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In a randomized trial, over 4500 patients undergoing cardiac surgery were assigned to receive tranexamic acid or placebo. There was no difference between groups in the rate of death or thrombotic complications. The tranexamic acid group had less bleeding and more seizures. Excessive bleeding and blood transfusions are common in patients undergoing cardiac surgery, 1 and in some of these patients, there is a need for reoperation because of life-threatening bleeding. 2 Both blood transfusion and reoperation are strongly associated with poor outcomes after cardiac surgery. 2 , 3 Antifibrinolytic therapy reduces the risk of blood loss and transfusion among patients undergoing cardiac surgery, 4 , 5 but it is unclear whether such therapy reduces the risk of reoperation for bleeding. 4 Antifibrinolytic agents that have been used in patients undergoing cardiac surgery include aprotinin 6 , 7 and the lysine analogues tranexamic acid and aminocaproic acid. 8 – 11 These agents may . . .

In this clinical trial involving patients undergoing high-risk cardiac surgery, aprotinin was somewhat more effective than either aminocaproic acid or tranexamic acid in reducing massive perioperative bleeding but at the expense of a higher rate of death, mainly from cardiac causes. Aprotinin cannot be recommended to control blood loss in this clinical setting. In patients undergoing high-risk cardiac surgery, aprotinin was somewhat more effective than either aminocaproic acid or tranexamic acid in reducing massive perioperative bleeding but at the expense of a higher rate of death, mainly from cardiac causes. Every year an estimated 1 million to 1.25 million patients worldwide undergo cardiac surgery, including high-risk procedures such as repeat coronary-artery bypass grafting (CABG), valve replacements, and combined procedures. 1 High-risk procedures present an increased risk of death, massive bleeding, renal failure, and thrombotic complications, as compared with first-time isolated CABG. 2 – 4 Three antifibrinolytic agents have been used in cardiac surgery to minimize bleeding and reduce the need for transfusion: aprotinin, a naturally occurring serine protease inhibitor, and two lysine analogues, tranexamic acid and aminocaproic acid. 5 In clinical trials, all three drugs have been shown to be effective in reducing the . . .

Purpose There is an elevated incidence of hypoxemia during the airway management of the morbidly obese. We aimed to assess whether optimizing body position and ventilation during pre-oxygenation allow a longer safe non-hypoxic apnea period (SNHAP). Methods Fifty morbidly obese patients were recruited and randomized for this study. Patients were positioned and preoxygenated for three minutes in the ramp position associated with spontaneous breathing without additional CPAP or PEEP (RP/ZEEP group) or in the reverse Trendelenburg position associated with pressure support ventilation mode with pressure support of 8 cmH 2 O and an additional 10 cmH 2 O of PEEP while breathing spontaneously (RT/PPV group) according to randomization. Results The SNHAP was significantly longer in the RT/PPV group (258.2 (55.1) vs. 216.7 (42.3) seconds, p  = 0.005). The RT/PPV group was also associated to a shorter time to obtain a fractional end-tidal oxygen concentration (FEtO 2 ) of 0.90 (85.1(47.8) vs 145.3(40.8) seconds, p  < 0.0001), a higher proportion of patients that reached the satisfactory FEtO 2 of 0.90 (21/24, 88% vs. 13/24, 54%, p  = 0.024), a higher FEtO 2 during preoxygenation (0.91(0.05) vs. 0.89(0.01), p  = 0.003) and a faster return to 97% oxygen saturation after ventilation resumption (69.8 (24.2) vs. 91.4 (39.2) seconds, p  = 0.038). Conclusion In the morbidly obese population, RT/PPV, compared to RP/ZEEP, lengthens the SNHAP, decreases the time to obtain optimal preoxygenation conditions, and allows a faster resuming of secure oxygen saturation. The former combination allows a more significant margin of time for endotracheal intubation and minimizes the risk of hypoxemia in this highly vulnerable population. Trial registration NCT02590406, 29/10/2015.

