A Statewide Hospital-Based Safe Infant Sleep Initiative: Measurement of Parental Knowledge and Behavior.

Sleep-related infant deaths are a leading cause of infant mortality in Georgia, and these deaths are largely associated with unsafe sleep practices among caregivers. In early 2016, the Georgia Department of Public Health launched the Georgia Safe to Sleep Hospital Initiative, providing hospitals with safe infant sleep information and educational materials to be distributed to families and newborns. This study examined the knowledge and behaviors of a sample of Georgia parents after the implementation of the Hospital Initiative and identified the family characteristics and intervention components most closely associated with the knowledge and practice of safe infant sleep. The primary caretakers of all infants born in Georgia from August to October 2016 were invited to complete a web-based survey 1 month after hospital discharge. The final sample size included 420 parents of newborns, and the primary outcomes assessed included two measures of knowledge and four measures of infant sleep behaviors regarding infant sleep position and location. Most respondents demonstrated knowledge of the correct recommended sleep position (90%) and location (85%). Logistic regression revealed that receipt of information in the hospital was significantly correlated with safe sleep behaviors, and infant sleep habits tended to influence safe sleep practices. Additionally, Medicaid parents receiving bassinets from the hospital were 74% less likely to bed share (OR 0.26; 95% CI 0.007). Implementation of a statewide hospital initiative was associated with high levels of parental knowledge and behavior and may have been successful in reducing the practice of bed sharing among Medicaid parents.

The incidence and economic burden of injuries in Jiangxi, China.

OBJECTIVES: This study estimated the incidence, direct medical and non-medical costs, and productivity losses due to morbidity and mortality across multiple strata for injuries that occurred in Jiangxi, China. STUDY DESIGN: Cross-sectional study. METHODS: Data came from the Jiangxi injury survey, a provincially-representative, population-based sample of 100,010 households. The major economic costs of injuries were divided into direct costs and indirect costs. Direct costs encompass medical costs and direct non-medical costs. Indirect costs refer to the productivity losses due to injury-related morbidity and mortality. RESULTS: In 2005, about one of 18 residents in Jiangxi, China, experienced an injury. Overall, fall, animal bite, and road traffic crash (RTC) injuries accounted for more than 66% of all injuries, while fall, RTC, drowning, and self-harm injuries accounted for 80% of fatal injuries. Average cost per case for a fatal injury was 163,389 RMB ($20,171) for lost productivity and 2800 RMB ($346) in direct medical & non-medical costs. A non-fatal injury resulting in hospitalisation or permanent disability on average caused 5221 RMB ($643) in direct costs and 18,437 RMB ($2276) in lost productivity and, an additional loss of three school days. A non-hospitalised non-fatal injury on average caused 303 ($37) RMB in direct costs and 491 RMB ($61) in lost productivity and, an additional loss of 0.5 school days. CONCLUSIONS: The unequivocal evidence of the substantial health and financial burden of injuries indicates to Chinese policy makers that more research and efforts are needed to find efficacious and cost-effective interventions targeting injury.

Incidence and lifetime costs of injuries in the United States.

BACKGROUND: Standardized methodologies for assessing economic burden of injury at the national or international level do not exist. OBJECTIVE: To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses. METHOD: The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000. MAIN OUTCOME MEASURES: Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. RESULTS: More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of $406 billion; $80 billion for medical treatment and $326 billion for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase. CONCLUSIONS: These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

Skin pigmentation interferes with the clinical measurement of regional cerebral oxygen saturation.

