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  • 1.
    Arbeus, Mikael
    et al.
    Dept of Cardiothoracic Surgery and Anesthesiology, Örebro University hospital.
    Axelsson, Birger
    Dept of Cardiothoracic Surgery and Anesthesiology, Örebro University hospital.
    Friberg, Örjan
    Dept of Cardiothoracic Surgery and Anesthesiology, Örebro University hospital.
    Magnuson, Anders
    Statistical and Epidemiological Unit, Örebro University hospital.
    Bodin, Lennart
    Statistical and Epidemiological Unit, Örebro University hospital.
    Hultman, Jan
    Dept of Thoracic and Cardiovascular Anesthesio, Uppsala University hospital.
    Milrinone increases flow in coronary artery bypass grafts after cardiopulmonary bypass: a prospective, randomized, double-blind, placebo-controlled study2009In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 23, no 1, p. 48-53Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To compare the effects of a bolus of milrinone, 50 microg/kg, versus placebo on flow in coronary artery bypass grafts after cardiopulmonary bypass (CPB).

    DESIGN: A prospective, randomized, double-blind study.

    SETTING: A university hospital.

    PARTICIPANTS: Forty-four patients with stable angina and left ventricular ejection fraction >30% scheduled for elective coronary artery bypass graft (CABG) surgery were included.

    INTERVENTION: Patients were randomized to receive 50 microg/kg of milrinone (n = 22) or placebo (n = 22) after aortic declamping.

    MEASUREMENTS AND MAIN RESULTS: The flow in coronary artery bypass grafts was measured with a transit time flow meter at 10 minutes and 30 minutes after termination of CPB. The hemodynamic evaluation included transesophageal echocardiography, mean arterial pressure (MAP), heart rate, and intracavitary measurement of left ventricular end-diastolic pressure (LVEDP). The flow in the saphenous vein grafts was significantly higher in the milrinone group when compared with the placebo group both at 10 and 30 minutes after termination of CPB (p < 0.001). At 10 minutes, the flow was 64.5 +/- 37.4 mL/min (mean +/- standard deviation) and 43.6 +/- 25.7 mL/min in nonsequential vein grafts for milrinone and placebo, respectively. Corresponding values at 30 minutes were 54.8 +/- 29.9 mL/min and 35.3 +/- 22.4 mL/min. The left internal thoracic artery (LITA) flow was higher in the milrinone group but did not reach statistical significance. The fractional area change was higher, and the MAP and calculated pressure gradient (MAP-LVEDP) were lower at 10 minutes in the milrinone group.

    CONCLUSION: Milrinone significantly increases the flow in anastomosed saphenous vein grafts after CPB, and has beneficial effects on left ventricular function.

  • 2.
    Axelsson, Birger
    et al.
    Dept of Cardiothoracic Surgery and Anestesiology, Örebro University hospital.
    Arbeus, Mikael
    Dept of Cardiothoracic Surgery and Anestesiology, Örebro University hospital.
    Magnuson, Anders
    Statistical and Epidemiological Unit, Örebro University hospital.
    Hultman, Jan
    Thoracic clinic, Karolinska University hospital.
    Milrinone improves diastolic function in coronary artery bypass surgery as assessed by acoustic quantification and peak filling rate: a prospective randomized study2010In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 24, no 2, p. 244-249Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To compare the effects of a bolus dose of milrinone, 50 microg/kg, to placebo on diastolic function (active relaxation) in patients undergoing on-pump coronary artery bypass grafting (CABG).

    DESIGN: Prospective, randomized, double-blind, placebo-controlled study.

    SETTING: University hospital.

    PARTICIPANTS: Twenty-four patients with stable angina and left ventricular ejection fraction >30%, scheduled for elective CABG using cardiopulmonary bypass (CPB), were included.

    INTERVENTION: Patients were randomized to receive either 50 microg/kg of milrinone (n = 12) or placebo (n = 12) after aortic declamping.

    MEASUREMENTS AND MAIN RESULTS: The diastolic function of the left ventricle (LV) was measured as peak filling rate (dA/dt [maximal diastolic area change over time]) with transesophageal echocardiography (TEE) using acoustic quantification (AQ) before CPB and 10 minutes after termination of CPB. The normalized peak filling rate (dA/dt)/EDA was also calculated. Active relaxation was statistically significantly increased in the milrinone group compared with the placebo group after CPB.

