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The total aortic arch replacement is one of the most technically demanding operations, the main risk of which is the intraoperative ischemic lesion of the brain. Despite progress, operating mortality associated with this operation, even at the most renowned specialized centers reaches 7.3%. An alternative to the classic “open” operation is aortic endoprosthesis, combined with the procedure of debranching. This approach allows diminishing trauma by reducing the duration of the cardiopulmonary bypass. The aim. To describe the rational approach for replacing the total aortic arch depending on the diameter of aneurysm, the condition of the arch vessels, and the acuteness of clinical condition.The main indications for the replacement of the aortic arch are the true atherosclerotic aneurysms, genetic connective tissue diseases (Marfan syndrome), syphilis. The total arch replacement recently becomes more frequent indication for acute type A aortic dissection. The newly introduced strategies of operation and perfusion for total aortic arch replacement are aimed to reduce the risk of neurological complications. This method is named “arch first technique” which gradually replaces the earlier technique, at which the first anastomosis is performed with a descending thoracic aorta. A more traditional method called the “descending aorta first” was selected. A mandatory element of both types of the operation is antegrade cerebral perfusion. The main advantage of this method is maintaining constant perfusion of the brain which significantly reduces the risk of its ischemic damage, avoids deep hypothermia and its negative impact on blood coagulation system. The technique of total arch replacement consists of the following elements: access, double arterial cannulation, the method of brain protection, formation of distal anastomosis with descending thoracic aorta, implantation of arch vessels into the prosthesis. Sequence of anastomosis depends on morphological and clinical peculiarities of the specific case. Changes in the strategy for “open” total aortic arch replacement in various aortic pathologies is discussed based on the author’s clinical experience and literature data. Conclusions. Total aortic arch replacement remains a traumatic and technically demanding operation, the main risks of which are hemorrhage and ischemic brain lesions. The method of arch replacement – “descending aorta first” includes double arterial cannulation, antegrade cerebral perfusion, deep hypothermia with complete blood flow stoppage for the lower half of the body and the use of multi-branch vascular prosthesis.

Objectives The aims of this study were to compare the core temperature changes between pediatric patients lying on regular operating room linen drapes and a water-repellent sheepskin rug during living donor liver transplantation (LDLT) and to evaluate the effectiveness of using a water-repellent sheepskin rug in preventing profound hypothermia due to fluid overflow from the abdominal cavity during LDLT. Patients and Methods The operative records of pediatric patients who underwent LDLT from June 1994-September 2003 were reviewed retrospectively. The nasopharyngeal temperature (NT) changes during the LDLT procedure between patients lying on regular operating room drapes (GI) and water-repellent sheepskin rug (GII) were compared and analyzed using the Mann-Whitney U test. A P value Results Thirty-two patients were included in GI and 56 in GII. Profound hypothermia was not observed in any recipients lying on a water-repellent sheepskin rug (GII). The NT after induction and the following 4 hours into the LT procedure were significantly higher in GII than GI. Conclusion Pediatric patients lying on water-repellent sheepskin preserved their core temperature better in comparison to patients lying on linen drapes. The use of a water-repellent sheepskin rug seems to be effective in preventing profound hypothermia related to physical contact with abdominal fluid overflow during the LDLT.

IntroductionSurvival in exsanguinating cardiac arrest patients is poor, as is neurological outcome in survivors. Hypothermia has traditionally been seen as harmful to trauma patients and associated with increased mortality; however, there has been speculation that cooling to very low temperatures (≤20°C) could be used to treat haemorrhagic trauma patients by the induction of a suspended animation period through extreme cooling, which improves survival and preserves neurological function. This has been termed emergency preservation and resuscitation (EPR).MethodsA systematic review of the literature was used to examine the evidence base behind the use of deep and profound hypothermia in haemorrhagic shock (HS). It included original research articles (human or animal) with cooling to ≤20°C after HS or an experimental model replicating it. Normovolaemic cardiac arrest, central nervous system injury and non-HS models were excluded.ResultsTwenty articles using 456 animal subjects were included, in which 327 were cooled to ≤20°C. All studies describing good survival rates were possible using EPR and 19/20 demonstrated that EPR can preserve neurological function after prolonged periods of circulatory arrest or minimal circulatory flow. This additional period can be used for surgical intervention to arrest haemorrhage in HS that would otherwise be lethal.ConclusionsThe outcomes of this review have significant implications for application to human patients and the ongoing human clinical trial (EPR for Cardiac Arrest from Trauma). Current evidence suggests that hypothermia ≤20°C used in the form of EPR could be beneficial to the HS patient.

