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Ann Thorac Surg 1993;55:1093-1103
© 1993 The Society of Thoracic Surgeons
a Departments of Cardiovascular Surgery, Pediatrics, Neurology, and Anesthesiology, Children's Hospital and Harvard Medical School, Boston, Massachusetts USA
b Departments of Cardiovascular Surgery, Pediatrics, Neurology, and Anesthesiology, Massachusetts Institute of Technology, Cambridge, Massachusetts USA
* Address reprint requests to Dr Jonas, Department of Cardiovascular Surgery, The Children's Hospital, 300 Longwood Ave, Boston, MA 02115.
The pH management that provides optimal organ protection during hypothermic circulatory arrest is uncertain. Recent retrospective clinical data suggest that the pH-stat strategy (maintenance of pH at 7.40 corrected to core temperature) may improve brain protection during hypothermic cardiopulmonary bypass with a period of circulatory arrest in infants. The impact of alpha-stat (group A) and pH-stat (group P) strategies on recovery of cerebral high-energy phosphates and intracellular pH measured by magnetic resonance spectroscopy (A, n = 7; P, n = 5), organ blood flow measured by microspheres, cerebral metabolic rate measured by oxygen and glucose extraction (A, n = 7; P, n = 6), and cerebral edema was studied in 25 4-week-old piglets undergoing core cooling and 1 hour of circulatory arrest at 15 °C. Group P had greater cerebral blood flow during core cooling (54.3% ± 4.7% versus 34.2% ± 1.5% of normothermic baseline, respectively; p = 0.001). The intracellular pH during core cooling showed an alkaline shift in both groups but became more alkaline in group A than in group P at the end of cooling (7.08 to 7.63 versus 7.09 to 7.41, respectively; p = 0.013). Recovery of cerebral adenosine triphosphate (p = 0.046) and intracellular pH (p = 0.014) in the initial 30 minutes of reperfusion was faster in group P. The cerebral intracellular pH became more acidotic during early reperfusion in group A, whereas it showed continuous recovery in group P. Brain water content postoperatively was less in group P (0.8075) than in group A (0.8124) (p = 0.05). These results suggest that compared with alpha-stat, the pH-stat strategy provides better early brain recovery after deep hypothermic cardiopulmonary bypass with circulatory arrest in the immature animal. Possible mechanisms include improved brain cooling by increased blood flow to subcortical areas, improved oxygen delivery, and reduction of reperfusion injury, as well as an alkaline shift in intracellular pH with hypothermia in spite of a stable blood pH.
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L. A. Skaryak, P. M. Kirshbom, L. R. DiBernardo, F. H. Kern, W. J. Greeley, R. M. Ungerleider, J. W. Gaynor, and S. b. D. C. Sabiston Jr. Modified ultrafiltration improves cerebral metabolic recovery after circulatory arrest J. Thorac. Cardiovasc. Surg., April 1, 1995; 109(4): 744 - 752. [Abstract] [Full Text]
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R. A. Jonas Invited letter concerning: Cerebral blood flow, carbon dioxide, and pH J. Thorac. Cardiovasc. Surg., November 1, 1994; 108(5): 984 - 985. [Full Text]
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M. Aoki, R. A. Jonas, F. Nomura, M. E. Stromski, M. K. Tsuji, P. R. Hickey, and D. Holtzman Effects of cerebroplegic solutions during hypothermic circulatory arrest and short-term recovery J. Thorac. