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Evaluation of Different Cannulation Strategies for Aortic Arch Surgery Using a Cardiovascular Numerical Simulator. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010060. [PMID: 36671632 PMCID: PMC9854437 DOI: 10.3390/bioengineering10010060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023]
Abstract
Aortic disease has a significant impact on quality of life. The involvement of the aortic arch requires the preservation of blood supply to the brain during surgery. Deep hypothermic circulatory arrest is an established technique for this purpose, although neurological injury remains high. Additional techniques have been used to reduce risk, although controversy still remains. A three-way cannulation approach, including both carotid arteries and the femoral artery or the ascending aorta, has been used successfully for aortic arch replacement and redo procedures. We developed circuits of the circulation to simulate blood flow during this type of cannulation set up. The CARDIOSIM© cardiovascular simulation platform was used to analyse the effect on haemodynamic and energetic parameters and the benefit derived in terms of organ perfusion pressure and flow. Our simulation approach based on lumped-parameter modelling, pressure-volume analysis and modified time-varying elastance provides a theoretical background to a three-way cannulation strategy for aortic arch surgery with correlation to the observed clinical practice.
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Mechanical Reperfusion Following Prolonged Global Cerebral Ischemia Attenuates Brain Injury. J Cardiovasc Transl Res 2020; 14:338-347. [PMID: 32681452 PMCID: PMC8043930 DOI: 10.1007/s12265-020-10058-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022]
Abstract
Previous experiments demonstrated improved outcome following prolonged cerebral ischemia given controlled brain reperfusion using extracorporeal circulation. The current study further investigates this. Young adult pigs were exposed to 30 min of global normothermic cerebral ischemia, achieved through intrathoracic clamping of cerebral arteries, followed by 20 min of isolated mechanical brain reperfusion. Leukocyte-filtered blood was delivered by a roller-pump at fixed pressure and flow. One experimental group additionally had a custom-made buffer solution delivered at 1:8 ratio with the blood. Hemodynamics including intracranial pressure were monitored. Blood gases were from peripheral arteries and the sagittal sinus, and intraparenchymal brain microdialysis was performed. The brains were examined by a neuropathologist. The group with the added buffer showed lower intracranial pressure as well as decreased intraparenchymal glycerol and less signs of excitotoxicity and ischemia, although histology revealed similar degrees of injury. A customized mechanical reperfusion improves multiple parameters after prolonged normothermic global cerebral ischemia. The current study investigates if it possible to improve neurological outcomes following prolonged global brain ischemia. The results indicate that a customized mechanical reperfusion protocol can attenuate neurological injury. ![]()
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Fahradyan V, Annunziata MJ, Said S, Rao M, Shah H, Ordenana C, Papay FA, Rampazzo A, Bassiri Gharb B. Leukoreduction in ex vivo perfusion circuits: comparison of leukocyte depletion efficiency with leukocyte filters. Perfusion 2020; 35:853-860. [PMID: 32404024 DOI: 10.1177/0267659120917872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Leukodepletion of whole blood-based perfusates remains a challenge in experimental models of ex vivo perfusion. This study investigated the leukoreduction efficacy of the commonly used LeukoGuard LG Arterial and BC2 Cardioplegia filters. METHODS Eleven liters of washed porcine blood was used to evaluate the filtration efficiency of LG (n = 6) and BC2 (n = 5) filters. Filter efficacy was tested by passing 1 L of washed blood through each filter. Complete blood count was performed to detect a reduction of white blood cells, red blood cells, and hemoglobin concentration. RESULTS The BC2 Cardioplegia filter showed a significant reduction in white blood cell count (13.16 ± 4.2 × 103 cells/μL pre-filtration, 0.62 ± 0.61 cells/μL post-filtration, p = 0.005), red blood cell count (9.18 ± 0.16 × 106 cells/μL pre-filtration, 9.02 ± 0.16 × 106 cells/μL post-filtration, p = 0.012) and hemoglobin concentration (15.89 ± 0.66 g/dL pre-filtration, 15.67 ± 0.83 g/dL post-filtration, p = 0.017). Platelet reduction in the LG filter group was statistically significant (13.23 ± 13.98 × 103 cells/μL pre-filtration, 7.15 ± 3.31 × 103 cells/μL post-filtration, p = 0.029), but no difference was seen in the BC2 group. There was no significant difference in white blood cell count in the LG filter group (10.12 ± 3.0 × 103 cells/μL pre-filtration, 10.32 ± 2.44 × 103 cells/μL post-filtration, p = 0.861). CONCLUSION Our results suggest that the LG filter should not be used in ex vivo perfusion circuits for the purpose of leukodepletion. The BC2 filter can be used in EVP circuits with flow rates of less than 350 mL/min. Alternatively, perfusate may be leukodepleted before perfusion.
