Zinc intake, status and indices of cognitive function in adults and children: a systematic review and meta-analysis.

In developing countries, deficiencies of micronutrients are thought to have a major impact on child development; however, a consensus on the specific relationship between dietary zinc intake and cognitive function remains elusive. The aim of this systematic review was to examine the relationship between zinc intake, status and indices of cognitive function in children and adults. A systematic literature search was conducted using EMBASE, MEDLINE and Cochrane Library databases from inception to March 2014. Included studies were those that supplied zinc as supplements or measured dietary zinc intake. A meta-analysis of the extracted data was performed where sufficient data were available. Of all of the potentially relevant papers, 18 studies met the inclusion criteria, 12 of which were randomised controlled trials (RCTs; 11 in children and 1 in adults) and 6 were observational studies (2 in children and 4 in adults). Nine of the 18 studies reported a positive association between zinc intake or status with one or more measure of cognitive function. Meta-analysis of data from the adult's studies was not possible because of limited number of studies. A meta-analysis of data from the six RCTs conducted in children revealed that there was no significant overall effect of zinc intake on any indices of cognitive function: intelligence, standard mean difference of <0.001 (95% confidence interval (CI) -0.12, 0.13) P=0.95; executive function, standard mean difference of 0.08 (95% CI, -0.06, 022) P=0.26; and motor skills standard mean difference of 0.11 (95% CI -0.17, 0.39) P=0.43. Heterogeneity in the study designs was a major limitation, hence only a small number (n=6) of studies could be included in the meta-analyses. Meta-analysis failed to show a significant effect of zinc supplementation on cognitive functioning in children though, taken as a whole, there were some small indicators of improvement on aspects of executive function and motor development following supplementation but high-quality RCTs are necessary to investigate this further.

The relationship between zinc intake and growth in children aged 1-8 years: a systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: It is estimated that zinc deficiency affects 17% of the world's population, and because of periods of rapid growth children are at an increased risk of deficiency, which may lead to stunting. This paper presents a systematic review and meta-analysis of the randomised controlled trials (RCTs) that assess zinc intake and growth in children aged 1-8 years. This review is part of a larger systematic review by the European Micronutrient Recommendations Aligned Network of Excellence that aims to harmonise the approach to setting micronutrient requirements for optimal health in European populations (www.eurreca.org). SUBJECT/METHODS: Searches were performed of literature published up to and including December 2013 using MEDLINE, Embase and the Cochrane Library databases. Included studies were RCTs in apparently healthy child populations aged from 1 to 8 years that supplied zinc supplements either as capsules or as part of a fortified meal. Pooled meta-analyses were performed when appropriate. RESULTS: Nine studies met the inclusion criteria. We found no significant effect of zinc supplementation of between 2 weeks and 12 months duration on weight gain, height for age, weight for age, length for age, weight for height (WHZ) or WHZ scores in children aged 1-8 years. CONCLUSIONS: Many of the children in the included studies were already stunted and may have been suffering from multiple micronutrient deficiencies, and therefore zinc supplementation alone may have only a limited effect on growth.

Expression of inflammatory cytokines following acute spinal cord injury in a rodent model.

Many therapies that have been developed for acute spinal cord injury (SCI) either influence or are influenced by posttraumatic inflammation. Many such therapies have reportedly produced promising neurologic benefits in animal models of SCI, but demonstrating convincing efficacy in human clinical trials has remained elusive. This discrepancy may be related in part to differences in the inflammatory response to SCI between human patients and the widely studied rodent models. Our objectives were, therefore, to establish the time course of inflammatory cytokine release in the spinal cord of rats after a thoracic contusion, to determine whether the cytokine release was injury dependent, and to correlate these findings with those that we have recently reported for the cerebrospinal fluid (CSF) of human SCI patients. After rodent SCI, GRO (the rat equivalent of IL-8), IL-6, IL-1α, IL-1ß, IL-13, MCP-1, MIP1α, RANTES, and TNFα were elevated within the spinal cord, whereas IL-12p70 was decreased. In human SCI, IL-6, IL-8, and MCP-1 were also elevated within the cerebrospinal fluid but at later times than those observed in the rodent spinal cord. IL-6, IL-8, and MCP-1 were released in an injury-dependent manner in both the rodent model of SCI and the human condition. In this regard, similar patterns of expression were observed for a number of inflammatory cytokines after SCI in rodent spinal cords and in human CSF. Such proteins may therefore have potential utility as biomarkers and surrogate outcome measures for evaluating biological response to therapeutic interventions.

