It has been suggested that the morbidity associated with cardiopulmonary bypass can be attributed in part to the blood-material and blood-air interactions in the extracorporeal circulation (ECC). A recently introduced minimized ECC-system (MECC System) should be able to reduce these negative effects associated with ECC. A retrospective analysis was performed comprising 485 patients who were operated on for elective coronary artery bypass grafting (CABG) using the MECC System with intermittent antegrade warm blood cardioplegia (group 1) from January 2000 to February 2004. A control group consisted of 485 patients (group 2) undergoing elective CABG in the same period using a conventional ECC and cold crystalloid cardioplegia. There were no significant differences between the two groups in terms of the duration of intubation following surgery, the length of intensive care unitstay and the total hospital stay. Although the 30-day mortality was similar between the two groups, the incidence of postoperative complications and the perioperative use of blood products were significantly higher in the control group compared to the MECC group. The MECC System may serve as an alternative and less invasive approach to conventional ECC.

Perioperative hemodynamic optimisation improves postoperative outcome for patients undergoing high-risk surgery (HRS). In this prospective randomized multicentre study we studied the effects of an individualized, goal-directed fluid management based on continuous stroke volume variation (SVV) and stroke volume (SV) monitoring on postoperative outcomes. 64 patients undergoing HRS were randomized either to a control group (CON, n = 32) or a goal-directed group (GDT, n = 32). In GDT, SVV and SV were continuously monitored (FloTrac/Vigileo) and patients were brought to and maintained on the plateau of the Frank-Starling curve (SVV <10 % and SV increase <10 % in response to fluid loading). Organ dysfunction was assessed using the SOFA score and resource utilization using the TISS score. Patients were followed up to 28 days for postoperative complications. Main outcome measures were the number of complications (infectious, cardiac, respiratory, renal, hematologic and abdominal post-operative complications), maximum SOFA score and cumulative TISS score during ICU stay, duration of mechanical ventilation, length of ICU stay, and time until fit for discharge. 12 patients had to be excluded from final analysis (6 in each group). During surgery, GDT received more colloids than CON (1,589 vs. 927 ml, P < 0.05) and SVV decreased in GDT (from 9.0 to 8.0 %, P < 0.05) but not in CON. The number of postoperative wound infections was lower in GDT (0 vs. 7, P < 0.01). Although not statistically significant, the proportion of patients with at least one complication (46 vs. 62 %), the number of postoperative complications per patient (0.65 vs. 1.40), the maximum sofa score (5.9 vs. 7.2), and the cumulative TISS score (69 vs. 83) tended to be lower. This multicentre study shows that fluid management based on a SVV and SV optimisation protocol is feasible and decreases postoperative wound infections. Our findings also suggest that a goal-directed strategy might decrease postoperative organ dysfunction.

Although arterial pressure-derived SVV revealed the best correlation to volume-induced changes in SVI, the results of our study suggest that both variables, SVV and PVI, can serve as valid indicators of fluid responsiveness in mechanically ventilated patients undergoing major surgery.

Anesthetic management importantly contributes to the containment of the perioperative complications of HIPEC. An appreciation of the technical aspects and physiologic disruptions associated with intra-abdominal HIPEC is critical to ensure effective anesthetic management. Although data on this specialized surgical procedure are scarce, some referral centers have accumulated extensive experience. This article reviews the current knowledge about the anesthesiological and intensive care management of patients undergoing HIPEC. It pinpoints strategies for perioperative monitoring as well as illustrates alterations in hemodynamic, hematopoetic, and fluid hemostasis.

The influence of an increase in training volume (ITV; February 1989) vs intensity (ITI; February 1990) on performance, catecholamines, energy metabolism and serum lipids was examined in two studies on eight, and nine experienced middle- or long-distance runners; seven participated in both studies. During ITV, mean training volume was doubled from 85.9 km.week-1 (pretrial phase) to 174.6 km within 3 weeks. Some 96%-98% of the training was performed at 67 (SD 8)% of maximal performance. During ITI, speed-endurance, high-speed and interval runs increased within 3 weeks from 9 km.week-1 (pretrial phase) to 22.7 km.week-1 and the total training distance from 61.6 to 84.7 km.week-1. The ITV resulted in stagnation of running velocity at 4 mmol lactate concentration and a decrease in total running distance in the increment test. Heart rate, energy metabolic parameters, nocturnal urinary catecholamine excretion, low density, very low density lipoprotein-cholesterol and triglyceride concentrations decreased significantly; the exercise-related catecholamine plasma concentrations increased at an identical exercise intensity. The ITI produced an improvement in running velocity at 4 mmol lactate concentration and in total running distance in the increment test; heart rate, energy metabolic parameters, nocturnal catecholamine excretion, and serum lipids remained nearly constant, and the exercise-related plasma catecholamine concentrations decreased at an identical exercise intensity. The ITV-related changes in metabolism and catecholamines may have indicated an exhaustion syndrome in the majority of the athletes examined but this hypothesis has to be proven by future experimental studies.

Our results indicate that high-dose TXA is associated with an increased incidence of postoperative generalized seizures in patients undergoing AVR compared with EACA, especially when suffering from renal impairment. A possible association between recombinant activated factor VIIa and the occurrence of postoperative seizures needs further investigation.

The results of our study suggest that stroke volume variation and its surrogate pulse pressure variation derived from pulse contour analysis using an improved algorithm can serve as indicators of fluid responsiveness in normoventilated cardiac surgical patients. Whenever changes in systemic vascular resistance are expected, the PiCCO plus system should be recalibrated.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important tool in the management of patients with peritoneal malignancies. It is a complex surgical procedure with significant fluid loss during debulking leading to relevant pathophysiological alterations and therefore a challenge for anesthesiologists and critical care physicians. This review summarizes perioperative changes in hemodynamics, oxygen supply, coagulation, hematopoetic parameters and fluid status during cytoreductive surgery and HIPEC and how to deal with these pathophysiological alterations.