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William J Gaynor - One of the best experts on this subject based on the ideXlab platform.
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variation in perioperative care across centers for infants undergoing the norwood procedure
The Journal of Thoracic and Cardiovascular Surgery, 2012Co-Authors: Sara K Pasquali, William J Gaynor, Richard G Ohye, Jonathan R Kaltman, Christopher A Caldarone, Christian Pizarro, Carolyn Dunbarmasterson, Jeffrey P Jacobs, Aditya K Kaza, Jane W NewburgerAbstract:Objectives In the Single Ventricle Reconstruction trial, infants undergoing the Norwood procedure were randomly allocated to undergo a right ventricle-to-pulmonary artery shunt or a Modified Blalock-Taussig shunt. Apart from shunt type, subjects received the local standard of care. We evaluated variation in perioperative care during the Norwood hospitalization across 14 trial sites. Methods Data on preoperative, operative, and postoperative variables for 546 enrolled subjects who underwent the Norwood procedure were collected prospectively on standardized case report forms, and variation across the centers was described. Results Gestational age, birth weight, and proportion with hypoplastic left heart syndrome were similar across sites. In contrast, all recorded variables related to preoperative care varied across centers, including fetal diagnosis (range, 55%-85%), preoperative intubation (range, 29%-91%), and enteral feeding. Perioperative and operative factors were also variable across sites, including median total support time (range, 74-189 minutes) and other perfusion variables, arch reconstruction technique, intraoperative medication use, and use of Modified Ultrafiltration (range, 48%-100%). Additional variation across centers was seen in variables related to postoperative care, including proportion with an open sternum (range, 35%-100%), median intensive care unit stay (range, 9-44 days), type of feeding at discharge, and enrollment in a home monitoring program (range, 1%-100%; 5 sites did not have a program). Overall, in-hospital death or transplant occurred in 18% (range across sites, 7%-39%). Conclusions Perioperative care during the Norwood hospitalization varies across centers. Further analysis evaluating the underlying causes and relationship of this variation to outcome is needed to inform future studies and quality improvement efforts.
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population pharmacokinetics of milrinone in neonates with hypoplastic left heart syndrome undergoing stage i reconstruction
Anesthesia & Analgesia, 2006Co-Authors: Athena F Zuppa, Timothy M Hoffman, John T Mondick, Nancy Burnham, William J Gaynor, Lauren Davis, Sarah C Nicolson, Peter C. Adamson, Gil Wernovsky, William J GreeleyAbstract:We performed a blinded, randomized pharmacokinetic study of milrinone in 16 neonates with hypoplastic left heart undergoing stage I reconstruction to determine the impact of cardiopulmonary bypass and Modified Ultrafiltration on drug disposition and to define the drug exposure during a continuous IV infusion of drug postoperatively. Neonates received an initial dose of either a 100 or 250 g/kg of milrinone into the cardiopulmonary bypass circuit at the start of rewarming. Postoperatively, milrinone was infused to clinical needs. A mixed-effect modeling approach was used to characterize milrinone pharmacokinetics during cardiopulmonary bypass, Modified Ultrafiltration, and postoperatively using the NONMEM algorithm. All patients in this study demonstrated a Modified Ultrafiltration concentrating effect that occurreddespiteaModifiedUltrafiltrationdrugclearance of 3.3 mL kg 1 min 1 . The infants in this study demonstratedanimpairedrenalclearanceduringtheimmedi
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population pharmacokinetics of milrinone in neonates with hypoplastic left heart syndrome undergoing stage i reconstruction
Anesthesia & Analgesia, 2006Co-Authors: Athena F Zuppa, Timothy M Hoffman, John T Mondick, Nancy Burnham, William J Gaynor, Lauren Davis, Peter C. Adamson, Gil Wernovsky, Susan C Nicolson, William J GreeleyAbstract:We performed a blinded, randomized pharmacokinetic study of milrinone in 16 neonates with hypoplastic left heart undergoing stage I reconstruction to determine the impact of cardiopulmonary bypass and Modified Ultrafiltration on drug disposition and to define the drug exposure during a continuous IV infusion of drug postoperatively. Neonates received an initial dose of either a 100 or 250 g/kg of milrinone into the cardiopulmonary bypass circuit at the start of rewarming. Postoperatively, milrinone was infused to clinical needs. A mixed-effect modeling approach was used to characterize milrinone pharmacokinetics during cardiopulmonary bypass, Modified Ultrafiltration, and postoperatively using the NONMEM algorithm. All patients in this study demonstrated a Modified Ultrafiltration concentrating effect that occurreddespiteaModifiedUltrafiltrationdrugclearance of 3.3 mL kg 1 min 1 . The infants in this study demonstratedanimpairedrenalclearanceduringtheimmedi