Chimeric pig hearts resist hyperacute rejection in ex vivo perfusion model.

With surrogate tolerogenesis. the recipient immune system is engrafted within the donor pig before organ transplant. Chimeric pig hearts may resist hyperacute rejection by inducing accommodation. This hypothesis was tested using an ex vivo isolated piglet heart perfusion model. Processed sheep marrow was infused into fetal pigs at 45 days gestation. Heart explants from chimeric or nonchimeric pigs were suspended in a Langendorff apparatus and perfused with plasma from unsensitized sheep or sensitized sheep. Nonchimeric hearts perfused with plasma from unsensitized functioned for 240 min (N = 3). Nonchimeric hearts perfused with sensitized plasma deteriorated rapidly, functioning at 19+/-12 min (N = 6); Immunohistochemistry of heart graft revealed extensive deposition of IgG, IgM in the microvascular. In contrast, chimeric hearts perfused with sensitized plasma functioned for 183+/-46 min (N = 3)(p <.001); Deposition of IgG, IgM had substantially less. Heart grafts procured from chimeric pigs survived in the presence of antidonor IgG, IgM, and complement, demonstrating that chimeric pig hearts resist hyperacute rejection.

The effect of PaCO2 on cerebral perfusion: an experimental swine model.

Adequate cerebral perfusion is of particular concern to the clinician and is a major factor in postoperative morbidity. Cerebral circulation has the ability to autoregulate blood flow in order to maintain nutrient delivery and prevent high intravascular pressures. The focus of this study was to characterize the impact of gradually changing arterial CO2 levels on cerebral perfusion. A total of eight porcine subjects were placed into either a normothermic group (NG, N = 4, rectal temperature = 35.4+/-1.2 degrees C) or a hypothermic group (HG, N = 4, 30.6+/-0.6 degrees C). After initiation of cardiopulmonary bypass, the PaCO2 values sequentially varied between 24 and 56 mmHg. Arterial, venous, and internal jugular blood gas data were collected at 4 mmHg increments, and relative cerebral blood flow was calculated as CBF = 1 (CarterialO2-CjugularO2)(-1) Physiological parameters were similar in both groups across all test conditions: mean arterial pressure-NG 81.6+/-11.9 mmHg versus HG 73.4+/-7.0 mmHg, p = NS, and systemic oxygen consumption-HG 110.6+/-30.0 mL min versus NG 136.4+/-37.9 mL min(-1), p = NS. No significant differences were found in CBF in the NG (21.8+/-4.4 mL min(-1) 100 gL at PaCO2 = 56 mmHg versus 20.5+/-5.0 mL min(-1) 100 g(-1) at PaCO2 = 24 mmHg) or the HG (24.3+/-9.5 mL min(-1) 100 g(-1) at PaCO2 = 56 mmHg versus 25.6+/-12.0 mL min(-1) 100 g(-1) at PaCO2 = 24 mmHg). In conclusion, the alteration of PaCO2 under both hypothermic and normothermic conditions resulted in no significant differences in 1 (CarterialO2 - CjugularO2)(-1) in this model.

An in vitro study of the effects of isoflurane on oxygen transfer.