Background: Prior to heart transplantation, static storage of donor hearts is currently limited to 4–5 h, despite profound hypothermia (4–8 °C). Because heart transplantation is an emergency procedure, improved protection to extend safe storage duration would be advantageous. We investigated whether the naturally respiratory pigment HEMO2life®, which is effective at hypothermia for the passive release of oxygen via oxygen gradient, could improve long-term preservation.Methods: Isolated Langendorff-perfused rat hearts (n = 12/group) were equilibrated (20 min) and function (left ventricular developed pressure: LVDP) measured by intraventricular balloon before arrest with cold (7.5 °C) Celsior® solution, either alone (control) or with the addition of HEMO2life® (Hemarina SA, Morlaix, France) at 1 g/L. Cold storage lasted 8 h prior to reperfusion (60 min) and recovery (as % of pre-ischemic function) was assessed. Hearts (minced and homogenized) were also assessed by TTC staining as a measure of viabil...

Chapter 10 describes the setup and functions of extracorporeal membrane oxygenation (ECMO) as compared to the heart-lung machine (HLM). Based on an underlying technical understanding, the variables that control mechanical organ replacement are discussed. The determining factor for clinically successful use is an understanding of the evaluation of cardiopulmonary function during the use of the machine, standardized patient management, and knowledge of the possible complications, their avoidance, identification, and treatment.

OBJECTIVE: To report outcome and intensive care strategy in a 7-year-old girl with accidental profound hypothermia and drowning. DATA SOURCES AND EXTRACTION: Patient records and interviews with search-and-rescue personnel. STUDY SELECTION: Case report. DATA SYNTHESIS: The girl was rescued after an estimated submersion time of at least 83 minutes in icy sea water. She presented with cardiac arrest, ice in her upper airways, a first-documented nasopharyngeal temperature of 13.8°C, and a serum potassium of 11.3 mmol/L. The patient was slowly rewarmed with extracorporeal membrane oxygenation and made an exceptional recovery after intensive care and a long rehabilitation time. CONCLUSION: Excellent outcome is possible in children with body temperature and serum potassium reaching the far limits of previously reported human survival and prolonged submersion time. Language: en

Pulmonary endarterectomy, which 25 years ago was only performed at the University of California, San Diego (UCSD), is now widely recognized as an effective way of treating pulmonary hypertension as a result of chronic thromboembolic disease. The operation is carried out using cardiopulmonary bypass to achieve profound hypothermia and circulatory arrest, which results in the bloodless field necessary for the visibility required for this delicate operation.

Background The successful treatment of military combat casualties with penetrating injuries is significantly dependent on the time needed to get the patient to an adequate treatment facility. Profound hypothermia-induced suspended animation for delayed resuscitation (SADR) is a novel approach for inducing cardiac arrest and buying additional time for such injuries. However, the time used to safely administer circulatory arrest (CA) is controversial. The goal of this study was to evaluate the safety of hypothermia-induced SADR over 90 and 120 min time intervals. Methods Sixteen male BAMA minipigs were randomized into two groups: CA90 group (90 min, n = 8) and CA120 group (120 min, n = 8). Cannulation of the right common carotid arteries and internal jugular veins was performed to establish cardiopulmonary bypass for each animal. Through the perfusion of cold organ preservation solution (OPS), cardioplegia and profound hypothermia (15 °C) were induced. After CA, cardiopumonary bypass (CPB) was restarted, and the animals were gradually re-warmed and resuscitated. The animals were assisted with ventilators until spontaneous breathing was achieved. The index of hemodynamic perioperative serum chemistry values [alanine transaminase (ALT), aspartate aminotransferase (AST), creatinine (CR), lactic dehydrogenase (LDH) and troponin T (TnT)] and survival were observed from pre-operation to 7 days post-operation. Results Fifteen animals were enrolled in the experiment, while 1 animal in CA120 group died from surgical error. All 8 animals in CA90 group recovered, with only 1 animal displaying mild disability. However, in CA120 group, only 2 animals survived with severe disability, and the other 5 animals died after 2 days post-operation. In CA90 group, the perioperative serum chemistry values increased at 1 day post-operation (ALT 84.43 ± 18.65 U/L; AST 88.99 ± 23.19 U/L; Cr 87.90 ± 24.49 μmol/L; LDH 1894.13 ± 322.26 U/L; TnT 0.849 ± 0.135 ng/ml) but decreased to normal or almost normal levels at 7 days post-operation (ALT 52.48 ± 9.04 U/L; AST 75.23 ± 21.46 U/L; Cr 82.69 ± 18.41 μmol/L; LDH 944.67 ± 834.32 U/L; TnT 0.336 ± 0.076 ng/ml). Conclusions Profound hypothermia-induced SADR is an effective method for inducing cardiac arrest. Our results indicate that inducing CA for 90 min (at 15 °C) is safer than doing so for 120 min. Our results indicate that 120 min of CA at 15 °C is dangerous and can result in high mortality and severe neurological complications. Further experimentation is needed to determine whether 120 min of CA at temperatures lower than 15 °C can lead to safe recovery.

