Treatment of massive endobronchial hemorrhage after cardiopulmonary bypass by selective coil embolization of the bronchial artery

A 68-year-old woman underwent aortic valve replacement to treat her aortic regurgitation. The operation was performed successfully. Just before coming off cardiopulmonary bypass, massive hemorrhage occurred through the endotracheal tube. Fiberoptic bronchoscopy could not find the bleeding site and 1,350 ml of blood had been lost. Bronchial angiography under percutaneous cardiopulmonary bypass revealed the right middle branch to be the bleeding site. The endotrachial bleeding was treated successfully by selective coil embolization of the bronchial artery. No further bronchial bleeding occurred. Although we found the bleeding site, we could not identify the cause of hemorrhage.     

Treatment of cardiac compression after cardiopulmonary bypass

A diversity of techniques for delayed closure of the sternum have been advocated for management of hypotension due to cardiac compression after cardiopulmonary bypass. A simple technique utilizing materials readily available in any operating room has been described. It provides for expansion of the cardiac space and sterile coverage of the mediastinum when the skin cannot be approximated.     

Inhaled iloprost controls pulmonary hypertension after cardiopulmonary bypass

PURPOSE: Severe pulmonary hypertension (PH) is a major cause of right ventricular (RV) dysfunction. Various iv vasodilator modalities have been used with limited results because of lack of pulmonary selectivity. The aim of the present controlled study was to evaluate the efficacy of inhaled iloprost, a synthetic prostacyclin analogue, in patients with elevated pulmonary vascular resistance (PVR) immediately after separation from cardiopulmonary bypass (CPB). METHODS: Twelve patients with persistent PH after discontinuation of CPB were included in the study. In all patients standard hemodynamic monitoring was used. Inhaled iloprost was administered via nebulized aerosol at a cumulative dose of 0.2 micro g*kg(-1) for a total duration of 20 min. Complete sets of hemodynamic measurements were performed before inhalation (baseline), during and after cessation of the inhalation period. Echocardiographic monitoring of RV function was also used. RESULTS: Inhaled iloprost induced a reduction in the transpulmonary gradient at the end of the inhalation period in comparison to baseline (9.33 +/- 3.83 mmHg vs 17.09 +/- 6.41 mmHg, P < 0.05). The mean pulmonary artery pressure to systemic artery pressure ratio decreased over this period (0.28 +/- 0.08 vs 0.45 +/- 0.17, P < 0.05). A statistically significant decrease of the PVR to systemic vascular resistance ratio was also observed (0.15 +/- 0.05 vs 0.21 +/- 0.05, P < 0.05). Improved indices of RV function were observed in echocardiographic monitoring. CONCLUSION: Inhaled iloprost appears to be a selective pulmonary vasodilator and may be effective in the initial treatment of PH and the improvement of RV performance in the perioperative setting.     

Effects of ischemia on pulmonary dysfunction after cardiopulmonary bypass

BACKGROUND: Pulmonary hypertension and lung injury secondary to cardiopulmonary bypass (CPB) are probably caused by a combination of ischemia and inflammation. This study was undertaken to investigate the potential ischemic effects of cessation of pulmonary arterial flow during CPB on pulmonary injury. METHODS: Twenty neonatal piglets (2.5 to 3.1 kg) were randomly assigned to two groups. Group A (n = 10) underwent 90 minutes of CPB at full flow (100 mL x kg(-1) x min(-1)) and clamping of the main pulmonary artery (PA). Group B (n = 10) underwent 90 minutes of partial CPB (66 mL x kg(-1) x min(-1)) with continued mechanical ventilation and without clamping of the PA. All hearts were instrumented with micromanometers and a PA ultrasonic flow probe. Endothelial function was assessed by measuring endothelial-dependent relaxation (measured by change in pulmonary vascular resistance after PA infusion of acetylcholine) and endothelial-independent relaxation (measured by change in pulmonary vascular resistance after ventilator infusion of nitric oxide and PA infusion of sodium nitroprusside). RESULTS: All groups exhibited signs of pulmonary injury after CPB as evidenced by significantly increased pulmonary vascular resistance, increased alveolar-arterial O2 gradients, and decreased pulmonary compliance (p<0.05); however, pulmonary injury was significantly worse in group A (p<0.05). CONCLUSIONS: This study suggests that although exposure to CPB alone is enough to cause pulmonary injury, cessation of PA flow during CPB contributes significantly to this pulmonary dysfunction.     