A common anesthetic technique utilized during cardiopulmonary bypass (CPB) includes the use of various inhalation agents, such as isoflurane. The purpose of this study was to evaluate the effects of this agent on oxygen transfer during CPB. An in vitro model was designed using bovine blood. Blood flow was held constant at 2 l/min, while gas flow was manipulated at 1 and 3 l/min. The percentage of inspired oxygen (FiO2) was set at 50 and 100%, and isoflurane was manipulated to 1.0, 3.0 and 5.0%. Blood gas analysis, oxygen transfer, and inlet and outlet isoflurane concentrations were measured at each of the given conditions. A total of 12 trials with four oxygenators were conducted. In the four oxygenators used in our study, no significant differences in oxygenator performance were found. At conditions of 1 I/min gas flow, 50% FiO2 and 1% isoflurane, there were no significant changes in O2 transfer between baseline and measurements taken during isoflurane administration (100.18 +/- 12.49 vs 102.35 +/- 10.99 ml O2/min, p=0.8031). At 3 I/min gas flow, 100% FiO2 and 5% isoflurane, no significant differences were found (142.35 +/- 10.76 vs 154.04 +/- 8.95 ml O2/min, p=0.1459). The only significant differences found for oxygen transfer were between 50 and 100% FiO2, all other conditions being set equal (102.35 +/- 10.99 vs 137.68 +/- 8.62 ml O2/min, p=0.0023). In conclusion, increasing concentrations of isoflurane up to 5% does not affect the efficiency of oxygen transfer in an in vitro circuit. Further studies are necessary to evaluate the effects in an in vivo setting.

Quantitative evaluation of hypothermia, hyperthermia, and hemodilution on coagulation.

The purpose of this study was to investigate the effects of temperature change on the coagulation time of blood at two different hematocrit levels by using various coagulation-monitoring devices. The devices used in this study were the Bayer Rapid Point Coag Analyzers, Hemochron Jr. Signature, Hemochron Response, Medtronic ACT II, and Haemoscope Thrombelastograph. One unit of human bank blood was used in this study. The hematocrit level was adjusted to 40% and 20%. A control bath and experimental bath were set up. Control blood was maintained at 37 degrees C and tested every 45 +/- 15 min throughout the experimental period of 6 h to demonstrate the stability of the model. The experimental blood was tested at temperature points of 37, 32, 27, 32, 37, 42, and 37 degrees C. Activated clotting time (ACT) tended to increase when the temperature was initially decreased from 37 to 27 degrees C, which reached a statistically significant level when measured by the Hemochron Response at both the 20% (147 +/- 10.7 to 159.3 +/- 11.0, p < .0332) and 40% hematocrit level (130 +/- 14.9 to 152.1 +/- 19.7, p < .0148). ACT was decreased significantly (p < .05) when the temperature was increased to 42 degrees C as measured by all machines except the Hemochron Jr. Signature at the 20% hematocrit level. ACT was significantly higher (p < .05) at a 20% hematocrit level as compared to that at a 40% hematocrit level on all devices for the majority of temperature points. These data suggested that hypothermia only increased ACT when measured by a macrosample device requiring a milliliter sample (Hemochron Response). However, hemodilution induced anticoagulatory effects and hyperthermia caused an acceleration in coagulation by all devices utilized in this study.

Effect of partial-filling autotransfusion bowls on the quality of reinfused product.

Intraoperative autotransfusion is used in a variety of surgical procedures with the quantity of blood loss dependent upon numerous factors. These procedures may or may not produce a full autotransfusion bowl. The inadequate removal of contaminants has been correlated to the incomplete filling of bowls, resulting in a condition called "Salvaged Blood Syndrome." The purpose of this study was to assess the quality of aspirated whole blood after processing with an autotransfusion system using various fill volumes and two wash volumes. An in vitro circuit was designed to mimic the mechanical effects of extracorporeal flow on blood. Twenty-four Baylor-style bowls were filled at 400 mL min(-1) and washed at 300 mL min(-1). Two wash volumes, 1000 and 2000 mL, and three bowl volumes: low, mid, and full, were used in this study. The bowl volumes were determined by using red cell quantities of 60, 100, and 135 mL for the low-fill, mid-fill, and full bowls, respectively. Samples were drawn pre-autotransfusion and post-autotransfusion and analyzed for plasma-free hemoglobin, IL-8, white blood cell count, platelet count, albumin, and total protein. All data were analyzed using one-way analysis of variance (ANOVA) with significance accepted at p > or = .05. Plasma-free hemoglobin levels and hematocrit were concentrated significantly (p < .05) as bowl volume increased. A significant difference in IL-8 levels was found in the wash volumes in the low-fill bowls (p < .02). Platelet count was significantly decreased between the full bowl with 1000 mL wash and the full bowl with 2000 mL wash (p < .0004). Total protein reduction was significantly less in the low-fill bowl with 1000 mL wash as compared to the other bowl treatments (p < .05). In conclusion, the quality of the washed product did not vary significantly between fill or wash volumes, with the exception of the low-fill bowl with 1000 mL wash.

