Calvert C. Alpert

Tranexamic Acid Reduces Bleeding After Cardiopulmonary Bypass When Compared to Epsilon Aminocaproic Acid and Placebo

Abstract Perioperative bleeding following coronary artery bypass grafting (CABG) is associated with increased blood product usage. Although aprotonin is effective in reducing perioperative blood loss, excessive cost prohibits routine utilization. Epsilon aminocaproic acid (EACA) and tranexamic acid (TA) are inexpensive antifibrinolytic agents, which, when give prophylactically, may reduce blood loss. The present study was undertaken to compare the efficacy of TA and EACA in reducing perioperative blood loss. Methods: The study population consisted of first‐time CABG patients. Patients were allocated in a prospective double‐blind fashion: (1) group EACA (loading dose 150 mg/kg, continuous infusion 10 mg/kg per hour for 6 hours, N = 20); (2) group TA (loading dose 15 mg/kg, continuous infusion 1 mg/kg per hour for 6 hours, N = 20); (3) control group (infusion of normal saline for 6 hours, N = 19). Results: Treatment groups were similar preoperatively. No significant difference in intraoperative blood loss or perioperative use of blood products was noted. D‐dimer concentration was elevated in the control group compared to the EACA and TA groups (p < 0.05). Group TA had less postoperative blood loss than the EACA and control groups at 6 and 12 hours postoperatively (p < 0.05). TA had reduced total blood loss (600 ± 49 mL) postoperatively compared to EACA (961 ± 148 mL) and control (1060 ± 127mL, p < 0.05). Conclusion: TA and EACA effectively inhibited fibrinolytic activity intraoperatively and throughout the first 24 hours postoperatively. TA was more effective in reducing blood loss postoperatively following CABG. This suggests that TA may be beneficial as an effective and inexpensive antifibrinolytic in first‐time CABG patients.

Comparison of blood pressure measurement by Doppler and by pulse oximetry techniques

The continuous assessment of arterial oxygen saturation by pulse oximetry was introduced into clinical anesthesia in 1983 (1). Such monitoring has now become standard in our institution for all patients during anesthesia. Routine blood pressure determinations performed in the same extremity with the oximeter probe consistently interrupt the function of the oximeter. Because of this, oximeter probes were usually placed at sites not affected by blood pressure cuff inflation. However, small infants and patients with major burn injuries have little surface area available for multiple sensor placement. In such patients the oxirneter probe and the Doppler flow meter for measurement of blood pressure often had to be placed on the same extremity. We noticed that the oximeter pulse display seemed to have some correlation with the svstolic blood pressure determined by Doppler meth-

A rational approach to anaesthetic premedication.

SummaryRational use of premedication for anaesthesia must always be modified and updated to keep pace with the evolving fields of anaesthesiology and surgery, as well as to meet changing patient needs and preferences. It is no longer axiomatic that all patients require, and therefore should receive, premedication. Unfortunately, a variety of traditional reasons have been proposed to justify routine premedication in many institutions. Smoothing induction, decreasing reflexes and arrhythmias, decreasing nausea and vomiting, decreasing pain, decreasing secretions, and producing sedation and amnesia have all been claimed historically as beneficial results of premedication. Modern anaesthetic agents and techniques have come a long way towards eliminating the routine need for premedication. In the preoperative period, the goal of an anxiety-free patient who is physiologically uncompromised requires an individualised approach based on experience and an adequate knowledge of current pharmacology. As our knowledge of potential problems associated with anaesthesia has expanded, we have added other classes of drugs such as the H2-histamine receptor blockers and antacids to our premedicant armamentarium. Outpatient and short-stay patients have further challenged our preoperative goal of an anxiety-free patient by requiring individuals to be ‘street ready’ within a brief period of time after surgery. Even for in-house elective procedures, not every patient is a candidate for routine premedication. A frank preoperative discussion is all that is necessary to effectively allay anxiety in many persons. In these and other special situations, this article will hopefully guide the reader toward a more rational approach to premedicating patients.

Intravenous sedation for placement of automatic implantable cardioverter-defibrillators

OBJECTIVE To evaluate a change in anesthetic technique for transvenous placement of the automatic implantable cardioverter-defibrillator (ICD). DESIGN Retrospective study. SETTING A university hospital. PARTICIPANTS Twenty-eight patients who underwent placement of ICDs. INTERVENTIONS Thirteen patients had the ICD placed via the transvenous approach with general anesthesia (group GA). Fifteen patients had the ICD placed via the transvenous approach with intravenous sedation (group IV). MEASUREMENTS AND MAIN RESULTS Intraoperative systolic and diastolic blood pressures were significantly higher in group IV compared with group GA. The ICD was successfully placed in all patients in both groups. There were no intraoperative complications noted in either group during induction of fibrillation and defibrillation, and there was no recall by any patient in either group. The average hospital stay was significantly less in group IV (1.8 days) compared with group GA (3.4 days). CONCLUSIONS Intravenous sedation for the placement of ICDs is a safe and effective technique. Patients who had their ICD placed while receiving intravenous sedation experienced higher intraoperative blood pressures and were discharged from the hospital earlier than those patients who received general anesthesia.

Independent placement of a bronchial blocker for single-lung ventilation : An alternative method for the difficult airway

F unctional separation of the lungs may be accomplished by double-lumen (DL) endotracheal intubation, bronchial blockade with the Univent tube (Fuji Systems Corp., Tokyo, Japan), bronchial blockade independent of a single-lumen tube (SLT), or endobronchial intubation with a SLT. In patients with abnormal upper airways who require one-lung ventilation, DL tube placement may not be possible. Nasotracheal intubation and one-lung ventilation using a Univent tube has been previously reported (1). However, Univent placement in small patients may be traumatic because of the large outer diameter of these tubes. The short length of a conventional SLT also prohibits endobronchial intubation via the nasal route. Recently, we managed a patient with restricted mouth opening requiring nasotracheal intubation and lung separation for thoracoscopy with an independent bronchial blocker placed outside a SLT.

ASPIRATION INTO THE TRACHEA OF A TRACHEAL T-TUBE IN A PEDIATRIC PATIENT

Congenital subglottic stenosis accounts for 6%-19% of all congenital laryngeal anomalies, and current reports place acquired subglottic stenosis between 4% and 8.5% of all infants leaving neonatal intensive care units. The silicone rubber, tracheal T-tube introduced by Montgomery in 1965 has been used increasingly as a stent for the stenotic area as well as a tracheostomal appliance in these patients. All physicians should be aware of the unique shape and flexibility of the T-tube because it can lead to unusual airway problems and require quick and unconventional management, as illustrated by the reported here

Hypoplastic left heart syndrome: a simplified palliative operation.

A simplified, palliative operation for hypoplastic left ventricular syndrome is proposed, its morphologic rationale is documented, and three cases are reported.

Physostigmine for the acute treatment of restless legs syndrome.

We present a case report of an acute episode of restless legs syndrome that interfered with the performance of a diagnostic imaging procedure of the cervical spine. The patient had a 19-yr history of restless leg syndrome with periodic limb movements during sleep. Treatment with additional sedation and opioids did not alleviate the leg movements. IV administration of 1 mg of physostigmine eradicated all extraneous leg motion.