PurposeIn morbidly obese patients, the position and ventilation strategy used during pre-oxygenation influence the safe non-hypoxic apnea time and the functional residual capacity (FRC). In awake morbidly obese volunteers, we hypothesized that the FRC would be higher after a five-minute period of positive pressure ventilation compared with spontaneous ventilation at zero inspiratory pressure.MethodsUsing a prospective crossover randomized trial design, obese subjects underwent, in a randomized order, a combination of one of three positions, supine (S), beach chair (BC), and reverse Trendelenburg (RT), and one of two ventilation strategies, spontaneous ventilation at zero inspiratory pressure (ZEEP-SV) or with positive pressure (PP-SV) set to an inspiratory pressure of 8 cmH2O, positive end-expiratory pressure of 10 cmH2O, and fraction of inspired oxygen of 0.21.ResultsSeventeen obese volunteers with a mean (standard deviation; SD) body mass index of 50 (8) kg·m−2 were included. Mean (SD) FRC in the three positions (S, BC, RT) was significantly higher using PP-SV compared with ZEEP-SV [2571 (477) vs 2215 (481) mL, respectively; mean difference, 356; 95% confidence interval (CI), 209 to 502; P < 0.001]. Mean (SD) FRC was significantly higher in the RT compared with BC position [2483 (521) vs 2338 (469) mL, respectively; mean difference, 145; 95% CI, 31 to 404; P = 0.01], while there was no difference between S and BC [2359 (519) mL vs 2338 (469) mL, respectively; mean difference, 21; 95% CI, -93 to 135; P = 0.89].ConclusionIn awake morbidly obese volunteers, an increase in the FRC is observed when spontaneous ventilation at zero inspiratory pressure is switched to positive pressure. Compared with S positioning, the BC position had no measurable impact on the FRC. The RT position resulted in an optimal FRC.Trial registrationclinicaltrials.gov (NCT02121808). Registered 24 April 2014.

Persistent postoperative pain continues to be an underrecognized complication. We examined the prevalence of and risk factors for this type of pain after cardiac surgery. We enrolled patients scheduled for coronary artery bypass grafting or valve replacement, or both, from Feb. 8, 2005, to Sept. 1, 2009. Validated measures were used to assess (a) preoperative anxiety and depression, tendency to catastrophize in the face of pain, health-related quality of life and presence of persistent pain; (b) pain intensity and interference in the first postoperative week; and (c) presence and intensity of persistent postoperative pain at 3, 6, 12 and 24 months after surgery. The primary outcome was the presence of persistent postoperative pain during 24 months of follow-up. A total of 1247 patients completed the preoperative assessment. Follow-up retention rates at 3 and 24 months were 84% and 78%, respectively. The prevalence of persistent postoperative pain decreased significantly over time, from 40.1% at 3 months to 22.1% at 6 months, 16.5% at 12 months and 9.5% at 24 months; the pain was rated as moderate to severe in 3.6% at 24 months. Acute postoperative pain predicted both the presence and severity of persistent postoperative pain. The more intense the pain during the first week after surgery and the more it interfered with functioning, the more likely the patients were to report persistent postoperative pain. Pre-existing persistent pain and increased preoperative anxiety also predicted the presence of persistent postoperative pain. Persistent postoperative pain of nonanginal origin after cardiac surgery affected a substantial proportion of the study population. Future research is needed to determine whether interventions to modify certain risk factors, such as preoperative anxiety and the severity of pain before and immediately after surgery, may help to minimize or prevent persistent postoperative pain.

Abstract Rationale Lower limb muscle dysfunction contributes to exercise intolerance in chronic obstructive pulmonary disease (COPD). We hypothesized that signaling from lower limb muscle group III/IV sensory afferents to the central motor command could be involved in premature cycling exercise termination in COPD. Objectives To evaluate the effects of spinal anesthesia, which presumably inhibited central feedback from the lower limb muscle group III/IV sensory afferents on exercise tolerance and cardiorespiratory response during constant work-rate cycling exercise in patients with COPD. Methods In a crossover and double-blind randomized design, eight patients with COPD (FEV1, 67 ± 8% predicted) completed a constant work-rate cycling exercise after sham (NaCl, interspinous L3–L4) or active (fentanyl 25 μg, intrathecal L3–L4) spinal anesthesia. Measurements and Main Results When compared with placebo, endurance time was significantly prolonged after spinal anesthesia with fentanyl (639 ± 87 s vs. 423 ± 38 s [mean ± SEM]; P = 0.01). Ventilation and respiratory rate were reduced at isotime points under the fentanyl condition, whereas ventilatory efficiency and dead space ventilation were improved. Patients exhibited less dynamic hyperinflation at isotime points with spinal anesthesia. Consequently, the rise in dyspnea was significantly flatter during the fentanyl condition than with placebo. Conclusions Spinal anesthesia enhanced cycling exercise tolerance in patients with COPD, mostly by reducing ventilatory response and dyspnea during exercise; these effects were possibly mediated through the inhibition of group III/IV lower limb sensory muscle afferents. Clinical trial registered with www.clinicaltrials.gov (NCT01522729).