Effects of ultrafiltration on enoxaparin: an in vitro analysis.

The use of low molecular weight heparins (LMWH) as an anticoagulant in the heparin-resistant patient poses challenges during cardiopulmonary bypass (CPB). The ultrafiltrability of LMWH has not been previously examined. The purpose of this study was to determine the effects of continuous ultrafiltration on the concentraton of a LMWH, enoxaparin. An in vitro analysis was performed using fresh whole human blood and an extracorporeal circuit containing four parallel ultrafiltrators and a cardiotomy reservoir with an integrated heat exchanger. Constant conditions included temperature (37 degrees C), flow (0.20 L-min(-1)) transmembrane pressure (200 mmHg), and hematocrit (25 +/- 2%). Samples were collected at the inlet, outlet, and ultrafiltrate line at one and three min for one control trial and again for each of the four hemoconcentrators following the bolus of enoxaparin. Coagulation measurements included a viscoelastic monitor (TEG), activated clotting time (ACT), activated partial thromboplastin time (aPTT), and quantitative analysis utilizing a membrane-based electrode for potentiometric measurement of polyanionic concentrations of enoxaparin. Enoxaparin concentration, from inlet to outlet, increased from 2.95 +/- 0.64 to 5.89 +/- 0.95 (p < .001) at 1 min and 4.24 +/- 0.49 to 7.89 +/- 0.606 (p < .001) at 3 min. Kinetic clot activity, as assessed by the TEG index, decreased from -3.8 +/- 2.5 vs. -10.5 +/- 6.0; (p < .01) pre- to postultrafiltrator samples after 3 min. ACT and aPTT results demonstrated no significant change. In conclusion, this study demonstrates enoxaparin is concentrated with the use of continuous ultrafiltration. Functional coagulation studies also indicate a concentrating effect, primarily via the TEG.

An update on perfusion safety: does the type of perfusion practice affect the rate of incidents related to cardiopulmonary bypass?

Cardiopulmonary bypass (CPB) techniques vary among adult and pediatric patients undergoing cardiac surgery. This may result in a differential conduct of CPB between various aged patients. The present study reports on perfusion incidents occurring in hospitals using extracorporeal circulation. An 80 question survey was mailed to chief perfusionists at all 1030 US cardiac surgical centers. Respondents were asked to report on device use and incidents occurring during a 2-year period from July 1996 to June 1998. Five hundred and twenty-four completed surveys were returned with the age of surgical patients operated on at each hospital defined as either an adult (n=407), pediatric (n=17), or combined-adult and pediatric (n=100). Centrifugal pumps were used as the primary systemic pumps in 54% of adult, 12% of pediatric, and 36% of combined centers. In-line blood gas monitoring was used in 76% of all pediatric hospitals, but in only 30% of adult facilities. Incident rates occurred once per every 120.9, 83.9, and 220.2 cases in adult, pediatric, and combined centers, respectively. Mortality rates related to CPB occurred 2.7 times higher in adult and pediatric centers as compared to combined hospitals. Arterial dissection was the number one cause of death in both pediatric and combined hospitals, while coagulation disturbances resulted in the highest mortality for adult procedures. Results of this study show that the lowest incident rates occur at hospitals performing combined adult and pediatric CPB.

The effect of priming techniques of ultrafiltrators on blood rheology: an in vitro evaluation.

