Methods. The literature on hemostasis as it relates to children, cardiac disease in children, and pediatric heart surgery was reviewed. We also reexamined the efficacy of several strategies in this patient population: on-site monitoring of coagulation, transfusion of fresh whole blood, and administration of desmopressin, ε-aminocaproic acid, or aprotinin.
Results. Children with heart disease may present with preoperative thrombocytopenia, reduced platelet aggregation, and a decreased level of von Willebrand factor. Infants less than 6 months of age show a significant dilution of coagulation factors and decreased platelet counts during cardiopulmonary bypass. Fresh whole blood reduces blood loss in children younger than 2 years undergoing complex operations. Desmopressin does not reduce bleeding, whereas on-site monitoring, synthetic antifibrinolytics, and aprotinin require further evaluation in pediatric cardiac surgical patients.
Conclusions. The use of fresh whole blood to reduce blood loss in children younger than 2 years undergoing complex heart operations is recommended. Therapy for excessive bleeding after cardiopulmonary bypass will vary according to the patient's age, platelet count, and activated partial thromboplastin and prothrombin times. 相似文献
Methods. Possible causes, diagnostic methods available, and therapeutic approaches are reviewed in the light of the literature published on excessive bleeding after cardiac operations.
Results. When bleeding is massive (>250 to 300 mL/h for the first 2 hours, >150 mL/h thereafter), immediate surgical reexploration is mandatory. When bleeding is less important (50 to 150 mL/h), the decision to reoperate should be based on the presence of hemodynamic compromise or a suspected surgical cause. Otherwise, coagulation testing should allow the correction of hemostatic defects as appropriate with protamine, platelet concentrates, fresh frozen plasma, desmopressin, or antifibrinolytics. Hypothermia and hypotension should be corrected and a trial of positive end-expiratory pressure may be considered if diffuse mediastinal oozing (especially from the bed of the mammary artery) is suspected.
Conclusions. A protocol is suggested to guide treatment, taking into account the rapidity of blood loss and the suspected underlying cause. 相似文献
Design: Review of rational use of heparin, mechanisms and treatment of coagulation disorders, and autologous blood transfusion.
Setting: Cardiac surgery in community and academic hospitals.
Patients: Adult cardiac surgical patients.
Main Results: Heparin is most commonly used for anticoagulation during cardiopulmonary bypass. Although activated clotting time is widely used to assess heparin-induced anticoagulation, the minimum time to prevent clotting during cardiopulmonary bypass remains unclear. Activated clotting time is affected by many factors other than heparin, such as antithrombin III, blood temperature, platelet count, and age. The rational use of activated clotting time still must be defined.
The frequency of abnormal bleeding after cardiopulmonary bypass is significant. Although inadequate surgical hemostasis is the most frequent cause of bleeding, altered coagulation often is present. A decreased number of functional platelets is one of the important causes of bleeding diathesis. Platelet dysfunction is induced by perioperative medication such as aspirin. Cardiopulmonary bypass decreases functional platelets by degranulation, fragmentation, and loss of fibrinogen receptors. Medications such as prostacyclin and iloprost may be useful to protect these platelets. Desmopressin increases factor VIII:C and von Willebrand's factor, leading to a decrease in bleeding time. Desmopressin may be useful to decrease blood loss in repeat cardiac operations, complex cardiac surgery, and abnormal postoperative bleeding.
Patients undergoing coronary artery bypass grafting immediately after streptokinase infusion also are at risk for abnormal bleeding. Transfusion of fresh frozen plasma and cryoprecipitate may be necessary.
Autologous blood transfusion is cost-effective and the safest way to avoid or decrease homologous blood transfusion. Predonation, intraoperative salvage, and postoperative salvage are encouraged. Erthroprotein may be useful in increasing the amount of predonation red cells.
