Bharathi H. Scott

Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery.

The purpose of the present investigation was to examine the impact of blood transfusion on resource utilisation, morbidity and mortality in patients undergoing coronary artery bypass graft (CABG) surgery at a major university hospital. The resources we examined are time to extubation, intensive care unit length of stay (ICULOS) and postoperative length of stay (PLOS). We further examined the impact of number of units of packed red blood cells (PRBCs) transfused during PLOS. This is a retrospective observational study and includes 1746 consecutive male and female patients undergoing primary CABG (on- and off-pump) at our institution. Of these, 1067 patients received blood transfusions, while 677 did not. The data regarding the demography, blood transfusion, resource utilisation, morbidity and mortality were collected from the records of patients undergoing CABG over a period of three years. The mean time to extubation following surgery was 8.0 h for the transfused group and 4.3 h for the nontransfused group ( P <or= 0.001). The mean ICULOS for the transfused group was 1.6 d and 1.2 d for the nontransfused group ( P P <or= 0.001). In all patients and in patients with no preoperative morbidity, partial correlation coefficients were used to examine the effects of transfusion on mortality, time to extubation, ICULOS and PLOS. Linear regression model was used to assess the effect of number of PRBC units transfused on PLOS. We noted that PLOS increased with the number of PRBCs units transfused. Transfusion is significantly correlated with the increased time to extubation, ICULOS, PLOS and mortality. The transfused patients had significantly more postoperative complications than their nontransfused counterparts ( P <or= 0.001). The 30-day hospital mortality was 3.1% for the transfused group with no deaths in the nontransfused group ( P <or= 0.001). We conclude that the CABG patients receiving blood transfusion have significantly longer time for tracheal extubation, ICULOS, PLOS and higher morbidity and 30-day hospital mortality. Blood transfusion was an independent predictor of increased resource utilisation, postoperative morbidity and mortality.

Blood use in patients undergoing coronary artery bypass surgery: Impact of cardiopulmonary bypass pump, hematocrit, gender, age, and body weight

We investigated the impact of cardiopulmonary bypass pump (CPB), hematocrit, gender, age, and body weight on blood use in patients undergoing coronary artery bypass graft surgery at a major university hospital. Participants were 1235 consecutive patients undergoing primary coronary artery surgery over a period of 2 yr (1999 and 2000); 681 patients underwent coronary surgery with use of CPB, and 554 patients underwent off-pump coronary artery bypass surgery using a median sternotomy incision. There were 881 males and 354 females. Average packed red blood cells (PRBC) transfusion for patients on CPB was 3.4 U compared with 1.6 U for the off-pump group (P = <0.001). Patients on CPB received more frequent PRBC transfusion (72.5%) compared with 45.7% of off-pump patients (P = <0.001). Average PRBC transfusion for males was 2.2 U compared with 3.6 U for females (P = <0.001). A lower percentage of males (52.6%) than females (79.4%) received transfusion (P = <0.001). The impact of CPB, off-pump status, preoperative hematocrit <35%, gender, age ≥65 yr, and weight ≤83 kilograms using median values as cut points, on blood use was examined using logistic regression models. Use of CPB, preoperative hematocrit, (<35%) female gender, increasing age, and decreased body weight were significant predictors of transfusion (P = <0.001). Preoperative hematocrit <35% and use of CPB were the strongest predictors of PRBC transfusion.

False aneurysm of the axillary artery following brachial plexus block

Brachial plexus blockade is a commonly used technique for providing surgical anesthesia for the upper extremity. Although various approaches have been described, the axillary approach is the safest and most frequently used. Most complications associated with axillary nerve block are related to local or systemic anesthetic toxicity, bleeding, infection, and nerve damage. A case of false aneurysm of the axillary artery following axillary nerve block is reported. The possible occurrence of this complication should be kept in mind to avoid permanent neurologic sequelae.

Opioids in cardiac surgery: Cardiopulmonary bypass and inflammatory response

After a brief overview of the history of narcotic use in anesthesia, the various opiates are reviewed mainly from a stress-reducing, antiinflammatory and hemodynamic perspective. The emphasis is placed on cardiac anesthesia.

Transfemoral Transcatheter Aortic Valve Replacement in a Patient With Heparin-Induced Thrombocytopenia: Intraoperative Anticoagulation Management With Bivalirudin (Angiomax)

ORTIC VALVE REPLACEMENT secondary to calcified aortic stenosis is the most common valvular replacement surgery in the United States, constituting nearly 50,000 cases per year. 1 Historically, aortic valve replacement required open heart surgery, which had a 4% to 18% risk of mortality, until 2002 when transcatheter aortic valve replacement (TAVR) was first described. 2 TAVR is an alternative for patients who are at high risk for perioperative complications for an open valve replacement. Maintaining adequate anticoagulation during a TAVR procedure is an integral component, with unfractionated heparin (UFH) being the anticoagulant of choice. Alternative agents for patients with contraindications to heparin undergoing TAVR have not been well-described in the literature. The authors present a case report of a patient with heparin-induced thrombocytopenia (HIT) type II who successfully underwent TAVR with bivalirudin anticoagulation. To the best of their knowledge, this is the first case report of utilizing an alternative anticoagulant, bivalirudin, during a TAVR procedure. CASE PRESENTATION