The increased interest of using ultrafiltration during cardiopulmonary bypass ICPB) has mandated a re-evaluation of the hematological effects of this blood conservation process. 'Rinse-free' ultrafiltrators can be primed using either crystalloid or blood prior to use. It is unknown whether one priming technique results in superior results in ultrafiltration quality. An in vitro circuit was designed to evaluate the Sorin/COBE HC1400 (n=6), the Lifestream HC70 (n=6), and the Terumo/Sarns HC11 (n=6). All test conditions were conducted at a blood flow rate of 250 ml/min and a transmembrane pressure of 250 mmHg. Samples were drawn and analyzed at four distinct time points for hematocrit, total protein, plasma free hemoglobin, interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNFalpha). The HC11 had significantly greater percent increases in hematocrit under the blood priming protocol (29.2+/-7.9) than either the HC1400 (11.0+/-7.8, p<0.03) or the HC70 (11.9+/-7.8, p<0.04). When crystalloid priming was compared to blood priming, the HC1400 and HC70 produced significant percent increases in hematocrit and total protein levels. The HC1400 devices produced significantly less plasma free hemoglobin when primed with crystalloid rather than blood (43.6+/-38.3 vs 21.3+/-5.6, p<0.01). There were no significant differences between devices or priming techniques for IL-6, IL-8 or TNFalpha levels. In conclusion, the efficiency of the ultrafiltrators was elevated when primed with crystalloid before use. Cytokine levels were relatively unchanged with priming techniques, while plasma free hemoglobin levels were reduced with those devices previously primed with crystalloid.

An experimental evaluation of continuous cardiotomy reservoir ultrafiltration.

Ultrafiltration has been suggested as a means to reduce the morbidity associated with blood activation. However, the application of ultrafiltration to the highly activated blood of the cardiotomy suction subcircuit has not been investigated. The purpose of this study was to determine whether cardiotomy reservoir ultrafiltration (CRUF) would be effective in altering cytokine levels. Six swine, undergoing 90 min of cardiopulmonary bypass (CPB), were divided into two groups; one group was assigned to receive CRUF (N = 3), the other was to serve as controls and did not receive ultrafiltration (N = 3). Blood samples were analyzed for hematocrit, plasma-free hemoglobin, total protein, interleukin-8 (IL-8), and tumor necrosis factor alpha (TNF-alpha). Samples were taken pre-bypass, postheparinization, every 30 min during CPB, post-CPB and postprotamine. All data were analyzed using a one-way analysis of variance (ANOVA), with significance accepted at p < .05. There were no significant differences found between treatment and control groups for plasma-free hemoglobin levels (22.4 +/- 22.2 vs. 14.6 +/- 14.4; 40.1 +/- 26.1 vs. 40.0 +/- 19.3). After 90 min of ultrafiltration, there was a significant decrease in TNF-alpha (261.6 +/- 119.6 vs. 71.8 +/- 11.4; p = .02). Although IL-8 levels decreased from throughout the experiment, concentrations did not reach statistical significance. In conclusion, CRUF can be used without increasing cellular destruction, and can decrease certain cytokine levels. Our results suggest that further clinical studies should be undertaken utilizing this technique with a larger sample size.

The effect of volume replacement on serum protein concentration during cardiopulmonary bypass.

Although controversy exists concerning the optimal total protein and colloid osmotic pressure that should be maintained during cardiopulmonary bypass (CPB), the primary volume expanders remain albumin and 6% hetastarch. The purpose of this study was to quantify the effect of adding boluses of volume replacement agents under various conditions to total serum protein values during CPB. A standard CPB circuit was utilized in eight 45-kg swine that had a priming volume (physiologic saline solution) of 2309 +/- 245 mL. Volumetric alterations occurred throughout the CPB period by the addition of combinations of physiologic saline solution, 6% hetastarch or 5% swine albumin. Pre- and postadministration samples were assayed for total serum protein, total protein, and albumin throughout the CPB period and at pre- and postvolume administration times. There was a significant decline in total serum protein with the initiation of CPB (6.14 +/- 0.49 g/dL vs. 3.40 +/- 0.43 g/dL, p < .0001). Addition of 12.5 g of swine albumin (N = 5) to two different swine increased total serum protein significantly when compared to adding 500 mL of 6% hetastarch (N = 6) (swine albumin 12.4 +/- 6.3% vs. hetastarch 3.3 +/- 2.1%, p < .005). A reduction in total serum protein occurred after hemodilution with varying amount of physiologic saline solution: 250-450 mL (7.4 +/- 4.5%), 451-650 mL (9.6 +/- 5.6%), and 651-1050 mL (19.4 +/- 4.0%). In summary, knowledge of total serum protein concentration and estimated circulating blood volume can be used to guide albumin and hetastarch administration following hemodilution.