Conclusions: Coagulation disorders in cardiac surgery are caused by many factors, such as heparin, platelet dysfunction, and fibronolysis. Rational use of blood component therapy and medications such as heparin, protamine, and desmorpessin are mandatory. Autologous blood transfusions is very useful in decreasing or obviating the use of homologous blood transfusion. 相似文献
Methods. Patients undergoing operations using cardiopulmonary bypass and ABO blood group compatible volunteers were studied. Whole blood impedance aggregometry assessed macroaggregation in response to collagen (0.6 μg ml−1) in blood diluted either with normal saline or with platelet poor plasma, obtained from patients at different stages of cardiopulmonary bypass.
Results. Before heparinization, blood diluted with its own platelet poor plasma recorded an impedance change of 13.0 (4.7 to 15.6) Ohms. Platelet poor plasma obtained after heparinization or during extracorporeal circulation reduced this response to 3.7 (1.1 to 8.4) and 2.0 (1.1 to 3.3) Ohms, respectively (both p < 0.0001 versus pre-heparin; n = 13). Macroaggregation in blood from volunteers was similarly inhibited by patients’ platelet poor plasma (n = 30). The macroaggregatory response in blood sampled after heparinization for cardiopulmonary bypass, decreased gradually from 11.4 (8.2 to 15.9) Ohms immediately after sampling to 1.7 (1.4 to 4.1) Ohms 2 hours later (p < 0.0001; n = 11).
Conclusions. In vivo heparinization induces plasma changes that inhibit platelet macroaggregation. This is an indirect, delayed inhibition that is transferable in vitro to normal platelets. 相似文献
Methods. A review of tissue glue use for the period from January 1993 to September 1998 was performed and pre-, intra-, and postoperative parameters were collected. After some unusual surgical findings, of special interest was a range of pathology found at late reoperation.
Results. A total of 67 cases of tissue glue use were identified, with the majority of operations for type A dissection (76%). There were two intraoperative deaths. Twenty-seven of 65 patients (41%) required 29 further open chest operations; of these, 17 were for acute problems of bleeding or tamponade. Twelve patients (18%) underwent late reoperations months to years later. Nine of these patients, concentrated in two operative groups (7 patients with aortic valve resuspension and 2 patients who had undergone “switch” operations for transposition of great vessels), displayed complications related to the application of gelatin-resorcinol-formaldehyde (GRF) tissue glue.
Conclusions. Indications for tissue glues in cardiothoracic surgery must be carefully considered. We have reviewed our use of some tissue glues in acute type A aortic dissections and in pediatric cardiac patients and have discontinued the use of GRF glues because of unsatisfactory long-term complications. 相似文献
Methods. The diameters at four levels of the aorta were measured in 36 patients who had undergone arterial switch operation and the distensibilities were calculated. The data were compared with that of age-matched controls.
Results. At the level of the Valsalva sinus, aortic diameters after one-staged and two-staged operations were 137.0% ± 21.3%N and 152.4% ± 17.7%N of the normal aorta, respectively. The distensibilities at the Valsalva sinus in patients after one-staged and two-staged operations were 1.2 ± 0.7 and 1.5 ± 0.8 cm2 · dyn−1 · 10−6, and at the supraaortic ridge were 2.5 ± 1.5 and 1.9 ± 1.5 cm2 · dyn−1 · 10−6, respectively.
Conclusions. In patients after arterial switch procedure, the distensibility of the base of aorta is decreased. Long-term follow-up is necessary to clarify the influence of the “stiffness” of the base of aorta. 相似文献
Methods. One hundred patients undergoing coronary grafting were randomized in two groups: control group (n = 50) and test group (n = 50, surface modifying additives circuit, SMA group). Blood samples were taken before, during, and after CPB. Postoperative blood loss, number of transfused blood products, and postoperative variables were recorded.
Results. The platelet count decreased less in the SMA group compared to the control group (end of CPB: respectively, 165 ± 9 × 103/mm3 vs 137 ± 8 × 103/mm3; p < 0.01). This was paralleled by a reduction in β-thromboglobulin plasma levels in the SMA group. There was a trend to decreased blood loss in the SMA group, but the difference was significant only in patients taking aspirin preoperatively (p < 0.05). In the SMA group nearly 50% less fresh frozen plasma and platelet units were administered (p < 0.01). No operative deaths were observed.