球囊临时阻断髂总动脉控制陈旧性骨盆骨折术中出血

目的 探讨球囊临时阻断髂总动脉控制陈旧性骨盆骨折术中出血的临床应用.方法 2006年1月至2009年6月,手术治疗12例Tile C型陈旧性骨盆骨折患者,男10例,女2例;年龄22～45岁,平均33.9岁.3例使用外固定架固定;9例因救治内脏损伤而贻误早期骨科手术,其中6例骨折未骨性愈合,3例骨折已畸形愈合.术中通过血...     

Increased pulmonary artery diastolicpulmonary wedge pressure gradient after cardiopulmonary bypass

In 29 patients undergoing elective coronary artery bypass grafting, the diastolic pulmonary arterial pressurepulmonary capillary wedge pressure gradient (DPAP-PCWP) and related haemodynamic parameters were determined before and after induction of anaesthesia, immediately after cardiopulmonary bypass (CPB) and one and three hours after CPB. The DPAP-PCWP gradient remained unchanged after induction of anaesthesia but was significantly increased after CPB. A gradient of 5 mmHg or greater was observed in 16 patients after CPB, whereas none of the patients showed such a gradient before CPB. A significant correlation was found between the change in DPAP-PCWP and the change in pulmonary vascular resistance (PVR). It is concluded that DPAP should not be used as a substitute of PCWP in the early postbypass period without frequent confirmation of the presence of the normal small DPAP-PCWP gradient. Since an increase of PVR may impair right ventricular ejection, we recommend the routine measurement of DPAP-PCWP gradient in the postbypass period.     

Increased pulmonary artery diastolic-pulmonary wedge pressure gradient after cardiopulmonary bypass

In 29 patients undergoing elective coronary artery bypass grafting, the diastolic pulmonary arterial pressure-pulmonary capillary wedge pressure gradient (DPAP-PCWP) and related haemodynamic parameters were determined before and after induction of anaesthesia, immediately after cardiopulmonary bypass (CPB) and one and three hours after CPB. The DPAP-PCWP gradient remained unchanged after induction of anaesthesia but was significantly increased after CPB. A gradient of 5 mmHg or greater was observed in 16 patients after CPB, whereas none of the patients showed such a gradient before CPB. A significant correlation was found between the change in DPAP-PCWP and the change in pulmonary vascular resistance (PVR). It is concluded that DPAP should not be used as a substitute of PCWP in the early postbypass period without frequent confirmation of the presence of the normal small DPAP-PCWP gradient. Since an increase of PVR may impair right ventricular ejection, we recommend the routine measurement of DPAP-PCWP gradient in the postbypass period.     

体外循环下肺动脉栓塞的外科治疗

目的 探讨体外循环下肺动脉切开取栓和肺动脉内膜剥脱术治疗慢性肺动脉栓塞的方法、围术期处理经验，以提高慢性肺动脉栓塞外科治疗的安全性。方法 全组12例慢性肺动脉栓塞患者均在浅低温体外循环心跳中切开肺动脉取栓及肺动脉内膜剥脱术。结果 全组12例无一例近期死亡，其中1例活检为平滑肌肉瘤，术后化疗，2年后复查元复发，其余11例均为血栓，术后临床症状减轻，活动能力明显提高。结论 体外循环下肺动脉切开取栓和内膜剥脱术是治疗慢性肺动脉栓塞的安全、有效的方法。     

Protective effect of antioxidants on pulmonary endothelial function after cardiopulmonary bypass

OBJECTIVES: Pulmonary endothelium-dependent vasodilation is impaired after cardiopulmonary bypass. One explanation might be the generation of reactive oxygen species during the period without flow in the pulmonary artery. The aim of the current study was to investigate if treatment with antioxidants could improve pulmonary endothelial function after cardiopulmonary bypass and influence the blood oxidative status. DESIGN: A prospective, randomized, double-blind study. SETTING: The operating room, intensive care unit, and the biochemistry laboratory in University Hospitals. PARTICIPANTS: Patients scheduled for cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Treatment with vitamin E, vitamin C, allopurinol, and acetylcysteine (n = 12) or placebo (n = 10). MEASUREMENTS AND MAIN RESULTS: The pulmonary reactivity to an infusion of acetylcholine and markers of oxidative stress in blood were measured before and after cardiopulmonary bypass. Sixteen control patients received saline instead of acetylcholine. Before surgery the pulmonary vascular resistance index decreased during infusion of acetylcholine by 24% and 21% in the treatment and placebo groups. After surgery the decrease was 20% and 8%, respectively, (p = 0.422 and p = 0.026) compared with preoperative response. Pulmonary vasodilation induced by acetylcholine was better maintained in the group treated with antioxidants (p = 0.048). In the treatment group, the blood concentrations of early intermediates of lipid peroxidation were higher, but not that of the end products. Glutathione and oxidized glutathione increased after cardiopulmonary bypass in the treatment group. CONCLUSION: The better maintained endothelium-dependent vasodilation after cardiopulmonary bypass in the treatment group indicated that antioxidant therapy reduced endothelial dysfunction.     