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the effect of Modified Ultrafiltration on the postoperative course in patients with congenital heart disease
Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac Surgery Annual, 2003Co-Authors: William J GaynorAbstract:Abstract Improvements in the technology of cardiopulmonary bypass have significantly reduced morbidity following repair of congenital cardiac defects. However, the use of cardiopulmonary bypass exposes infants to extremes of hemodilution and hyperthermia, often in association with tissue ischemia. Exposure of the blood to surfaces of the bypass circuit initiates a systemic inflammatory response that may result in organ dysfunction after cardiopulmonary bypass, especially the heart, lungs, and brain. The technique of Modified Ultrafiltration (MUF) was introduced by Naik and colleagues at the Hospital for Sick Children in London over 10 years ago. Since that time, multiple studies have evaluated the effects of MUF on organ function and postoperative morbidity following repair of congenital heart defects. Use of MUF after cardiopulmonary bypass reverses hemodilution and decreases tissue edema resulting in improved pulmonary function with decreased duration of postoperative ventilation, improved left ventricular function, decreased postoperative bleeding, and a decrease in the incidence and duration of pleural effusions following the Fontan procedure. Despite the increasing evidence that the use of MUF reduces postoperative morbidity, many important questions remain unresolved. The mechanisms by which MUF results in these beneficial effects requires additional investigation. In addition, further studies are necessary to identify patients most likely to benefit from MUF and to define the optimal protocols for its use. In the future, prospective randomized studies incorporating recent advances in the technology of cardiopulmonary bypass will be necessary to define the optimal utilization of Ultrafiltration during and after cardiopulmonary bypass. Copyright 2003 Elsevier, Inc. All rights reserved.
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Modified Ultrafiltration improves left ventricular systolic function in infants after cardiopulmonary bypass
The Journal of Thoracic and Cardiovascular Surgery, 1998Co-Authors: Michael J Davies, William J Gaynor, Khan Nguyen, Martin J ElliottAbstract:Abstract Objective : Our objective was to test the hypothesis that use of Modified Ultrafiltration after cardiopulmonary bypass improves intrinsic left ventricular systolic function in children. Methods : Twenty-one infants undergoing cardiopulmonary bypass were instrumented with ultrasonic dimension transducers, to measure the anteroposterior minor axis diameter, and a left ventricular micromanometer. Patients were randomized to Modified Ultrafiltration ( n = 11, age 226 ± 355 days, weight 6.7 ± 3.1 kg) or control ( n = 10, age 300 ± 240 days, weight 7.0 ± 2.5 kg) (all differences p > 0.05 between groups). Left ventricular systolic function was assessed by means of the slope of the preload-recruitable stroke work index. Myocardial cross-sectional area was measured by echocardiography. Data were acquired immediately after separation from bypass, at steady state, and during transient vena caval occlusion. Data acquisition was repeated after 13 ± 5 minutes of Modified Ultrafiltration or after 12 ± 5 minutes without Modified Ultrafiltration in the control group. Inotropic drug support was the same at both study points. Results : In the Modified Ultrafiltration group, the filtrate volume was 363 ± 262 ml. The hematocrit value increased from 26.0% ± 2.7% to 36.7% ± 9.5% ( p = 0.018), myocardial cross-sectional area decreased from 3.72 ± 0.35 cm 2 to 3.63 ± 0.36 cm 2 ( p = 0.04), end-diastolic length increased from 25.6 ± 9.0 mm to 28.8 ± 9.9 mm ( p = 0.01), and end-diastolic pressure fell from 5.6 ± 0.8 mm Hg to 4.2 ± 0.8 mm Hg ( p = 0.005), suggesting an improved diastolic compliance. In the control group, the hematocrit value, myocardial cross-sectional area, end-diastolic length, and pressure did not change (all p > 0.05). Mean ejection pressure increased in the Ultrafiltration group ( p = 0.001) but did not change in the control group ( p = 0.22). The slope of the preload-recruitable stroke work index increased after Ultrafiltration from 52.3 ± 52.0 to 74.2 ± 66.0 (10 3 erg/cm 3 ) ( p = 0.02) but did not change in the control group ( p = 0.07). One patient from each group died in the postoperative period. Patients in the Ultrafiltration group received less inotropic drug support in the first 24 hours after the operation (156.62 ± 92.31 μg/kg in 24 hours) than patients in the control group (865.33 ± 1772.26 μg/kg in 24 hours, p = 0.03). Conclusions : Use of Modified Ultrafiltration after cardiopulmonary bypass improves intrinsic left ventricular systolic function, improves diastolic compliance, increases blood pressure, and decreases inotropic drug use in the early postoperative period. (J Thorac Cardiovasc Surg 1998;115:361-70)
William J Greeley - One of the best experts on this subject based on the ideXlab platform.