BACKGROUND: Devices utilizing near-infrared (NIR) spectroscopy have been used to assess regional intracerebral oxygen saturation (rSO2) during anaesthesia for a decade. The presence of wide differences among individuals reduces their applicability to steady-state measurements. Current devices may not adequately account for variations in skin pigmentation. METHODS: From our ongoing departmental registry, 3282 consecutive patients underwent cardiac surgery between 2010 and 2012 and their pre-induction measurements of rSO2 were available. Of these, 2096 identified themselves as Caucasian (Cauc) and 1186 as African-American (AA). Pre-induction rSO2, clinical and operative features were compared. RESULTS: Clinical and operative details of these patients differed widely between the two populations. High-risk features were more common in AA patients, but no difference in mortality was observed (4.8% in AAs vs 4.7% in Caucs, P=0.87). Preprocedure rSO2 was systematically higher in Cauc (65.5% vs 53.3%, P<0.001). After multivariate linear regression adjustment, AA ethnicity proved to be associated independently with low rSO2 [odds ratio (OR) -8.28, 95% confidence interval (CI) -9.12 to -7.44, P<0.001]. Multivariate logistic regression analysis showed that preprocedural rSO2 was independently associated with operative mortality both in the Cauc group (OR 0.97, 95% CI 0.96-0.99, P=0.001) and in the AA group (OR 0.97, 95% CI 0.95-0.99, P=0.01). CONCLUSIONS: AAs have a lower rSO2 than Caucs as measured by the INVOS 5100C cerebral oximeter. Reasonably, this could be attributed to attenuation of the NIR light by skin pigment. Despite this limitation, in both ethnic groups, lower preoperative rSO2 was predictive of greater operative mortality.

Yield of undetected tuberculosis and human immunodeficiency virus coinfection from active case finding in urban Uganda.

OBJECTIVES: To determine the yield of undetected active tuberculosis (TB), TB and human immunodeficiency virus (HIV) coinfection and the number needed to screen (NNS) to detect a case using active case finding (ACF) in an urban community in Kampala, Uganda. METHODS: In a door-to-door survey conducted in Rubaga community from January 2008 to June 2009, residents aged ≥15 years were screened for chronic cough (≥2 weeks) and tested for TB disease using smear microscopy and/or culture. Rapid testing was used to screen for HIV infection. The NNS to detect one case was calculated based on population screened and undetected cases found. RESULTS: Of 5102 participants, 3868 (75.8%) were females; the median age was 24 years (IQR 20-30). Of 199 (4%) with chronic cough, 160 (80.4%) submitted sputum, of whom 39 (24.4%, 95%CI 17.4-31.5) had undetected active TB and 13 (8.1%, 95%CI 6.7-22.9) were TB-HIV co-infected. The NNS to detect one TB case was 131 in the whole study population, but only five among the subgroup with chronic cough. CONCLUSION: ACF obtained a high yield of previously undetected active TB and TB-HIV cases. The NNS in the general population was 131, but the number needed to test in persons with chronic cough was five. These findings suggest that boosting the identification of persons with chronic cough may increase the overall efficiency of TB case detection at a community level.

Blood-brain barrier disruption after cardiac surgery.

BACKGROUND AND PURPOSE: CNS complications are often seen after heart surgery, and postsurgical disruption of the BBB may play an etiologic role. The objective of this study was to determine the prevalence of MR imaging-detected BBB disruption (HARM) and DWI lesions after cardiac surgery. MATERIALS AND METHODS: All patients had an MRI after cardiac surgery. For half the patients (group 1), we administered gadolinium 24 hours after surgery and obtained high-resolution DWI and FLAIR images 24-48 hours later. We administered gadolinium to the other half (group 2) at the time of the postoperative scan, 2-4 days after surgery. Two stroke neurologists evaluated the images. RESULTS: Of the 19 patients we studied, none had clinical evidence of a stroke or delirium at the time of the gadolinium administration or the scan, but 9 patients (47%) had HARM (67% in group 1; 30% in group 2; P = .18) and 14 patients (74%) had DWI lesions (70% in group 1; 78% in group 2; P = 1.0). Not all patients with DWI lesions had HARM, and not all patients with HARM had DWI lesions (P = .56). CONCLUSIONS: Almost half the patients undergoing cardiac surgery have evidence of HARM, and three-quarters have acute lesions on DWI after surgery. BBB disruption is more prevalent in the first 24 hours after surgery. These findings suggest that MR imaging can be used as an imaging biomarker to assess therapies that may protect the BBB in patients undergoing heart surgery.

Evaluating the role for the optical density in the diagnosis of heparin-induced thrombocytopenia following cardiac surgery.