The preoperative bleeding time as a predictor of postoperative hemorrhage after cardiopulmonary bypass

To determine whether the preoperative bleeding time, the most reliable indicator of in vivo platelet dysfunction, can prognosticate excessive postoperative hemorrhage and, hence, the need for infusion of platelet concentrations, we studied blood loss versus bleeding time in 43 patients undergoing coronary bypass grafting. There was no correlation between bleeding time and either fall in hemoglobin level (r = 0.04) or chest tube drainage (r = 0.004). In addition, bleeding time did not correlate with the number of units of platelet concentrate (r = 0.12) or packed red cells (r = 0.2) infused. The bleeding time, which has been recommended as an essential screening test before all cardiopulmonary bypass procedures, need not be performed as a preoperative screen in otherwise healthy patients with no history of bleeding abnormalities and a normal coagulation profile.     

Use of high-frequency ventilation to wean off cardiopulmonary bypass in a patient with pulmonary hemorrhage after failure of conventional ventilation

The management of an infant who underwent corrective surgery for a supracardiac total anomalous pulmonary venous drainage, which was complicated by the development of pulmonary hemorrhage while separating from cardiopulmonary bypass, is presented. Initiation of high-frequency oscillatory ventilation was effective in weaning the patient off cardiopulmonary bypass.     

婴儿深低温体外循环术后肺表面活性物质的变化

目的 比较婴儿先天性心脏病在深低温停循环(DHCA)或深低温低流量(DHLF)下行心内直视手术后肺表面活性物质(PS)活性水平的变化. 方法 根据采用的体外循环(CPB)方法不同,将20例室间隔缺损伴肺动脉高压的婴儿分为DHCA组和DHLF组,每组10例.测定CPB前,CPB结束5分钟和2小时时PS活性水平的饱和卵磷脂/总磷脂(SatPC/TPL)和饱和卵磷脂/总蛋白(SatPC/TP)值和肺静态顺应性. 结果 DHLF组术后住ICU时间明显长于DHCA组(P<0.05), DHLF组术后SatPC/TPL、SatPC/TP和肺静态顺应性下降的幅度均明显大于DHCA组(P<0.01). 结论 DHLF较DHCA更能引起PS活性水平的降低,从而引起更严重的肺损伤.     

No effect of L-arginine supplementation on pulmonary endothelial dysfunction after cardiopulmonary bypass

BACKGROUND: Acetylcholine is an endothelium-dependent vasodilator through the L-arginine-nitric oxide pathway. After ischemia-reperfusion this effect is attenuated, also demonstrated in the pulmonary circulation after cardiopulmonary bypass. Administration of L-arginine has been shown to have a protective effect on endothelial function in reperfusion injury. The aim of the current study was to test the possible effect of L-arginine on the acetylcholine reactivity in the pulmonary circulation after cardiopulmonary bypass. METHODS: Thirty-five patients with ischemic and/or valvular heart disease were investigated in a randomized, double-blinded, placebo-controlled study. The patients were divided into three groups. Group 1: high dose L-arginine (n=10), group 2: low dose L-arginine (n=10), group 3: placebo, no L-arginine, (n=15). The acetylcholine reactivity was tested with measurements of pulmonary vascular resistance before surgery and 1, 2 and 3-4 h after cardiopulmonary bypass. RESULTS: After cardiopulmonary bypass an attenuation of the acetylcholine reactivity over time was observed in all groups, with no differences between groups. CONCLUSION: In the current study L-arginine had no protective effect on the pulmonary endothelium after cardiopulmonary bypass, measured as reactivity to an infusion of acetylcholine.     