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population pharmacokinetics of milrinone in neonates with hypoplastic left heart syndrome undergoing stage i reconstruction
Anesthesia & Analgesia, 2006Co-Authors: Athena F Zuppa, Timothy M Hoffman, John T Mondick, Nancy Burnham, William J Gaynor, Lauren Davis, Sarah C Nicolson, Peter C. Adamson, Gil Wernovsky, William J GreeleyAbstract:We performed a blinded, randomized pharmacokinetic study of milrinone in 16 neonates with hypoplastic left heart undergoing stage I reconstruction to determine the impact of cardiopulmonary bypass and Modified Ultrafiltration on drug disposition and to define the drug exposure during a continuous IV infusion of drug postoperatively. Neonates received an initial dose of either a 100 or 250 g/kg of milrinone into the cardiopulmonary bypass circuit at the start of rewarming. Postoperatively, milrinone was infused to clinical needs. A mixed-effect modeling approach was used to characterize milrinone pharmacokinetics during cardiopulmonary bypass, Modified Ultrafiltration, and postoperatively using the NONMEM algorithm. All patients in this study demonstrated a Modified Ultrafiltration concentrating effect that occurreddespiteaModifiedUltrafiltrationdrugclearance of 3.3 mL kg 1 min 1 . The infants in this study demonstratedanimpairedrenalclearanceduringtheimmedi
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population pharmacokinetics of milrinone in neonates with hypoplastic left heart syndrome undergoing stage i reconstruction
Anesthesia & Analgesia, 2006Co-Authors: Athena F Zuppa, Timothy M Hoffman, John T Mondick, Nancy Burnham, William J Gaynor, Lauren Davis, Peter C. Adamson, Gil Wernovsky, Susan C Nicolson, William J GreeleyAbstract:We performed a blinded, randomized pharmacokinetic study of milrinone in 16 neonates with hypoplastic left heart undergoing stage I reconstruction to determine the impact of cardiopulmonary bypass and Modified Ultrafiltration on drug disposition and to define the drug exposure during a continuous IV infusion of drug postoperatively. Neonates received an initial dose of either a 100 or 250 g/kg of milrinone into the cardiopulmonary bypass circuit at the start of rewarming. Postoperatively, milrinone was infused to clinical needs. A mixed-effect modeling approach was used to characterize milrinone pharmacokinetics during cardiopulmonary bypass, Modified Ultrafiltration, and postoperatively using the NONMEM algorithm. All patients in this study demonstrated a Modified Ultrafiltration concentrating effect that occurreddespiteaModifiedUltrafiltrationdrugclearance of 3.3 mL kg 1 min 1 . The infants in this study demonstratedanimpairedrenalclearanceduringtheimmedi
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Modified Ultrafiltration improves cerebral metabolic recovery after circulatory arrest
The Journal of Thoracic and Cardiovascular Surgery, 1995Co-Authors: Lynne A Skaryak, William J Greeley, Paul M Kirshbom, Louis R Dibernardo, Frank H Kern, Ross M Ungerleider, William J GaynorAbstract:Abstract Modified Ultrafiltration uses hemofiltration of the patient and bypass circuit after separation from cardiopulmonary bypass to reverse hemodilution and edema. This study investigated the effect of Modified Ultrafiltration on cerebral metabolic recovery after deep hypothermic circulatory arrest. Twenty-six 1-week-old piglets (2 to 3 kg) were supported by cardiopulmonary bypass (37° C) at 100 ml · kg -1 · min -1 and cooled to 18° C. Animals underwent 90 minutes of circulatory arrest followed by rewarming to 37° C. After being weaned from cardiopulmonary bypass, animals were divided into three groups: controls ( n = 10); Modified Ultrafiltration for 20 minutes ( n = 9); transfusion