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Affiliation(s)
- Vahe Fahradyan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sayf Said
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Maya Rao
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Hirsh Shah
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Carlos Ordenana
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Frank A Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Lindblom RPF, Tovedal T, Norlin B, Hillered L, Popova SN, Alafuzoff I, Thelin S. Mechanical reperfusion with leucocyte-filtered blood does not prevent injury following global cerebral ischaemia. Eur J Cardiothorac Surg 2017; 51:773-782. [PMID: 28007877 DOI: 10.1093/ejcts/ezw367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 10/19/2016] [Indexed: 01/09/2023] Open
Abstract
Objectives Prolonged global cerebral ischaemia leads to irreversible injury, often with lethal outcome. Brain injuries are partly caused by the uncontrolled reperfusion that occurs once the circulation is re-established. Recent animal experiments suggest that controlled reperfusion following lengthy ischaemia might prevent severe brain injury. This study aimed at further exploring cerebral alterations and outcome following prolonged global cerebral ischaemia and mechanically manipulated reperfusion. Methods Three groups of pigs were included; one sham operated ( n = 3) and two that underwent 30-min global cerebral ischaemia. All vessels that supply the brain were isolated intrathoracically, after which they were occluded for 30 min in the ischaemic groups. In one of the ischaemic groups uncontrolled reperfusion was applied (URep, n = 6), i.e. normal circulation was restored 30 min after arrested cerebral circulation. The second ischaemic group received mechanical reperfusion (MRep, n = 6) with leucocyte-filtered blood at constant flow and pressure for 20 min using extracorporeal circulation following the 30-min ischaemia, after which normal blood flow resumed. All animals were monitored for 3 h after start of uncontrolled reperfusion. Haemodynamic parameters, arterial and sagittal sinus blood gases, cerebral oxygen extraction rates and intraparenchymal biomarkers using microdialysis were measured. Brain histology was performed post-mortem. Results Global brain ischaemia led to the same extent of severe morphological changes at the level of light microscopy in the two ischaemic experimental groups, regardless of reperfusion protocol. Furthermore, no significant differences were found between the URep and MRep groups regarding cerebral blood gases or microdialysis biomarkers. Conclusions Mechanical reperfusion following the current protocol does not modify brain alterations caused by 30 min of arrested cerebral circulation.
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Affiliation(s)
- Rickard P F Lindblom
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, Uppsala, Sweden.,Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Thomas Tovedal
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, Uppsala, Sweden.,Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Bo Norlin
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, Uppsala, Sweden
| | - Lars Hillered
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Svetlana N Popova
- Department of Pathology, Uppsala University Hospital, Uppsala, Sweden
| | - Irina Alafuzoff
- Department of Pathology, Uppsala University Hospital, Uppsala, Sweden.,Section of Genetics and Pathology, Department of Immunology, Uppsala University, Uppsala, Sweden
| | - Stefan Thelin
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, Uppsala, Sweden.,Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Arvola O, Haapanen H, Herajärvi J, Anttila T, Puistola U, Karihtala P, Tuominen H, Anttila V, Juvonen T. Remote Ischemic Preconditioning Reduces Cerebral Oxidative Stress Following Hypothermic Circulatory Arrest in a Porcine Model. Semin Thorac Cardiovasc Surg 2016; 28:92-102. [PMID: 27568144 DOI: 10.1053/j.semtcvs.2016.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2016] [Indexed: 11/11/2022]
Abstract
Remote ischemic precondition has become prominent as one of the most promising methods to mitigate neurological damage following ischemic insult. The purpose of this study was to investigate whether the effects of remote ischemic preconditioning can be seen in the markers of oxidative stress or in redox-regulating enzymes in a porcine model. A total of 12 female piglets were randomly assigned to 2 groups. The study group underwent an intervention of 4 cycles of 5-minute ischemic preconditioning on the right hind leg. All piglets underwent 60-minute hypothermic circulatory arrest. Oxidative stress marker 8-hydroxydeoxyguanosine (8-OHdG) was measured from blood samples with enzyme-linked immunosorbent assay. After 7 days of follow-up, samples from the brain, heart, kidney, and ovary were harvested for histopathologic examination. The immunohistochemical stainings of hypoxia marker hypoxia-inducible factor-1-α, oxidative stress marker 8-OHdG, DNA repair enzyme 8-oxoguanine glycosylase, and antioxidant response regulators nuclear factor erythroid 2-related factor 2 and protein deglycase were analyzed. The level of 8-OHdG referred to baseline was decreased in the sagittal sinus׳ blood samples in the study group after a prolonged deep hypothermic circulatory arrest at 360 minutes after reperfusion. Total histopathologic score was 3.8 (1.8-6.0) in the study group and was 4.4 (2.5-6.5) in the control group (P = 0.72), demonstrating no statistically significant difference in cerebral injury. Our findings demonstrate that the positive effects of remote ischemic preconditioning can be seen in cellular oxidative balance regulators in an animal model after 7 days of preconditioned ischemic insult.