    CONCLUSION: Patients undergoing CABG surgery and treated with milrinone after aortic declamping had better diastolic function following cardiopulmonary bypass.

  • 3. Engström, Gunnar
    et al.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences.
    Brorsson, Bengt
    Mechanisms behind operating-room blood transfusions in coronary bypass patients with insignificant bleeding.2002In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 16, no 5, p. 539-544Article in journal (Refereed)
  • 4.
    Hällgren, Oskar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Implementing a Statistical Model for Protamine Titration: Effects on Coagulation in Cardiac Surgical Patients2017In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 31, no 2, p. 516-521Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To implement a statistical model for protamine titration. DESIGN: Prospective randomized trial. SETTING: University hospital. PARTICIPANTS: Sixty (n = 30+30) patients scheduled for elective coronary artery bypass surgery were randomly assigned to 2 groups. INTERVENTIONS: Protamine dose calculated according to an algorithm established from a statistical model or to a fixed protamine-heparin dose ratio (1:1). MEASUREMENTS AND MAIN RESULTS: Both groups demonstrated comparable patient demographics and intraoperative data. Coagulation effects were evaluated using rotational thromboelastometry. Using the statistical model reduced (p<0.01) the protamine dose from 426±43 mg to 251±66 mg, followed by significantly (p<0.01) shorter intrinsic clotting time (208±29 seconds versus 244±52 seconds) and stronger clot firmness (p = 0.01), and effects on indices of extrinsic or fibrinogen coagulation pathways were insignificant. Test of residual heparin was negative in all patients after protamine administration, aligned with insignificant (p = 0.27) intergroup heparinase-verified clotting time differences. CONCLUSIONS: The statistical model for protamine titration is clinically feasible and protects the patient from exposure to excessive doses of protamine, with advantageous effects on coagulation as measured using rotational thromboelastometry. Significance regarding clinical outcome is yet to be defined.

  • 5.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Cardiothoracic Surgery Division, Heart Center.
    Lingehall, Helena Claesson
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium2018In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 32, no 2, p. 684-690Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to determine risk factors for postoperative delirium after cardiac surgery, specifically associated with the conduct of cardiopulmonary bypass (CPB).

    Design: Prospective observational study.

    Setting: Heart Centre, University Hospital.

    Participants: The study included 142 patients aged 70 years and older scheduled for elective cardiac surgery with CPB.

    Interventions: Risk factor analysis comprised information collected from the hospital clinical and CPB dedicated databases in addition to the medical chart. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criterion using the Mini Mental State Examination and the Organic Brain Syndrome scale.

    Measurements and Main Results: Assessments of delirium diagnosis were executed preoperatively and on the following first and fourth postoperative days. Delirium occurred in 55% (78/142) of the patients. Patients with delirium were identified with significantly higher body weight and body surface area preoperatively, accompanied with longer CPB time, higher positive fluid balance per CPB, and lower systemic pump flow related to body surface area. Furthermore, the duration of the mixed venous oxygen saturation (SvO2) below 75% was significantly longer during CPB. The result from the multivariable logistic regression analysis included the duration of SvO2 below 75%, fluid balance per CPB and patient age as independent risk factors for postoperative delirium.

    Conclusions: The influence of the SvO2 level during CPB, fluid balance, and patient age should be recognized as risk factors for postoperative delirium after cardiac surgery in patients 70 years and older.

  • 6.
    Ödling Davidsson, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Johagen, Daniel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Reversal of Heparin After Cardiac Surgery: Protamine Titration Using a Statistical Model2015In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 29, no 3, p. 710-714Article in journal (Refereed)
    Abstract [en]

    Objective: To establish a statistical model for determination of protamine dose in conjunction with cardiopulmonary bypass. Design: Prospective.

    Setting: University hospital.

    Participants: Ninety consecutive cardiac surgical patients.

    Interventions: None.

    Measurements and Main Results: A series of clinically oriented variables were introduced into a statistical model for projection of the protamine dose after cardiopulmonary bypass. The following significant predictors were identified using multivariable regression analysis: The patient's body surface area, the administered dose of heparin, heparin clearance, and the preoperative platelet count. The statistical model projected the protamine dose within 3 +/- 23 mg of the point-of-care test used as reference.

    Conclusion: Protamine dosing based on statistical modeling represents an alternative to point-of-care tests.

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