of hemoconcentrated blood for 20 minutes ( n = 7). Global cerebral blood flow was measured by xenon 133 clearance methods: stage I--before cardiopulmonary bypass; stage II—5 minutes after cardiopulmonary bypass; and stage III—25 minutes after cardiopulmonary bypass. Cerebral metabolic rate of oxygen consumption, cerebral oxygen delivery, and hematocrit value were calculated for each time point. At point III, the hematocrit value (percent) was elevated above baseline in the Ultrafiltration and transfusion groups (44 ± 1.8, 42 ± 1.8 versus 28 ± 1.7, 30 ± 0.7, respectively, p -1 · min -1 ) increased significantly above baseline at point III after Ultrafiltration (4.98 ± 0.32 versus 3.85 ± 0.16, p p p -1 · min -1 ) at point III in the control group (1.95 ± 0.15 versus 2.47 ± 0.07, p p p
Gil Wernovsky - One of the best experts on this subject based on the ideXlab platform.
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population pharmacokinetics of milrinone in neonates with hypoplastic left heart syndrome undergoing stage i reconstruction
Anesthesia & Analgesia, 2006Co-Authors: Athena F Zuppa, Timothy M Hoffman, John T Mondick, Nancy Burnham, William J Gaynor, Lauren Davis, Sarah C Nicolson, Peter C. Adamson, Gil Wernovsky, William J GreeleyAbstract:We performed a blinded, randomized pharmacokinetic study of milrinone in 16 neonates with hypoplastic left heart undergoing stage I reconstruction to determine the impact of cardiopulmonary bypass and Modified Ultrafiltration on drug disposition and to define the drug exposure during a continuous IV infusion of drug postoperatively. Neonates received an initial dose of either a 100 or 250 g/kg of milrinone into the cardiopulmonary bypass circuit at the start of rewarming. Postoperatively, milrinone was infused to clinical needs. A mixed-effect modeling approach was used to characterize milrinone pharmacokinetics during cardiopulmonary bypass, Modified Ultrafiltration, and postoperatively using the NONMEM algorithm. All patients in this study demonstrated a Modified Ultrafiltration concentrating effect that occurreddespiteaModifiedUltrafiltrationdrugclearance of 3.3 mL kg 1 min 1 . The infants in this study demonstratedanimpairedrenalclearanceduringtheimmedi
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population pharmacokinetics of milrinone in neonates with hypoplastic left heart syndrome undergoing stage i reconstruction
Anesthesia & Analgesia, 2006Co-Authors: Athena F Zuppa, Timothy M Hoffman, John T Mondick, Nancy Burnham, William J Gaynor, Lauren Davis, Peter C. Adamson, Gil Wernovsky, Susan C Nicolson, William J GreeleyAbstract:We performed a blinded, randomized pharmacokinetic study of milrinone in 16 neonates with hypoplastic left heart undergoing stage I reconstruction to determine the impact of cardiopulmonary bypass and Modified Ultrafiltration on drug disposition and to define the drug exposure during a continuous IV infusion of drug postoperatively. Neonates received an initial dose of either a 100 or 250 g/kg of milrinone into the cardiopulmonary bypass circuit at the start of rewarming. Postoperatively, milrinone was infused to clinical needs. A mixed-effect modeling approach was used to characterize milrinone pharmacokinetics during cardiopulmonary bypass, Modified Ultrafiltration, and postoperatively using the NONMEM algorithm. All patients in this study demonstrated a Modified Ultrafiltration concentrating effect that occurreddespiteaModifiedUltrafiltrationdrugclearance of 3.3 mL kg 1 min 1 . The infants in this study demonstratedanimpairedrenalclearanceduringtheimmedi
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Outcomes of the Fontan procedure using cardiopulmonary bypass with aortic cross-clamping.