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Affiliation(s)
- Oiva Arvola
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Henri Haapanen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | | | - Tuomas Anttila
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Ulla Puistola
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
| | - Peeter Karihtala
- Department of Oncology and Radiotherapy, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Hannu Tuominen
- Department of Pathology, Oulu University Hospital, Oulu, Finland
| | - Vesa Anttila
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tatu Juvonen
- Department of Surgery, Oulu University Hospital, Oulu, Finland; Department of Cardiac Surgery, Heart and Lung Center HUCH, Helsinki, Finland.
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Liguori GR, Kanas AF, Moreira LFP. Managing the inflammatory response after cardiopulmonary bypass: review of the studies in animal models. Braz J Cardiovasc Surg 2014; 29:93-102. [PMID: 24896169 PMCID: PMC4389477 DOI: 10.5935/1678-9741.20140017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 09/24/2013] [Indexed: 11/28/2022] Open
Abstract
Objective To review studies performed in animal models that evaluated therapeutic
interventions to inflammatory response and microcirculatory changes after
cardiopulmonary bypass. Methods It was used the search strategy ("Cardiopulmonary Bypass" (MeSH)) and
("Microcirculation" (MeSH) or "Inflammation" (MeSH) or
"Inflammation Mediators" (MeSH)). Repeated results, human studies,
non-English language articles, reviews and studies without control were
excluded. Results Blood filters, system miniaturization, specific primers regional perfusion,
adequate flow and temperature and pharmacological therapies with anticoagulants,
vasoactive drugs and anti-inflammatories reduced changes in microcirculation and
inflammatory response. Conclusion Demonstrated efficacy in animal models establishes a perspective for evaluating
these interventions in clinical practice.
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Affiliation(s)
- Gabriel Romero Liguori
- Correspondence address: Gabriel Romero Liguori, Instituto do Coração
(InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo,
Av. Dr. Enéas de Carvalho Aguiar, 44 - 2º andar - bloco II - sala 13 - Cerqueira
César, São Paulo, SP, Brazil - Zip code: 05403-000. E-mail:
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Li CN, Chen L, Ge YP, Zhu JM, Liu YM, Zheng J, Liu W, Ma WG, Sun LZ. Risk Factors for Prolonged Mechanical Ventilation After Total Aortic Arch Replacement for Acute DeBakey Type I Aortic Dissection. Heart Lung Circ 2014; 23:869-74. [DOI: 10.1016/j.hlc.2014.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/03/2014] [Accepted: 03/13/2014] [Indexed: 11/26/2022]
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Yannopoulos FS, Arvola O, Haapanen H, Herajärvi J, Miinalainen I, Jensen H, Kiviluoma K, Juvonen T. Leg ischaemia before circulatory arrest alters brain leucocyte count and respiratory chain redox state. Interact Cardiovasc Thorac Surg 2013; 18:272-7. [PMID: 24343749 DOI: 10.1093/icvts/ivt415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Remote ischaemic preconditioning and its neuroprotective abilities are currently under investigation and the method has shown significant effects in several small and large animal studies. In our previous studies, leucocyte filtration during cardiopulmonary bypass reduced cerebrocortical adherent leucocyte count and mitigated cerebral damage after hypothermic circulatory arrest (HCA) in piglets. This study aimed to obtain and assess direct visual data of leucocyte behaviour in cerebral vessels after hypothermic circulatory arrest following remote ischaemic preconditioning. METHODS Twelve native stock piglets were randomized into a remote ischaemic preconditioning group (n = 6) and a control group (n = 6). The intervention group underwent hind-leg ischaemia, whereas the control group received a sham-treatment before a 60-min period of hypothermic circulatory arrest. An intravital microscope was used to obtain measurements from the cerebrocortical vessel in vivo. It included three sets of filters: a violet filter to visualize microvascular perfusion and vessel diameter, a green filter for visualization of rhodamine-labelled leucocytes and an ultraviolet filter for reduced nicotinamide adenine dinucleotide (NADH) analysis. The final magnification on the microscope was 400. After the experiment, cerebral and cerebellar biopsies were collected and analysed with transmission electron microscope by a blinded analyst. RESULTS In the transmission electron microscope analysis, the entire intervention group had normal, unaffected rough endoplasmic reticulum's in their cerebellar tissue, whereas the control group had a mean score of 1.06 (standard deviation 0.41) (P = 0.026). The measured amount of adherent leucocytes was lower in the remote ischaemic preconditioning group. The difference was statistically significant at 5, 15 and 45 min after circulatory arrest. Statistically significant differences were seen also in the recovery phase at 90 and 120 min after reperfusion. Nicotinamide adenine dinucleotide autofluorescence had statistically significant differences at 10 min after cooling and at 120 and 180 min after hypothermic circulatory arrest. CONCLUSIONS Remote ischaemic preconditioning seems to provide better mitochondrial respiratory chain function as indicated by the higher NADH content. It simultaneously provides a reduction of adherent leucocytes in cerebral vessels after hypothermic circulatory arrest. Additionally, it might provide some degree of cellular organ preservation as implied by the electron microscopy results.
