulmonary bypass surgery, and we processed mediastinal blood with a cell-saver device before reinfusion. All patients received aprotinin, and we reinfused blood shed from the mediastinum postoperatively. RESULTS: No major peri- or postoperative complications occurred. We interrupted preoperative blood donation in 2 patients (8%) because of worsened angina pectoris. The mean time between the first blood donation and surgery was 22.5 (standard deviation [SD] 9.4, range 12-50) days. In group A, 9 patients (39.1%) were exposed to allogeneic blood products. In group B, 11 patients (47.8%) were exposed to blood products (p=0.73), and 4 (16%) were exposed to allogeneic blood products (p=0.036). CONCLUSION: Preoperative blood donation was completed in 92% of the targeted low-risk population. The procedure significantly reduced exposure to perioperative allogeneic blood products.

Safety and efficiency of recombinant activated factor VII in postcardiotomy massive hemorrhage.

Postoperative massive hemorrhage is a difficult clinical situation after cardiac surgery. Recombinant activated factor VII (rf-VIIa) can be a useful adjunct to surgical hemostasis and blood product transfusion. Four cases of massive hemorrhage treated with rf-VIIa after complex cardiac surgery are reported. A review of the literature and possible guidelines for the use of rf-VIIa in cardiac surgery are provided.

Heparin versus danaparoid in off-pump coronary bypass grafting: results of a prospective randomized clinical trial.

OBJECTIVE: The incidence of heparin-induced thrombocytopenia is increasing, and the thrombin inhibitor danaparoid could be a useful alternative. The objective of the present study was to compare danaparoid and heparin in patients undergoing off-pump coronary artery bypass grafting. METHODS: In a prospective, randomized, double-blind clinical trial comparing heparin (bolus of 1 mg/kg) with danaparoid (bolus of 40 U/kg), 71 patients underwent off-pump coronary artery bypass grafting with one of the study drugs. The amount of blood lost, the number of homologous blood products transfused, the troponin T levels, and the amount of anti-Xa activity were monitored. RESULTS: Thirty-four patients underwent 2.6 +/- 0.7 bypasses with danaparoid, and 37 patients underwent 2.5 +/- 0.9 grafts with heparin (P =.8). Postoperative blood losses averaged 1394 +/- 1033 mL in patients receiving danaparoid and 1130 +/- 868 mL in patients receiving heparin (P =.2). The number of homologous blood products transfused averaged 3.6 +/- 7 units in patients receiving danaparoid and 1.9 +/- 4.4 units in patients receiving heparin (P =.2). The number of patients requiring homologous blood transfusion was higher in patients receiving danaparoid (18/34 [53%]) than in patients receiving heparin (10/37 [27%], P =.03). Serum anti-Xa activity averaged 1.6 +/- 0.6 U/mL in patients receiving danaparoid and 1.9 +/- 0.8 U/mL in patients receiving heparin 30 minutes after injection of the drugs (P =.1) and 0.3 +/- 0.1 and 0.04 +/- 0.08 U/mL, respectively, 12 hours after coronary artery bypass grafting (P =.001). Troponin serum levels were similar 48 hours after coronary artery bypass grafting (0.5 +/- 0.6 and 0.4 +/- 0.6 microg/L, respectively). CONCLUSION: Although off-pump coronary artery bypass grafting with danaparoid versus heparin increases the number of patients exposed to homologous blood transfusion (relative risk, 2; 95% confidence limits, 1-4), off-pump coronary artery bypass grafting with danaparoid is a valuable alternative to heparin in patients with thrombocytopenia requiring surgical intervention.

Inhaled epoprostenol (prostacyclin) and pulmonary hypertension before cardiac surgery.

OBJECTIVE: Pulmonary hypertension is commonly found in patients undergoing valvular surgery and can be worsened by cardiopulmonary bypass. Inhaled epoprostenol (prostacyclin) has been used for the treatment of pulmonary hypertension, but its effects compared with those of placebo on hemodynamics, oxygenation, echocardiographic examination, and platelet function have not been studied during cardiac surgery. METHODS: Twenty patients with pulmonary hypertension undergoing cardiac surgery were randomized in a double-blind study to receive inhaled epoprostenol (60 microg) or placebo. The inhalation occurred after induction of anesthesia and before surgical incision. The effects on left and right systolic and diastolic cardiac functions evaluated by means of pulmonary artery catheterization and transesophageal echocardiography, as well as oxygenation and platelet aggregation, were studied. RESULTS: Inhalation of epoprostenol significantly reduced indexed right ventricular stroke work from 10.7 +/- 4.57 g. m. m(-2) to 7.8 +/- 3.94 g. m. m(-2) (P =.003) and systolic pulmonary artery pressure from 48.4 +/- 18 mm Hg to 38.9 +/- 11.9 mm Hg (P =.002). The effect was correlated with the severity of pulmonary hypertension (r = 0.76, P =.01) and was no longer apparent after 25 minutes. There was no significant effect on systemic arterial pressures, left ventricular function, arterial oxygenation, platelet aggregation, and surgical blood loss. CONCLUSION: Inhaled epoprostenol reduces pulmonary pressure and improves right ventricular stroke work in patients with pulmonary hypertension undergoing cardiac surgery. A dose of 60 microg is hemodynamically safe, and its effect is completely reversed after 25 minutes. We did not observe any evidence of platelet dysfunction or an increase in surgical bleeding after administration of inhaled epoprostenol.