In vitro evaluation of the Medtronic cardioplegia safety system.

Myocardial preservation demands the precise and accurate delivery of cardioplegic solutions to provide nutritive delivery and metabolic waste removal. The purpose of this study was to evaluate the performance characteristics of the Medtronic CSS Cardioplegia Safety System in an in vitro setting. The CSS was evaluated under the following conditions: blood to crystalloid ratios of 1:0, 1:1, 4:1, 8:1, 0:1; potassium concentrations of 10, 20, and 40 mEq L-1; volumetric delivery collection at 100, 250, 500, 750, and 990 mL/min; pressure accuracy at 100 and 300 mmHg; and system safety mechanisms. Measured and predicted values from the CSS were compared using one way ANOVA, with statistical significance accepted at p < or = 0.05. The measured values for the tested ratios and volume collections were all within the manufacturer's technical parameters. Potassium concentration results were all within expected values except at 100 mL/min, where the measured value of 17.1 +/- 2.1 mmol was lower than the expected 20.0 +/- 0.2 mmol (p < .034). As flow rates changed, the CSS line pressure error was constant (0.5 to 3.7%), and the only significant difference was observed at 100 mmHg, 500 mL/min (102.3 +/- 1.7 vs. 100.0 +/- 0.0 mmHg, P < .003). The device performed accurately and reliably under all simulated safety conditions, including bubble detection, over pressurization and battery backup. In conclusion, the performance of the CSS was within the manufacturer's specifications for the majority of the tested conditions and operated safely when challenged under varying conditions.

Factors affecting perfusionists' decisions on equipment utilization: results of a United States survey.

The decision to utilize extracorporeal equipment is influenced by a number of factors, including clinical efficacy, cost effectiveness, and personal judgment. The purpose of this study was to report the results of a national survey that examined factors affecting perfusionists' decisions on equipment utilization. An 80-question survey was mailed to chief perfusionists at 1030 U.S. hospitals performing open-heart surgery. 524 completed surveys were returned, which represented 797 hospitals (78.8%) and 671,290 procedures over a 2-year period (July 1996-June 1998). Within the survey, 36 questions pertained to equipment utilization and served as the basis for this report. The perfusion equipment that had seen the greatest reduction in use were; heparin-coated circuits (HCC) (12.0%), in-line blood gas monitors (9.7%), soft-shell venous reservoirs (SSVR) (7.2%), and in-line arterial hemoglobin monitors (6.3%). Cost was the major determinant affecting the decision for the following devices: in-line blood gas monitors (82.4%), cardioplegia in-line delivery filters (75.0%), in-line arterial hemoglobin monitors (69.7%), HCC (55.6%), and SSVR (43.2). Ineffectiveness was the major reason reported for discontinuation of arterial-line bubble traps (64.7%), venous reservoir level detectors (50.0%), and arterial-line pressure manometers with pump shutdown (50.0%). 438 respondents discontinued use of one or more of 29 different devices during the past 2 years. Cost was the major reason in 52.7% of the cases, ineffectiveness in 33.1%, and 14.2% were in a category labeled "other." The pressures brought upon by the changing healthcare structure have influenced perfusionists' equipment selection, with cost being a major factor affecting clinical decisions for certain device utilization.

Pre-operative coagulopathy management of a neonate with complex congenital heart disease: a case study.