Douglas Stewart Robbie was born to Margaret and George Robbie, brother of Glen and Yvonne. He was raised in Aberdeen and was joint dux at Aberdeen Grammar School in 1948. Although he was offered a scholarship to Fettes College in Edinburgh, his parents preferred the local school, from where he progressed to Aberdeen University to study medicine and qualified with commendation. He married Terry, whom he had met in Aberdeen, in 1956. From his houseman post at Aberdeen Royal Infirmary, where he worked in wards 2 and 9, he went south to Hampshire to join the Royal Army Medical Corps, from 1955 to 1957. At Crookham he was a captain under the notorious Colonel Benson (“there is BULL and there is BULL!”). While stationed there he was asked to parachute into Suez, and nearly did so, but was somewhat grateful to be relieved of this duty when somebody else keenly requested to take his place. While at Crookham he read a lot on the theory of anaesthesia, in preparation for his job as senior house officer at the Westminster and Brompton hospitals in London, where he subsequently was registrar and senior registrar. After conducting some important research on profound hypothermia, and on completion of his FFARCS, …

It is well recognized that brain death starts to occur just 4-6 min after cardiac arrest, and few attempts at resuscitation succeed after 10 min of severe cerebral ischemia and anoxia. We sought to determine the therapeutic window of selective cerebral profound hypothermia of primates following severe cerebral ischemia in primates. Fourteen rhesus monkeys with severe cerebral ischemia were divided into four groups: normothermia (n = 3); profound hypothermia I (n = 4), with cooling initiated 10 min after ischemia; profound hypothermia II (n = 4), with cooling initiated 15 min after ischemia; and profound hypothermia III (n = 3), with cooling initiated 20 min after ischemia. Severe cerebral ischemia was induced by clamping both the internal and external carotid arteries, as well as the internal and external jugular veins. Profound cerebral hypothermia (15.8 degrees +/- 0.9 degrees C) was achieved and maintained for 60 min, and the animals were then re-warmed gradually. All four animals in hypothermia group I survived without any neurological deficits. Only 1 animal survived and 3 animals died in hypothermia group II. All 4 animals died in both hypothermia group III and the normothermia group. Neurological functions were normal in all surviving animals, and MRI scans showed no cerebral infarction in these animals. Microscopic examination showed no injured neurons in the hippocampus and cerebral cortex of the surviving animals, and showed that the heart, lung, liver, and kidneys were normal in these animals. Our data indicate that post-ischemic profound cerebral hypothermia provided significant cerebral protection with no systemic complications, and that the effective therapeutic window is more than 10 min, but less than 15 min, after severe cerebral ischemia.

