cardiacAnesUpdate08 - Update in Cardiac Anesthesia Charles...

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Update in Cardiac Anesthesia Charles Smith, MD Professor of Anesthesia Director, Cardiothoracic Anesthesia MetroHealth Medical Center Case Western Reserve University School of Medicine Cleveland, Ohio
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Objectives Review practice trends Discuss lessons learned from SCA annual meeting, Vancouver, June 2008 Evaluate controversial issues
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Aprotinin Cardiac surgery pts receive 10% RBCs Antifibrinolytics: standard of care to ↓ trx Multiple RCTs: aprotonin ↓ blood loss + trx 2006 observational study [Mangano]: Aprotinin AEs: renal, cardiac + neuro outcome. Labeling changed by manufacturer + ongoing studies stopped abruptly C. David Mazer. The Aprotinin Controversy
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Aprotinin, cont’d Manufacturer released database: 70,000 pts - ↑ AEs + mortality BART study: B lood conservation using A ntifibrinolytics. Canadian multicenter R CT Amicar vs tranexamic acid vs aprotinin Terminated early after 2163 pts b/c ↑ mortality in aprotinin gp despite ↓ bleeding + reop Subsequent studies: aprotinin assoc w renal dysfunction, ↑ Cr + ↑ mortality C. David Mazer. The Aprotinin Controversy
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Recombinant Factor VIIa Approved for hemophilia if bleeding + inhibitors against replacement coag factors. First report of its use was in an Israeli soldier with uncontrollable bleeding in 1999 Rationale: will only induce coagulation in those sites where tissue factor (TF) is also present. Multiple case reports of success in uncontrolled hemorrhage after failure of standard therapy Ian Black. Anesthesia on the frontlines. Lessons from Iraq
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Recombinant Factor VIIa Military in Iraq using FVIIa off label Massive trx protocol: 1-2 doses FVIIa, 35-70 mcg/kg 1:1 FFP: pRBC Level of evidence: 2C (weak) b/c lack of studies AEs: arterial thrombosis, MI, DVT, PE, CVA Ian Black. Anesthesia on the frontlines. Lessons from Iraq
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Ascending Aorta + Transverse Arch Surgery Neuroprotection strategy is key element for repair of ascending aorta + transverse arch Techniques vary widely: DHCA Selective brain perfusion Retrograde brain perfusion All geared towards preventing stroke + neurocognitive dysfunction David L. Reich. Brain protection during ascending aortic and transverse aortic arch surgery.
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Ascending Aorta + Transverse Arch Surgery Many non-randomized reports of clinical cohorts- problems w institutional preferences, publication bias, and changes over time: surgical technique, perfusion technology, anesthesia, monitors, prosthetic graft materials, ICU. Best method: short periods of DHCA + antegrade axillary artery perfusion David L. Reich. Brain protection during ascending aortic and transverse aortic arch surgery.
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DHCA 30-40 min at 18 C generally safe in infants + children Longer periods: preferential damage to basal ganglia which controls tone + movement Formation of free radicals + dopamine release may be major cause of endothelial damage +
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This note was uploaded on 12/16/2011 for the course BIOLOGY 101 taught by Professor Mr.wallace during the Fall '11 term at Montgomery College.

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cardiacAnesUpdate08 - Update in Cardiac Anesthesia Charles...

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