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While at rest young subjects have lower mean arterial blood pressure than old subjects and lower circulating levels of the neurotransmitter of the sympathetic nervous system, norepinephrine (NE). After standing and performing an isometric exercise, young subjects increase their circulating levels of NE less than old subjects. The cold pressor test is commonly used as a stimulus to the sympathetic nervous system, and young subjects have a much smaller pressor response than old subjects. In response to uniform stresses young subjects secrete less NE and have a smaller blood pressure response than old subjects.

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Bivalirudin is a short-acting direct thrombin inhibitor that has been used in cardiac surgical patients with heparin-induced thrombocytopenia (HIT) or suspected HIT. Although no direct thrombin inhibitor is indicated for anticoagulation during cardiac surgery in patients with heparin-induced thrombocytopenia (HIT) or suspected HIT, use of heparin-alternatives are increasing as the awareness of HIT increases. Reports of anticoagulation with bivalirudin are sporadic, however, with variable dosing and management strategies. In this report, we describe our management techniques for cardiopulmonary bypass with bivalirudin based upon our personal experience. Although the reported clinical experience with bivalirudin in cardiac surgery is reviewed, operative techniques for the perfusionist/surgeon team are discussed in detail. We recognize that the use of bivalirudin during cardiopulmonary bypass is evolving and modifications of technique will undoubtedly occur as further data and experience accumulate.