Effect of respiratory care on pulmonary function in patients after cardiopulmonary bypass

BACKGROUND: Respiratory failure after cardiopulmonary bypass (CPB) remains one of the major complications after cardiac surgery. This study was designed to evaluate effects of respiratory care after CPB on pulmonary function. METHODS: Eighteen patients scheduled for cardiac surgery were investigated. Preoperative respiratory functions (%VC, FEV1.0%, V25/Ht, FRC-CC, deltaN2) were measured in all the patients. Both induction and maintenance of anesthesia were performed using propofol, midazolam, fentanyl, and vecuronium bromide. All the patients were ventilated using volume controlled ventilation by setting FIO2 at 0.5, the respiratory frequency at 15 x min(-1), the tidal volume at 6-10 ml x kg(-1) adjusted to maintain PaCO2 between 30 to 40 mmHg, and the peak airway pressures below 40 cmH2O, PEEP of 0 cmH2O. From 1 hour after the operation, the patients were randomly divided into 2 groups: group A, ventilated artificially with PEEP of 5 cmH2O and group B, ventilated with PEEP adjusted to the patient's lower inflection point (LIP) obtained by the pressure-volume curve. PaO2, Qs/Qt and FRC were measured after induction of anesthesia, just after surgery, 1 hour after surgery and 1 hour after artificial ventilation with PEEP. The values of the LIP were obtained from the P-V curves with the constant-flow methods before and after surgery. RESULTS: PaO2 and FRC decreased and Qs/Qt increased significantly after the surgery in all the patients. One hour after artificial ventilation with PEEP, PaO2 increased and Qs/Qt decreased significantly compared with the values after operation. However, there was no significant difference in the magnitude of these changes among the different groups. The changes in PaO2 and Qs/Qt were not correlated with the changes in FRC and preoperative respiratory functions. The LIP tended to increase after surgery in 2 groups. CONCLUSIONS: Although pulmonary function deteriorated after CPB. PEEP could improve oxygenation in all the patients. There were no significant differences in the degree of these improvements between patients receiving PEEP of 5 cmH2O and patients with PEEP adjusted to their LIP. There was no significant relationship between preoperative pulmonary function and changes in oxygenation after CPB.     

Benefits of combined balloon pumping and percutaneous cardiopulmonary bypass.

Sixteen patients (2 women, 14 men) aged 29 to 72 years with continued cardiogenic shock during intraaortic balloon pumping (IABP) had additional treatment with percutaneous cardiopulmonary bypass (PBY). Cause of cardiogenic shock was myocardial infarction in 7 (3 survived), failed percutaneous transluminal coronary angioplasty requiring emergency coronary artery bypass grafting in 5, postoperative aortic valve replacement in 1, postoperative emergency coronary artery bypass grafting in 1, after cardiac transplantation in 1, and bridging to transplantation in 1. Mean blood pressure with PBY and IABP combined was 75 mm Hg versus 60 mm Hg with IABP off. Percutaneous cardiopulmonary bypass flows ranged from 0.8 to 2.1 L/min with a mean flow of 1.3 L/min. Time on IABP ranged from 24 hours to 1 week. Time on IABP to PBY ranged from 1 to 20 hours, and time on PBY ranged from 65 minutes to 20 hours. Ten of 16 (63%) were successfully weaned, and 3 died after weaning. Seven of 16 (44%) survive. Combined IABP with PBY appears to be a better therapy than either one individually. Staging the therapy as the balloon first in and last out appears to be a good methodology.     

Non-A, non-B posttransfusion hepatitis after cardiopulmonary bypass

One hundred and eight patients who required transfusion during and after cardiopulmonary bypass, and were followed for more than three months postoperatively. Non-A, non-B posttransfusion hepatitis (NANB-PTH) occurred in 19 patients (17.6%) between three and twelve weeks after the operation. The patients who developed NANB-PTH had received a large amount of blood transfusion than those who had not (24 +/- 12 Units versus 16 +/- 10 Units, p less than 0.05). The mean age of the former was 48 +/- 18 year-old and that of the latter was 33 +/- 24 year-old (p less than 0.05). The difference of the cardiopulmonary bypass time between them was not significant. The mean age and number of transfused blood units between the male and female patients were statistically not significant. However the incidence of NANB-PTH in male (13 of 54 patients, 24.1%) was higher than that (5 of 54 patients, 9.3%) in female (p less than 0.05).