Cardiopulmonary bypass (CPB) in cardiac surgery is associated with a high risk of postoperative neurological complications. Perioperative use of vasopressors is common to counteract arterial hypotension in this setting. However, use of α‐agonist vasopressors has been associated with cerebral desaturations. Given that reductions in cerebral oxygen saturation (ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$ ) can increase postoperative neurological dysfunction, we aimed to investigate the impact of noradrenaline (NA) and phenylephrine (PE) on ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$during the CPB period of a cardiac surgery in 36 patients scheduled for an elective cardiac surgery. Patients were randomized to the intra‐operative use of either NA or PE. During CPB, mean arterial pressure (MAP) was elevated pharmacologically to predefined thresholds of 60 and 80 mmHg, while CPB flow was kept constant. The ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$values were recorded for 5 min per MAP threshold. The MAP increased adequately between thresholds of 60 and 80 mmHg (NA, 59 ± 3 vs. 81 ± 3 mmHg and PE, 61 ± 4 vs. 81 ± 3 mmHg; P ˂ 0.01). The ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$decreased between pressure thresholds of 60 and 80 mmHg (NA, 70 ± 11 vs. 69 ± 11 mmHg and PE, 64 ± 11 vs. 63 ± 11 mmHg; P ˂ 0.01). Reduction in ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$did not differ between vasopressors. The mean relative decrease in ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$across groups was 2.0% (95% confidence interval: 0.6 to 2.1). Elevation in MAP mediated solely by vasopressors induces significant decreases in ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$during cardiac surgery under CPB. However, their impact on ScO2 ${S_{{\\mathrm{c}}{{\\mathrm{O}}_2}}}$remains clinically non‐significant according to current guidelines. What is the central question of this study? What is the impact of an elevation in mean arterial pressure, mediated by noradrenaline or phenylephrine, on cerebral oxygenation in patients undergoing cardiac surgery with cardiopulmonary bypass. What is the main finding and its importance? The findings indicate that relative cerebral oxygenation decreased by 2% between 60 and 80 mmHg with noradrenaline and phenylephrine. These statistically significant decreases in cerebral oxygenation have no clinical impact. These results support the safety of increasing mean arterial pressure to the upper limit of recommended mean arterial pressure under cardiopulmonary bypass.

In a randomized trial involving 2100 patients undergoing coronary artery surgery, the risk of bleeding within 30 days after surgery was not higher with aspirin than with placebo, nor was the risk of death or thrombosis within 30 days after surgery lower with aspirin than with placebo. Most patients with coronary artery disease take aspirin for primary or secondary prevention of thrombotic events. 1 Aspirin inhibits platelet function and therefore poses an increased risk of bleeding among patients undergoing coronary artery bypass grafting (CABG), 1 although this risk appears to be small. 2 – 5 Until recently, it has been traditional practice in most cardiac surgical centers to have patients stop taking aspirin 5 to 7 days before surgery to reduce the risk of bleeding. However, the increased risk of surgical bleeding could be outweighed by the beneficial effect of aspirin on coronary-graft flow and on reduction in the risk of . . .

PurposeDouble-lumen endotracheal tubes (DL-ETT) and bronchial blockers (BB) are frequently used to allow one-lung ventilation (OLV) during video-assisted thoracic surgery (VATS). Recently, faster lung collapse has been documented with a BB than with a DL-ETT. The physiologic mechanisms behind this faster collapse remained unknown. We aimed to measure ambient air absorption (Vresorb) and intra-bronchial pressure (Pairway) into the non-ventilated lung during OLV using DL-ETT and BB.MethodsPatients undergoing VATS and OLV for lung resection were randomly assigned to have measurements made of Vresorb or Pairway within the non-ventilated lung using either a DL-ETT or BB.ResultsThirty-nine patients were included in the analyses. The mean (standard error of the mean [SEM]) Vresorb was similar in the DL-ETT and BB groups [504 (85) vs 630 (86) mL, respectively; mean difference, 126; 95% confidence interval [CI], -128 to 380; P = 0.31]. The mean (SEM) Pairway became progressively negative in the non-ventilated lung in both the DL-ETT and the BB groups reaching [-20 (5) and -31 (10) cmH2O, respectively; mean difference, -11; 95% CI, -34 to 12; P = 0.44] at the time of the pleural opening.ConclusionsDuring OLV before pleural opening, entrainment of ambient air into the non-ventilated lung occurs when the lumen of the lung isolation device is kept open. This phenomenon is prevented by occluding the lumen of the isolation device before pleural opening, resulting in a progressive build-up of negative pressure in the non-ventilated lung. Future clinical studies are needed to confirm these physiologic results and their impact on lung collapse and operative outcomes.Trial registrationwww.clinicaltrials.gov (NCT02919267); registered 28 September 2016.