Severe coagulation defects often develop in neonates undergoing cardiac surgery, both as a result of the surgical intervention, and as pre-existing defects in the hemostatic mechanisms. The following case report describes a newborn patient with complex congenital heart disease and respiratory failure whose pre-operative coagulopathy was aggressively managed prior to surgical correction. A 5-day-old, 2.5 kg child presented with interrupted aortic arch, ventricular septal defect, atrial septal defect, and patent ductus arteriosus. On admission, he was in respiratory arrest suffering from profound acidemia. In addition, the child was hypothermic (30.1 degrees C), septic (Streptococcus viridans), and coagulopathic (disseminated intravascular coagulation-DIC). The patient was immediately intubated and initial coagulation assessment revealed the following: prothrombin time (PT) 48.9 s (international normalized ratio (INR) 15.7), activated partial thromboplastin time (aPTT) >106 s, platelet count 30,000 mm(3), fibrinogen 15 mg dL(-1) and antithrombin III (AT-III) 10%. Before cardiac surgery could be performed, the patient's DIC was corrected with the administration of cryoprecipitate (15 ml), fresh frozen plasma (300 ml), and platelets (195 ml). In spite of the large transfusion of fresh frozen plasma, the AT-III activity, measured as a percentage, remained depressed at 33. Initial thromboelastographic (TEG) determination revealed an index of +2.02, and following 100 IU administration of an AT-III concentrate, declined to -2.32. Sequential TEG profiles were performed over several days, with the results used to guide both transfusion and medical therapy. The congenital heart defect correction was subsequently performed with satisfactory initial results, but the patient developed a fungal infection and expired on the 16th post-operative day. The present case describes techniques of coagulation management for a newborn with both a severe hemostatic defect and congenital heart disease.

A retrospective study on perfusion incidents and safety devices.

Despite the acceptance of extracorporeal circulation as an effective modality to facilitate cardiac surgery, patient outcomes can be negatively influenced by the occurrence of perfusion incidents. A perfusion survey was conducted to identify safety techniques and incidents related to cardiopulmonary bypass (CPB). An 80-question survey was mailed to chief perfusionists of all 1030 USA cardiac surgical centers using CPB. The survey was designed to examine practices and incidents that occurred during a 2-year period (July 1996 to July 1998). Five-hundred-and-fifty-two (54% response rate) surveys were returned, which accounted for 797 hospitals (79% of all cardiac centers) and 653,621 surgical procedures. Of the 27 identified CPB safety devices, the highest utilization was arterial line filters (98.5%) and the lowest arterial line bubble traps (3.4%). Of the reported cases, a CPB incident occurred once every 138 cases. The most common occurring incidents were protamine reactions (1:783), coagulation problems (1:771), and heater/cooler failures 11:1809). The rate of occurrence of an incident resulting in a serious injury or death was one for every 1453 procedures. Although techniques and safety devices create a relatively secure environment for CPB, lower incident rates may be achieved with further improvements in coagulation monitoring and incident reporting.

The effects of continuous blood gas monitoring during cardiopulmonary bypass: a prospective, randomized study--Part I.

The use of continuous in-line blood gas management (CILBGM) is steeped in controversy concerning its potential utility and impact on patient outcomes. The purpose of this study was to determine whether the use of CILBGM results in improved quality of patient care. Fifty-nine patients were enrolled in a Institutional Review Board-approved, prospective, randomized study. An in-line blood gas monitor (CDI 500) was placed into the arterial and venous lines for all patients. Blood gas monitoring in the control group was managed by intermittent sampling (every 20-30 min), while the treatment group was managed with continuous monitoring. There were no differences between groups in preoperative, surgical, anesthetic, or perfusion variables. The accuracy of the in-line monitor was comparable to laboratory analysis for arterial blood gas parameters (N = 160; pH bias = 0.00; PaCO2 bias = -1.1 mmHg; and PaO2 bias = 0.7 mmHg). There was less deviation from target values (pH = 7.40, PaCO2 = 40 mmHg, PaO2 = 150-200 mmHg) when in-line monitoring was used versus intermittent sampling (N = 784; pH deviation = 0.05 +/- 0.03 vs. 0.03 +/- 0.01, p < 0.0001; PaCO2 deviation = 4.0 +/- 2.9 mmHg vs. 2.0 +/- 0.9 mmHg, p < 0.0001; and PaO2 deviation = 22.7 +/- 16.9 mmHg vs. 11.7 +/- 8.3 mmHg, p < 0.0001). In conclusion, the results of part I of this study demonstrate that the use of CILBGM results in more accurate blood gas management during CPB.