SUMMARY We assessed neurological status and cognitive, verbal, social and motor skills of 17 children who had undergone cardiac surgery under profound hypothermia, and of seven siblings (controls). None of the subjects had significant neurological impairment. The mean development quotient (dq) for the patients was 92.5 (in the low-average range) and for the controls was 103 (average). The dq of one patient (71) was below the normal range. Development of the patients was comparable with that reported by other authors for children with cyanotic congenital heart-disease who have not undergone cardiac surgery. It correlated with the type of congenital heart-disease but not with the duration of hypoxic arrest. It is concluded that profound hypothermia can be used safely during the correction of cardiac defects in infants, without fear of retarding psychomotor development. RESUME Developpement psycho-moteur de nourrissons et d'enfants avec malformation cardiaque congenitale et apres forte hypothermie d'intervention L'etat neurologique et les aptitudes cognitives, verbales, sociales et motrices ont ete apprecies chez 17 enfants ayant subi une chirurgie cardiaque sous forte hypothermie. Sept membres des fratries ont ete etudies comme controle. Aucun des malades n'ont presente d'alterations neurologiques significatives. La moyenne du quotient de developpement (qd) pour les malades etait de 92,5 (dans la zone inferieure de la moyenne) celle des controles 103 (moyenne). Le qd chez un malade etait en dessous de la normale. Le developpement des malades fut comparable a ce qui est rapporte par d'autres auteurs pour des enfants atteints de malformations cardiaques congenitales cyanogenes n'ayant pas beneficie de chirurgie cardiaque; il y eut une correlation avec le type de malformation cardiaque con-genitale mais non avec la duree de l'arret hypoxique. Les auteurs concluent qu'une forte hypothermie peut etre utilisee avec securite durant la correction d'anomalies cardiaques du nourrisson sans crainte de retarder le developpement psycho-moteur. ZUSAMMENFASSUNG Psychomotorische Entwicklung von Kleindkindern und Kindern mit angeborenen Herzfehlern nach langanhaltender Hypothermie bei der Operation 17 Kinder, die eine Herzoperation in Hypothermie hatten, wurden hinsichtlich ihres neurologischen Status, ihrer cognitiven, verbalen, sozialen und motorischen Fahigkeiten beurteilt. Kein Patient hatte eine signifikante neurologische Storung. Der durchschnittliche Entwicklungsquotient (dq) fur die Patienten war 92.5 (unterer Normbereich), bei Kontroll-kindern 103 (Durchschnitt). Der dq eines Patienten war unter dem Normbereich. Die Entwicklung der Patienten war vergleichbar mit der fur Kinder mit cyanotischen Herzfehlern ohne Operation, wie andere Autoren berichtet haben; sie korrelierte mit dem Typ des Herzfehlers, aber nicht mit der Dauer der Hypoxie bei der Operation. Die Autoren sind der Meinung, dass die Hypothermie bei der Korrektur von Herzfehlern bei Kindern ohne Risiko angewandt werden kann und dass keine Retardierung der psychomotorischen Entwicklung zu befurchten ist. RESUMEN Desarrollo psicomotor en lactantes y ninos con enfermedades congenitas cardiacas despues de una cirugia con hipotermia profunda Se valoro el estatus neurologico y las habilidades cognitiva, social, verbal y motriz de 17 ninos que habian sufrido una cirugia cardiaca bajo hipotermia profunda. Se estudiaron siete hermanos a modo de control. Ninguno de los pacientes presentaban alteracion neurologica significativa. El cociente de desarrollo promedio (cd) para los pacientes era de 92,5 (dentro del margen promedio bajo): el de los controles era 103 (promedio). El cd de un paciente estaba por debajo del margen normal. El desarrollo de los pacientes fue comparable a los aportados por otros autores con respecto a ninos con enfermedades cardiacas cianoticas que no habian sufrido cirugia cardiaca; estaba en correlacion con el tipo de enfermedad congenita cardiaca pero no con la duracion del paro hipoxico. Se concluye que la hipotermia profunda puede usarse sin peligro durante la correccion de defectos cardiacos en lactantes sin miedo a retarder el desarrollo psicomotor.

The clinical condition of profound hypothermia is well described in the medical literature. There have been many case reports and studies describing successful aspects of caring for this problem. Significant bradycardia is a known pathophysiologic consequence of profound hypothermia. Transcutaneous pacing for this condition is not a routine or recommended practice in the literature. This case report details 2 patients with profound hypothermia and resultant bradycardia with hypotension. In both cases, transcutaneous pacing was successfully applied and used as part of the resuscitation. In both cases, transcutaneous pacing was required to maintain an adequate blood pressure so that continuous arteriovenous rewarming could be used during the resuscitation. Both cases had successful outcomes, and the rewarming process was greatly assisted by the pacing procedure.

Rapid induction of a profound hypothermic state (suspended animation) can maintain viability of key organs during repair of lethal injuries. Conventional cardiopulmonary bypass equipment (roller pump) used to induce and reverse hypothermia is expensive, bulky, requires standard electricity, and is not transportable. Development of a small, portable, battery operated, disposable, pump can logistically facilitate induction and maintenance of hypothermia. In this experiment, a portable prototype pump was tested and its performance was compared with the regular roller pump in a swine model of lethal vascular injuries.Uncontrolled hemorrhage was induced in 16 swine (80-120 lbs) by creating an iliac artery and vein injury (nonlethal). After 30 minutes of pulseless shock, the descending thoracic aorta was lacerated (lethal injury). Through a left thoracotomy approach, a catheter was placed in the aorta and cold organ preservation solution was infused to rapidly (2 degrees C/min) induce hypothermia (10 degrees C) for 60 minutes. The performance of the prototype pump was initially tested in a nonsurvival experiment (four animals). Then, 12 animals were cooled either with (n = 6/group) (1) conventional roller pump or (2) small prototype pump. The injuries were repaired during hypothermic arrest and the animals were re-warmed (0.5 degrees C/min). Whole blood was infused during resuscitation on cardiopulmonary bypass. Surviving animals were closely monitored for 3 weeks for postoperative complications, neurologic deficits, and organ dysfunction.The flow rates and the time needed to induce and reverse profound hypothermia were no different between the prototype and the conventional roller pumps. Three-week survival rates were 83% in both groups. Only a transient increase in liver enzymes, and markers of cellular injury (creatine kinase, lactate dehydrogenase) was noted (no meaningful difference between groups), with no long-term organ dysfunction.In this large animal model of lethal vascular injuries, a portable, battery operated, disposable, rotary pump performed as well as the conventional roller pump. The logistical advantages of this system make it an attractive choice for inducing hypothermia in emergency departments and austere settings, and for maintaining hypothermia during transport.