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Onorati F, Santini F, Menon T, Amoncelli E, Campanella F, Pechlivanidis K, Faggian G, Mazzucco A. Leukocyte filtration of blood cardioplegia attenuates myocardial damage and inflammation†. Eur J Cardiothorac Surg 2012; 43:81-9. [DOI: 10.1093/ejcts/ezs145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lee JK, Blaine Easley R, Brady KM. Neurocognitive monitoring and care during pediatric cardiopulmonary bypass-current and future directions. Curr Cardiol Rev 2011; 4:123-39. [PMID: 19936287 PMCID: PMC2779352 DOI: 10.2174/157340308784245766] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 12/17/2007] [Accepted: 12/21/2007] [Indexed: 11/22/2022] Open
Abstract
Neurologic injury in patients with congenital heart disease remains an important source of morbidity and mortality. Advances in surgical repair and perioperative management have resulted in longer life expectancies for these patients. Current practice and research must focus on identifying treatable risk factors for neurocognitive dysfunction, advancing methods for perioperative neuromonitoring, and refining treatment and care of the congenital heart patient with potential neurologic injury. Techniques for neuromonitoring and future directions will be discussed.
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Affiliation(s)
- Jennifer K Lee
- Departments of Anesthesiology/Critical Care Medicine and Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Current World Literature. Curr Opin Anaesthesiol 2008; 21:85-8. [DOI: 10.1097/aco.0b013e3282f5415f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dahlbacka S, Alaoja H, Mäkelä J, Niemelä E, Laurila P, Kiviluoma K, Honkanen A, Ohtonen P, Anttila V, Juvonen T. Effects of pH Management During Selective Antegrade Cerebral Perfusion on Cerebral Microcirculation and Metabolism: Alpha-Stat Versus pH-Stat. Ann Thorac Surg 2007; 84:847-55. [PMID: 17720388 DOI: 10.1016/j.athoracsur.2007.03.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2007] [Revised: 03/13/2007] [Accepted: 03/19/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Selective cerebral perfusion (SCP) is used for extending the period during which surgical procedures can be safely performed. We sought to determine the direct effects of pH management on cerebral microcirculation and metabolism during SCP. METHODS An experimental SCP porcine model was created by selectively allowing cold perfusate only into the bicarotid brachiocephalic trunk during the SCP period. Twenty-four piglets (6 to 8 weeks; mean weight, 26.1 +/- 4.1 kg) underwent 15-minute normothermic cardiopulmonary bypass, 45-minute cooling cardiopulmonary bypass, 60-minute SCP at 25 degrees C, and 45-minute rewarming cardiopulmonary bypass with either alpha-stat or pH-stat perfusion strategy randomly assigned. A cranial window was created over the parietal cortex for visualization of the cerebral vessels with intravital microscopy. Rhodamine-stained leukocytes were observed in cerebral postcapillary venules for adhesion and rolling. Microdialysis analysis was used for determination of brain metabolism. RESULTS Brain concentration of lactate was significantly higher in the alpha-stat group at 45 minutes of SCP, and at 15- and 45-minute rewarming intervals (p = 0.03; p = 0.003; and p = 0.05; respectively), reaching borderline statistical significance when assessed throughout the experiment (p = 0.06 for differences between groups). Further, at the end of cooling, the oxygen delivery tended to be higher in the pH-stat group (p = 0.07), whereas at the 30-minute rewarming interval, the oxygen extraction tended to be higher in the alpha-stat group (p = 0.06). There were no statistically significant differences between the groups in leukocyte-endothelial interaction, arterial diameter, or tissue oxygenation. CONCLUSIONS The higher concentration of brain lactate and the tendency to higher oxygen extraction levels during rewarming with alpha-stat strategy suggests anaerobic metabolism occurred during SCP. No major differences between pH management strategies in cerebral microcirculation could be shown during SCP.
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Affiliation(s)
- Sebastian Dahlbacka
- Department of Surgery, Clinical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland.
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