The poor accuracy of the enzyme immune assay (EIA) contributes to the diagnostic challenge of heparin-induced thrombocytopenia (HIT) following cardiac surgery. We sought to determine if adjusting the threshold optical density (OD) defining a positive EIA improves the test's accuracy in subjects with an OD>0.40. We retrospectively analysed the results from both EIA and confirmatory serotonin release assays (SRAs) in cardiac surgery patients with EIA OD of >0.4. Employing the SRA as the standard, we compared the area under the receiver-operating characteristic (AUROC) curves of various OD measurements for identifying HIT. We examined baseline clinical variables associated with a positive SRA in the setting of a positive HIT EIA (OD >0.4). We then used logistic regression to identify baseline clinical variables independently associated with a positive SRA given a positive EIA. The cohort included 99 subjects with positive EIAs and 35% had positive SRAs. An OD>0.40 had moderate utility as a screening test for a positive SRA (AUROC: 0.68; 95% CI: 0.55-0.80). Increasing the OD threshold did not improve the HIT EIA's screening utility. Clinical variables independently associated with a positive SRA if the EIA were positive included female gender, absence of diabetes, and use of cardiopulmonary bypass. A relatively modest elevation in the OD measurement, when it is already known to be greater than 0.4, does not reliably exclude the potential for a positive SRA in this setting.

The costs of fatal and non-fatal falls among older adults.

OBJECTIVE: To estimate the incidence and direct medical costs for fatal and non-fatal fall injuries among US adults aged >or=65 years in 2000, for three treatment settings stratified by age, sex, body region, and type of injury. METHODS: Incidence data came from the 2000 National Vital Statistics System, 2001 National Electronic Injury Surveillance System-All Injury Program, 2000 Health Care Utilization Program National Inpatient Sample, and 1999 Medical Expenditure Panel Survey. Costs for fatal falls came from Incidence and economic burden of injuries in the United States; costs for non-fatal falls were based on claims from the 1998 and 1999 Medicare fee-for-service 5% Standard Analytical Files. A case crossover approach was used to compare the monthly costs before and after the fall. RESULTS: In 2000, there were almost 10 300 fatal and 2.6 million medically treated non-fatal fall related injuries. Direct medical costs totaled 0.2 billion dollars for fatal and 19 billion dollars for non-fatal injuries. Of the non-fatal injury costs, 63% (12 billion dollars ) were for hospitalizations, 21% (4 billion dollars) were for emergency department visits, and 16% (3 billion dollars) were for treatment in outpatient settings. Medical expenditures for women, who comprised 58% of the older adult population, were 2-3 times higher than for men for all medical treatment settings. Fractures accounted for just 35% of non-fatal injuries but 61% of costs. CONCLUSIONS: Fall related injuries among older adults, especially among older women, are associated with substantial economic costs. Implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.

Incidence and lifetime costs of injuries in the United States.

BACKGROUND: Standardized methodologies for assessing economic burden of injury at the national or international level do not exist. OBJECTIVE: To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses. METHOD: The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000. MAIN OUTCOME MEASURES: Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. RESULTS: More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of 406 billion dollars; 80 billion dollars for medical treatment and 326 billion dollars for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase. CONCLUSIONS: These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

Prevention of atrial fibrillation after cardiac surgery: the significance of postoperative oral amiodarone.