The Annals of thoracic surgery, 2006Co-Authors: David B. Meyer, Gil Wernovsky, Susan C Nicolson, Guillermo Zamora, Richard F. Ittenbach, Paul R. Gallagher, Sarah Tabbutt, Peter J. Gruber, J. William Gaynor, Thomas L SprayAbstract:Background Avoidance of cardiopulmonary bypass (CPB) and aortic cross-clamping during the Fontan procedure has been advocated to improve outcomes. We continue to use CPB with aortic cross-clamping for the Fontan procedure. Methods We performed a review of patients undergoing the Fontan procedure between January 1, 2000 and December 31, 2004. Results The Fontan procedure was performed in 160 patients. The median age was 2.2 years (range, 1.0 to 29.1 years). Hypoplastic left heart syndrome or a variant was present in 114 patients (71%), and heterotaxy was present in 19 (12%). CPB and Modified Ultrafiltration were used in all patients. Aortic cross-clamping was used in 154 (96%) of 160 patients and deep hypothermic circulatory arrest (DHCA) in 132 (83%). A lateral tunnel Fontan was performed in 69 patients (43%) and an extracardiac Fontan in 91 (57%). A fenestration was created in 144 patients (90%). Two patients died. Freedom from death or takedown was 98% (157/160). Median duration of pleural drainage was 2 days (range, 1 to 44 days) and was more than 14 days in 16 patients. Median duration of hospitalization was 6 days (range, 3 to 55 days). The small number of deaths precluded assessment of risk factors for mortality. By multivariable analysis, risk factors for pleural drainage longer than 3 days were extracardiac connection ( p p = 0.033). By multivariable analysis, risk factors for hospitalization for more than 7 days were extracardiac connection ( p = 0.003), increasing duration of total support (CPB and DHCA, p = 0.027), and decreasing systemic oxygen saturation before the Fontan procedure ( p = 0.048). Conclusions The Fontan procedure can be performed using CPB and aortic cross-clamping with low morbidity and mortality.
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Modified Ultrafiltration reduces postoperative morbidity after cavopulmonary connection
The Annals of Thoracic Surgery, 1997Co-Authors: Theodore C Koutlas, William J Gaynor, James M Steven, Sarah C Nicolson, Gil Wernovsky, Thomas L SprayAbstract:Abstract Background . Modified Ultrafiltration reduces the deleterious effects of cardiopulmonary bypass in children. Patients undergoing repair of single-ventricle cardiac anomalies may be particularly sensitive to these adverse effects, and benefit from the use of Modified Ultrafiltration. Methods . From January 1995 to June 1996, 120 consecutive cavopulmonary operations were performed at The Children's Hospital of Philadelphia. Procedures included lateral tunnel fenestrated Fontan (n = 50), extracardiac Fontan (n = 5), hemi-Fontan (n = 60), and bidirectional Glenn shunt (n = 5). Modified Ultrafiltration was performed after cardiopulmonary bypass in 41 patients, and results were compared by t test with a control group of 79 patients in whom Modified Ultrafiltration was not used. Results . There was one death for an operative (30-day) mortality of 0.8%. Age, weight, diagnosis, ischemic arrest time, and cardiopulmonary bypass time were similar between the Modified Ultrafiltration and control groups. Postoperative blood use, chest tube output, the incidence of pleural and pericardial effusions, and hospital stay were all significantly decreased when Modified Ultrafiltration was used. Conclusions . By lowering the perioperative morbidity of staged cavopulmonary operations, Modified Ultrafiltration makes an important contribution to improving outcome after the correction of single-ventricle cardiac anomalies.
John W Brown - One of the best experts on this subject based on the ideXlab platform.