It has been postulated that unsuccessful resuscitation of victims of accidental hypothermia is caused by insufficient tissue oxygenation. The aim of this study was to test whether inadequate O2supply and/or malfunctioning O2extraction occur during rewarming from deep/profound hypothermia of different duration. Three groups of rats ( n = 7 each) were used: group 1 served as normothermic control for 5 h; groups 2 and 3 were core cooled to 15°C, kept at 15°C for 1 and 5 h, respectively, and then rewarmed. In both hypothermic groups, cardiac output (CO) decreased spontaneously by >50% in response to cooling. O2consumption fell to less than one-third during cooling but recovered completely in both groups during rewarming. During hypothermia, circulating blood volume in both groups was reduced to approximately one-third of baseline, indicating that some vascular beds were critically perfused during hypothermia. CO recovered completely in animals rewarmed after 1 h ( group 2) but recovered to only 60% in those rewarmed after 5 h ( group 3), whereas blood volume increased to approximately three-fourths of baseline in both groups. Metabolic acidosis was observed only after 5 h of hypothermia (15°C). A significant increase in myocardial tissue heat shock protein 70 after rewarming in group 3, but not in group 2, indicates an association with the duration of hypothermia. Thus mechanisms facilitating O2extraction function well during deep/profound hypothermia, and, despite low CO, O2supply was not a limiting factor for survival in the present experiments.

Rapid induction of profound hypothermic arrest (suspended animation) can provide valuable time for the repair of complex injuries and improve survival. The optimal rate for re-warming from a state of profound hypothermia is unknown. This experiment was designed to test the impact of different warming rates on outcome in a swine model of lethal hemorrhage from complex vascular injuries.Uncontrolled lethal hemorrhage was induced in 40 swine (80-120 lbs) by creating an iliac artery and vein injury, followed 30 minutes later (simulating transport time) by laceration of the descending thoracic aorta. Through a thoracotomy approach, a catheter was placed in the aorta and hyperkalemic organ preservation solution was infused on cardiopulmonary bypass to rapidly (2 degrees C/min) induce profound (10 degrees C) hypothermia. Vascular injuries were repaired during 60 minutes of hypothermic arrest. The 4 groups (n = 10/group) included normothermic controls (NC) where core temperature was maintained between 36 to 37 degrees C, and re-warming from profound hypothermia at rates of: 0.25 degrees C/min (slow), 0.5 degrees C/min (medium), or 1 degrees C/min (fast). Hyperkalemia was reversed during the hypothermic arrest period, and blood was infused for resuscitation during re-warming. After discontinuation of cardiopulmonary bypass, the animals were recovered and monitored for 6 weeks for neurologic deficits, cognitive function (learning new skills), and organ dysfunction. Detailed examination of brains was performed at 6 weeks.All the normothermic animals died, whereas survival rates for slow, medium and fast re-warming from hypothermic arrest were 50, 90, and 30%, respectively (p0.05 slow and medium warming versus normothermic control, p0.05 medium versus fast re-warming). All the surviving animals were neurologically intact, displayed normal learning capacity, and had no long-term organ dysfunction.Rapid induction of hypothermic arrest maintains viability of brain during repair of lethal vascular injuries. Long-term survival is influenced by the rate of reversal of hypothermia.

Budd-Chiari症候群は肝静脈3主幹あるいは肝部下大静脈の閉塞ないし狭窄を示す疾患である.治療にっいては内科的治療,カテーテル治療,外科的治療があるが,選択については議論のあるところである.今回われわれは下大静脈の膜性狭窄 (web) によるBudd-Chiari症候群に対して低体温併用脳分離体外循環,循環停止法を用いて根治術を行った1例を経験したので報告する.症例は31歳,女性で下大静脈の膜性狭窄によるBudd-Chiari症候群であった.手術は低体温併用脳分離体外循環,循環停止法を用いて経右房的に下大静脈内のwebを切除した.以上の方法により良好な無血術野が得られ, webの遺残もなく根治性の高い治療ができた.