Conclusions. The use of circuits with surface additives is clinically safe, preserves platelet levels, and attenuates platelet activation. This may lead to a reduced need for blood products. 相似文献
Methods. The literature on preoperative coagulation testing was reexamined, taking into account the low prevalence of unknown and unsuspected hemorrhagic disease, and the risk of false positive results.
Results. Carefully controlled, randomized trials are lacking but it seems appropriate to perform a few inexpensive tests (platelet count, activated partial thromboplastin time, and prothrombin time), mainly to obtain baseline values for patients who are about to undergo a major hemostatic challenge. A more complete coagulation profile (eg, bleeding time, fibrinogen concentration, thrombin time) should be considered in patients who present with a history of bleeding.
Conclusions. A careful medical history is the key element to detect a bleeding disorder. Only a very limited coagulation profile should be obtained in asymptomatic patients before cardiac operations. 相似文献
Methods. We have developed and applied flow cytometric assays for activated platelets, platelet microaggregates, and platelet life span and consumption to calves implanted with an axial flow VAD and calves undergoing a sham surgical procedure.
Results. Surgical sham calves had significant increases in circulating activated platelets (p < 0.05) that resolved within 17 days, and no increases in circulating platelet microaggregates. Calves with uneventful VAD implant periods had early transient elevations in platelet microaggregates and prolonged elevations in activated platelets that did not recover to preoperative values during the study. Daily platelet consumption in VAD implanted calves was increased by 20% ± 3%. Calves with thrombotic deposition within the VAD and elevated thromboembolism observed at autopsy experienced increases in circulating activated platelets and microaggregates at the end of the implant period when VAD flow decreased.
Conclusions. This study demonstrates the ability of flow cytometry-based platelet assays to differentiate VAD implant operations from VAD support, and suggests differences that exist between uneventful VAD support and support with complications. These techniques should have value in evaluating other cardiovascular devices undergoing preclinical testing and provide insight into the temporal impact of these devices on the hemostatic system. 相似文献
Methods. The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement.
Results. This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation.
Conclusions. The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first. 相似文献
Methods. Blood conservation methods were reviewed in chronologic order, as they become available to patients during the perisurgical period. The literature in support of or against each strategy was reexamined critically.
Results. Avoidance of preoperative anemia and adherence to published guidelines for the practice of transfusion are of paramount importance. Intraoperatively, tolerance of low hemoglobin concentrations and use of autologous blood (predonated or harvested before bypass) will reduce allogeneic transfusions. The usefulness of plateletpheresis and retransfusion of shed mediastinal fluid remains controversial. Intraoperatively and postoperatively, maintenance of normothermia contributes to improved hemostasis.
Conclusions. Several approaches have been shown to be effective. An efficient combination of methods can reduce, and sometimes abolish, the need for allogeneic blood products after cardiac operations, inasmuch as all those involved in the care of cardiac surgical patients adhere thoughtfully to existing transfusion guidelines. 相似文献
Methods. Articles published between 1976 and 1996 on the preoperative assessment of surgical patients were reviewed to determine the clinical elements most likely to predict increased perioperative blood requirements.
Results. Preoperative assessment is based on a carefully conducted interview (history of bruising, petechiae, recent or excessive bleeding after operation, chronic drug therapy) and physical examination. A standardized questionnaire to enhance the reliability of the assessment is presented. Thus, patients at high risk of being transfused can be identified early on and may be enrolled in various programs designed to decrease bleeding and the need for allogeneic blood transfusions.
Conclusions. Clinical assessment of hemostatic function before cardiac operations is both effective and efficient. It obviates the need for routine laboratory testing and favors the introduction of blood conservation strategies early on during the process of care. 相似文献
Methods. This experiment was designed to study the optimal dose of glucose and its effect on function during warm arrest. Isolated, retrograde-perfused rabbit hearts received multidose cardioplegia containing increasing concentrations of glucose, from 0 to 88 mmol/L, and underwent 120 minutes of “warm” 34°C global ischemia. Osmolarities were adjusted equivalently.