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effect of Modified Ultrafiltration in high risk patients undergoing operations for congenital heart disease
The Annals of Thoracic Surgery, 1998Co-Authors: Ko Bando, Palaniswamy Vijay, Mark W Turrentine, Thomas G Sharp, Brian J Lalone, Yasuo Sekine, Laszlo Szekely, John W BrownAbstract:Abstract Background. Modified Ultrafiltration (MUF) after cardiopulmonary bypass (CPB) in children decreases body water, removes inflammatory mediators, improves hemodynamics, and decreases transfusion requirements. The optimal target population for MUF needs to be defined. This prospective, randomized study attempted to identify the best candidates for MUF during operations for congenital heart disease. Methods. Informed consent was obtained from 100 consecutive patients with complex congenital heart disease undergoing operations with CPB. They were randomized into a control group (n = 50) of conventional Ultrafiltration during bypass and an experimental group using dilutional Ultrafiltration during bypass and venovenous Modified Ultrafiltration after bypass (MUF group, n=50). Postoperative arterial oxygenation, duration of ventilatory support, transfusion requirements, hematocrit, chest tube output, and time to chest tube removal were compared between the groups stratified by age and weight, CPB technique, existence of preoperative pulmonary hypertension, and diagnosis. Results. There were no MUF-related complications. In patients with preoperative pulmonary hypertension, MUF significantly improved postoperative oxygenation (445 ± 129 mm Hg versus control: 307 ± 113 mm Hg, p = 0.002), shortened ventilatory support (42.9 ± 29.5 hours versus control: 162.4 ± 131.2 hours, p = 0.0005), decreased blood transfusion (red blood cells: 16.2 ± 18.2 mL/kg versus control: 41.4 ± 27.8 mL/kg, p = 0.01; coagulation factors: 5.3. ± 6.9 mL/kg versus control: 32.3 ± 15.5 mL/kg, p = 0.01), and led to earlier chest tube removal. In neonates (≤30 days), MUF significantly reduced transfusion of coagulation factors (5.4 ± 5.0 mL/kg versus control: 39.9 ± 25.8 mL/kg, p = 0.007), and duration of ventilatory support (59.3 ± 36.2 hours versus 242.1 ± 143.1 hours, p = 0.0009). In patients with prolonged CPB (>120 minutes), MUF significantly reduced the duration of ventilatory support (44.7 ± 37.0 hours versus 128.7 ± 133.4 hours, p = 0.002). No significant differences were observed between MUF and control patients for any parameter in the presence of ventricular septal defect without pulmonary hypertension, tetralogy of Fallot, or aortic stenosis. Conclusions. Modified Ultrafiltration after CPB is safe and decreases the need for homologous blood transfusion, the duration of ventilatory support, and chest tube placement in selected patients with complex congenital heart disease. The optimal use of MUF includes patients with preoperative pulmonary hypertension, neonates, and patients who require prolonged CPB.
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dilutional and Modified Ultrafiltration reduces pulmonary hypertension after operations for congenital heart disease a prospective randomized study
The Journal of Thoracic and Cardiovascular Surgery, 1998Co-Authors: Ko Bando, Palaniswamy Vijay, Mark W Turrentine, Thomas G Sharp, Lynda J Means, Gregory J Ensing, Brian J Lalone, Yasuo Sekine, Laszlo Szekely, John W BrownAbstract:Abstract Objective: A prospective randomized study was performed to test whether removal of endothelin-1, by Ultrafiltration techniques, will reduce pulmonary hypertension after operations for congenital heart disease. Methods : Twenty-four patients with pulmonary hypertension (systolic pulmonary/systemic arterial pressure ratio > 60%) undergoing cardiac operations were randomized into a control group ( n = 12) having conventional Ultrafiltration and an experimental group ( n = 12) undergoing dilutional Ultrafiltration during and Modified Ultrafiltration after cardiopulmonary bypass. Plasma endothelin-1, nitric oxide metabolites, and cyclic guanosine monophosphate were assayed before bypass, 10 minutes into bypass, after bypass, and 0, 3, 6, and 12 hours after the operation in both groups, as well as in the ultrafiltrates and after Modified Ultrafiltration in the experimental group. Both groups received α-blockers (chlorpromazine and/or prazosin) postoperatively using the same guidelines. Results: The ultrafiltrates contained significant amounts of endothelin-1 (1.81 ± 0.86 pg/ml, dilutional, and 6.44 ± 1.82 pg/ml, Modified ultrafiltrate). Endothelin-1 and the pulmonary/systemic pressure ratio were significantly lower in experimental compared with control patients. Nitric oxide metabolites and cyclic guanosine monophosphate increased similarly in both groups for 12 hours after the operation ( p = not significant). Three of 12 control patients (25%) but no experimental patients had pulmonary hypertensive crises ( p = 0.07). The experimental patients required significantly less ventilatory support (67 ± 47 hours vs 178 ± 139 hours for control patients, p = 0.048). Conclusions: Dilutional and Modified Ultrafiltration reduce endothelin-1 and the pulmonary/systemic pressure ratio postoperatively and may become an important adjunct for preventing pulmonary hypertension after operations for congenital heart disease in high-risk patients. (J Thorac Cardiovasc Surg 1998;115:517-27)
Anders Jeppsson - One of the best experts on this subject based on the ideXlab platform.