STUDY OBJECTIVES: Atrial fibrillation (AF) is a common occurrence after cardiac surgery (10 to 53%) that contributes to increased length of stay and hospital cost. Recent evidence suggests that treatment with amiodarone may provide safe and effective prophylaxis against AF in many patients undergoing cardiac operations. This study sought to investigate whether oral amiodarone administered postoperatively would reduce the incidence of postoperative AF. DESIGN: Prospective nonrandomized cohort study. PATIENTS AND PARTICIPANTS: In this prospective study, 1,196 consecutive patients who underwent various open-heart procedures with cardiopulmonary bypass between July 1999 and February 2000 received oral amiodarone, 400 mg bid, from the transfer to the cardiovascular recovery room until the day of hospital discharge, or up to 7 days postoperatively. The incidence of AF in this group of patients was compared with a group of 1,246 patients who underwent cardiac surgery with cardiopulmonary bypass in the preceding 8-month period (November 1998 to June 1999) at the same institution without receiving amiodarone postoperatively. SETTING: Tertiary health-care center. MEASUREMENT AND RESULTS: AF developed in 294 patients (25%) in amiodarone-treated group and in 385 patients (31%) in the control group (p = 0.001). In multivariate logistic regression analysis, oral amiodarone treatment emerged as an independent predictor of lower risk of AF (odds ratio, 0.7; 95%; 95% confidence interval, 0.6 to 0.9; p = 0.002) and shorter hospital length of stay (odds ratio, 0.8; 95% confidence interval, 0.5 to 0.9; p = 0.006). CONCLUSIONS: Postoperative oral amiodarone treatment is a safe and effective regimen associated with a reduced incidence of new-onset AF and decreased length of hospital stay. Prospective randomized trials are needed to evaluate the benefits of amiodarone treatment relative to its side effect profiles.

Rotavirus vaccine and intussusception: how much risk will parents in the United States accept to obtain vaccine benefits?

Postlicensure surveillance of a newly licensed rotavirus vaccine suggested an increased risk of intussusception. Little was known about the amount of risk parents would tolerate to obtain the vaccine's benefits or the extent to which risk would reduce the price parents would pay for the vaccine. Parents of infants aged 12 months or younger were asked to accept or reject two hypothetical vaccines associated with varying degrees of risk. Parents chose from a list the amount they would pay for two additional hypothetical vaccines, with and without a risk of intussuception. The authors conducted face-to-face surveys in September 1999 among a convenience sample of parents in three US cities. Of 405 eligible parents, 260 (64%) participated. To achieve a 90% acceptance rate, the vaccine could be associated with no more than 1,794 (95% confidence interval: 1,551, 2,025) cases of intussusception in a fully vaccinated, national cohort of infants. The median willingness to pay for three vaccine doses, when vaccination was associated with 1,400 cases of intussusception, was $36 (95% confidence interval: $28, $46) compared with $110 (95% confidence interval: $96, $126) for the risk-free vaccine. The most important aspect of this study may be the methodology to assess how parents balance the benefits and risks of childhood vaccines.

Late outcome of reoperative coronary revascularization on the beating heart.

BACKGROUND: Reoperative (redo) coronary artery bypass grafting (CABG) is associated with a higher morbidity and mortality than first-time CABG. An off-cardiopulmonary bypass (off-pump) approach to redo CABG, however, may potentially benefit redo patients. The aim of the present report is to describe the early and long-term clinical outcome of patients who underwent off-pump redo CABG between July 1985 and January 1999 in our institution. METHODS: Redo patients (n = 138) represented 13% of patients who had off-pump CABG during the period of study (n = 1072). Mean patient age was 63 +/- 12 years, and 67% were men. Surgical approaches included median sternotomy (n = 93, 67%), anterior (n = 20, 15%) and lateral (n = 25, 18%) minimally invasive direct coronary artery bypass (MIDCAB). RESULTS: Operative mortality was 2% (n = 3). Target lesion re-intervention was 6% (n = 9) Actuarial survival at a mean period of follow-up of 2.5 +/- 1 year (range: 1 month to 11 years) was 83%. Event-free survival (freedom from death, myocardial infarction, and repeat intervention) was 67%. Overall cardiac-related mortality was 10% (n = 14). CONCLUSION: Off-pump redo CABG can be safely performed with a relatively low mortality rate and a low rate of target lesion revascularization.

Stroke after coronary artery bypass: incidence, predictors, and clinical outcome.