Results. After 34°C ischemia, hearts treated with 5 to 88 mmol/L glucose showed significantly better functional recovery than those treated with 0 to 1 mmol/L glucose. However, the addition of 22 mmol/L glucose demonstrated optimal recovery with no further incremental enhancement with more glucose. Additional hearts receiving 0 or 22 mmol/L glucose had high-energy phosphates, lactate, CO2, and pH measured. The 22 mmol/L glucose hearts demonstrated active metabolism and significantly better recovery of high-energy phosphate levels than controls.
Conclusions. Increasing glucose level modestly during warm arrest enhanced recovery, but profound hyperglycemia did not incrementally improve this effect, mandating a cautious use of glucose. 相似文献
Methods. A case-control retrospective study covering a 4.5-year period was conducted to determine risk factors for pharyngeal dysfunction resulting in silent aspiration.
Results. Significant predictors of silent aspiration were age, history of cerebral vascular disease, insulin-dependent diabetes mellitus, myocardial infarction, and chronic obstructive pulmonary disease. Intraaortic balloon pump and number of units of fresh-frozen plasma were the only independent intraoperative factors associated with silent aspiration in a model using continuous variables directly. Cold fibrillation was used in 7 of 53 study cases but no control patients, so it could not be modeled. Postoperative complications occurring with greater frequency included neurologic complications, adverse pulmonary outcomes, repeat surgical interventions, infection, and death. Using an Aspiration Risk Profile developed from the retrospective study, in a detailed prospective study of 10 patients, 3 of 4 patients with postoperative dysphagia had objective evidence of stroke.
Conclusions. These findings suggest that postoperative coronary artery bypass graft dysphagia may be the result of intraoperative cerebral injury, and that careful postoperative clinical evaluation of coronary artery bypass graft patients with risk factors may result in early diagnosis of pharyngeal dysfunction with the goals of preventing silent aspiration and reducing morbidity, mortality, and hospital cost. 相似文献
Design: Randomized, single-blind study.
Setting: University hospital outpatient surgery center.
Patients: 61 ASA physical status I and II, healthy female outpatients undergoing laparoscopic surgery.
Interventions: Patients were randomly assigned to one of three anesthetic regimes. Group 1 (control) received thiopental sodium 4 mg/kg intravenously (IV), followed by 0.5% to 1.5% enfurane and 67% N20 in oxygen (O2). Group 2 received propofol 2 mg/kg IV, followed by 0.5% to 1.5% enfurane and 67% N2O in O2. Group 3 received propofol 2 mg/kg IV, followed by propofol 50 to 160 μg/kg/min IV and 67% N2O in O2. All patients received succinylcholine 1 mglkg IV to facilitate tracheal intubation and atracurium 10 to 20 mg IV to provide adequate relaxation during the maintenance period.
Measurements and Main Results: Recovery from anesthesia was assessed by a research nurse who was unaware of the anesthetic technique used. The mean ± SD time to eye opening was significantly longer in the thiopental-enflurane-N2O group (Group 1) than in the propofol-propofol-N20 group (Group 3) (6.1 ± 2.5 minutes vs. 3.5 ± 2.8 minutes, respectively). In addition, the mean time to respond to verbal commands was significantly shorter in the propofol induction groups compared with the thiopental induction group. However, the use of enfurane versus propofol for maintenance of anesthesia did not significantly prolong the time from arrival in the recovery room to sitting, tolerating oral fluids, walking, or being judged “fit for discharge.” There were no differences among the three groups with respect to postoperative pain or analgesic requirements. Finally, patients who received enfurane for maintenance of anesthesia had a significantly higher frequency of nausea and vomiting than the propofol maintenance group.
Conclusion: Induction of anesthesia with propofol is associated with a more rapid emergence from anesthesia than induction with thiopental. Maintenance of anesthesia with enfurane did not prolong recovery compared with maintenance with propofol, but enfurane was associated with increased frequency of postoperative nausea and vomiting. 相似文献