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platelet count and function in paediatric cardiac surgery a prospective observational study
BJA: British Journal of Anaesthesia, 2014Co-Authors: Birgitta S Romlin, F Soderlund, Hakan Wahlander, B Nilsson, Fariba Baghaei, Anders JeppssonAbstract:Background Platelet deficiency, impaired platelet function, or both increase the risk of bleeding complications. We assessed platelet count and function during and after paediatric cardiac surgery. Secondary aims included the effect of Modified Ultrafiltration, identification of factors associated with platelet dysfunction, and to assess associations between platelet function and transfusion requirements. Methods Fifty-seven patients were included in a prospective observational study. Platelet count and platelet function (multiple-electrode impedance aggregometry) were analysed before and during cardiopulmonary bypass (CPB), after Modified Ultrafiltration, on arrival at the intensive care unit, and on the first postoperative day. Intraoperative transfusions of blood products were registered. Results Both platelet count and platelet aggregation were markedly reduced during surgery with the greatest reduction at the end of CPB. On postoperative day 1, platelet count was still reduced by 50%, while platelet aggregation had returned to—or above—preoperative levels. There were only moderate correlations between platelet count and platelet aggregation. Modified Ultrafiltration had no significant influence on platelet count or aggregation. Young age, low weight, and long operation time were associated with poor platelet aggregation during surgery, while young age, low weight, high preoperative haemoglobin levels, and low preoperative platelet count were associated with poor aggregation after operation. Patients with impaired platelet function during CPB had markedly increased intraoperative transfusion requirements. Conclusions Platelet count and platelet aggregation are markedly reduced during and immediately after paediatric cardiac surgery, especially in neonates. The recovery in aggregation is faster than that in platelet count. Intraoperative platelet dysfunction is associated with increased transfusion requirements.
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earlier detection of coagulopathy with thromboelastometry during pediatric cardiac surgery a prospective observational study
Pediatric Anesthesia, 2013Co-Authors: Birgitta S Romlin, Hakan Wahlander, Fariba Baghaei, Anders Jeppsson, Mats SynnergrenAbstract:SummaryObjective Earlier detection of coagulopathy in pediatric cardiac surgery patients. Aim To determine whether thromboelastometry (TEM) analysis before weaning from cardiopulmonary bypass (CPB) and hemoconcentration is predictive of post-CPB results and whether analysis of clot firmness already after 10 min yields reliable results. Background Cardiac surgery with CPB induces a coagulopathy that may contribute to postoperative complications. Earlier detection increases the possibility of initiating countermeasures. Methods/Material Fifty-six pediatric cardiac surgery patients were included in a prospective observational study. HEPTEM and FIBTEM clotting time (CT), clot formation time (CFT), and clot firmness after 10 min (A10) and at maximum (MCF) were analyzed during CPB and after CPB and Ultrafiltration with Modified rotational thromboelastometry (ROTEM®). The analyses were compared, and correlations and differences were calculated. Results Hemoconcentration with Modified Ultrafiltration increased hematocrit from 28 ± 3 to 37 ± 4% (P < 0.001). Correlation coefficients of the TEM variables during and after CPB ranged from 0.61 to 0.82 (all P < 0.001). HEPTEM-CT and HEPTEM-MCF differed significantly but the differences were marginal. Both HEPTEM and FIBTEM A10 measurements during CPB were significantly less than MCF (P < 0.001 for both), but the correlations were highly significant (HEPTEM: r = 0.95, P < 0.001; FIBTEM: r = 0.96, P < 0.001), and the differences were predictable, with narrow confidence intervals (HEPTEM: −8.2 mm (−8.9 to −7.5); FIBTEM: −0.5 mm (−0.7 to −0.3). Conclusion The results suggest that intraoperative TEM analyses can be accelerated by analyzing HEPTEM/FIBTEM on CPB before hemoconcentration and by analyzing clot firmness already after 10 min.