BACKGROUND AND PURPOSE: Early postoperative stroke is a serious adverse event after coronary artery bypass grafting (CABG). This study sought to investigate risk factors, prevalence, and prognostic implications of postoperative stroke in patients undergoing CABG. METHODS: We investigated the predictors of postoperative stroke (n=333, 2%) in 16 528 consecutive patients who underwent CABG between September 1989 and June 1999 in our institution. Predictors of postoperative stroke were identified by logistic regression analysis. RESULTS: Among the preoperative and postoperative factors, significant correlates of stroke included (1) chronic renal insufficiency (P<0.001), (2) recent myocardial infarction (P=0.01), (3) previous cerebrovascular accident (P<0.001), (4) carotid artery disease (P<0.001), (5) hypertension (P<0.001), (6) diabetes (P=0.001), (7) age >75 years (P=0.008), (8) moderate/severe left ventricular dysfunction (P=0.01), (9) low cardiac output syndrome (P<0.001), and (10) atrial fibrillation (P<0.001). Postoperative stroke was associated with longer postoperative stay (11+/-4 versus 7+/-3 days for patients without stroke, P<0.001) and with higher in-hospital mortality (14% versus 2.7% for patients without stroke; P<0.001). CONCLUSIONS: Stroke after CABG is associated with high short-term morbidity and mortality. Increased stroke risk can be predicted by preoperative and postoperative clinical factors.

Coronary revascularization without cardiopulmonary bypass in high-risk patients: a route to the future.

Previous reports have demonstrated that reoperative coronary revascularization, advanced age, female sex, and impaired left ventricular dysfunction are independent predictors of operative mortality after coronary artery bypass grafting (CABG). CABG without cardiopulmonary bypass (off-pump CABG) has been proposed as a potential therapeutic alternative in these high-risk patient groups. Despite the substantial learning curve associated with off-pump CABG, early outcomes of off-pump CABG in high-risk patients are better than those associated with the conventional on-pump CABG approach. These results suggest that off-pump CABG is a safe alternative to on-pump CABG in high-risk patients. Randomized prospective studies are needed to validate the results of these initial retrospective reports and to demonstrate the long-term benefits of this approach.

Minimally invasive coronary revascularization in women: A safe approach for a high-risk group.

PURPOSE: Female gender has been shown to be an independent risk factor for mortality in coronary artery bypass graft (CABG) surgery. This report analyzes our early outcomes in 304 women who underwent off-pump coronary artery bypass (OPCAB) surgery at the Washington Hospital Center (Washington, DC) over the last 3 years to determine whether this is a safe approach for coronary bypass in women. METHODS: A retrospective review of 5528 cases of CABG bypass (on-pump) and 840 cases of OPCAB surgery, from June 1996 to July 1999, was performed. Women accounted for 1527 (27.6%) of the on-pump bypass cases and 304 (36.2%) of the OPCABs. All cases without cardiopulmonary bypass were included, with the majority of the most recent cases being multivessel revascularization. The data for analysis were obtained from our cardiac surgery database and included cases from all surgeons operating at the Washington Hospital Center, although the majority of off-pump cases were performed by only a few of these surgeons. RESULTS: The two groups were similar with respect to urgent cases, redos, and other comorbities including preoperative congestive heart failure, peripheral vascular disease, transient ischemic attack (TIA), cerebral vascular accident, and previous myocardial infarction. The mean age for the two groups was similar, 67 years for the off-pump group and 66 years for the on-pump group. The absolute number of all off-pump cases increased each year (from 175 to a total of 373), representing a corresponding increase in percentage of all coronary artery bypass procedures (from 9% to 16%). Of the total number of patients undergoing CABG, the percentage of women who underwent OPCAB doubled from 3% to 6% over the time period analyzed. The percentage of single-vessel cases in the off-pump group fell from 88% to 41% as multivessel bypasses became more routine However, the percentage of patients aged > 75 years was greater for the off-pump group (30%) than for the on-pump group (24%). Otherwise, the two groups differed only in diabetic disease (36% off-pump compared with 46% on-pump; p = 0.001) and previous transcatheter therapy (38% off-pump compared with 29% on-pump; p = 0.003). Patients who had OPCABs received fewer postoperative transfusions (40%) than the on-pump group (59%; p < 0.001). The off-pump group also had fewer neurological complications in the form of TIAs or strokes (0.3%) compared with the on-pump group (3.5%; p = 0.001). The mortality rate was 2.3% off -pump versus 4.1% on pump but did not reach statistical significance in this study (p =.12). CONCLUSION: Myocardial revascularization in women can be performed safely without cardiopulmonary bypass. In our series, the mortality for women receiving off-pump revascularization was lower than the on-pump cohorts despite an older age and higher incidence of diabetes. Although the absolute mortality rates did not reach statistical significance, we were encouraged that the mortality rate for women operated on without CPB dropped to the mortality rate typically seen in men. We also observed a favorable tendency in the off-pump group for a shorter length of stay and a lower incidences of transient ischemic attacks, strokes, post-op bleeding, and blood transfusions. A larger series of patients with multivariate analysis and/or a prospective trial will need to be analyzed in order to confirm our findings.

Coronary revascularization of the circumflex system: different approaches and long-term outcome.

BACKGROUND: Minimally invasive direct coronary artery bypass, without cardiopulmonary bypass, through a left lateral thoracotomy approach (lateral MIDCAB), is a safe alternative to coronary artery bypass surgery using cardiopulmonary bypass (on-pump CABG) of the circumflex system via median sternotomy. However, it is unknown whether lateral MIDCAB may yield an improved long-term outcome over the conventional on-pump median sternotomy approach. METHODS: We compared the perioperative outcomes of patients undergoing lateral MIDCAB (n = 34) versus conventional on-pump CABG of the circumflex system (n = 16) from June 1996 to July 1999. The two groups were similar with respect to baseline characteristics and risk stratification. Patients who required only one or two grafts for complete revascularization were included. RESULTS: Lateral MIDCAB patients had a lower need than on-pump CABG patients for intraoperative (12% MIDCAB vs 43% on-pump CABG, p = 0.03) and postoperative transfusions (29% vs 69%, p = 0.01), had fewer neuropsychologic changes (0% vs 19%, p = 0.03), and had a lower rate of postoperative atrial fibrillation (12% vs 44%, p = 0.02). Lateral MIDCAB was also associated with a significantly lower postoperative length of stay (5 +/- 2 vs 7 +/- 3 days, p = 0.02). Actuarial survival at a mean period of follow-up of 19 +/- 11 months was 97% for the lateral MIDCAB versus 88% for the on-pump CABG group (p = 0.6). Event-free survival was 88% for lateral MIDCAB versus 81% for on-pump CABG (p = 0.1). CONCLUSIONS: Lateral MIDCAB may safely be performed in patients with isolated coronary artery disease of the circumflex system with improved early morbidity and an abbreviated hospital stay compared with conventional median sternotomy on-pump CABG.

Complete myocardial revascularization on the beating heart with epicardial stabilization: anesthetic considerations.

OBJECTIVE: To describe an anesthetic management protocol for patients undergoing cardiac surgery with multiple coronary artery bypass grafts without cardiopulmonary bypass (off-pump CABG surgery) by median sternotomy with mechanical stabilization. DESIGN: Retrospective nonrandomized analysis. SETTING: Tertiary care hospital. PARTICIPANTS: Sixty-six consecutive patients on whom off-pump CABG surgery by median sternotomy was attempted. INTERVENTIONS: Anesthesia was induced with a combination of etomidate and fentanyl; pancuronium bromide was given for muscle relaxation; and anesthesia was maintained with isoflurane, desflurane, or sevoflurane in 100% oxygen. Maintenance of normothermia was attempted by keeping the room temperature at 70 degrees F, warming all fluids to 41 degrees C, and using 2.5 L/min of fresh gas flows and a heat and humidity exchanger. When available, a convective forced-air blanket was used to cover patients' head and shoulders. Patients who were not slated for revascularization of the circumflex vessels and who had good ventricular function received central venous pressure monitoring (26%); all other patients received a pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS: Of the 66 patients, 36% required an epinephrine infusion at a mean rate of 1.45+/-2.05 microg/min intraoperatively to maintain hemodynamic stability; 25% required inotropic support for < 12 hours in the intensive care unit. CONCLUSION: Institution of systematic hemodynamic management was associated with the successful completion of the surgical procedure in 61 patients (92%). Only 5 patients required conversion to regular CABG surgery with cardiopulmonary bypass.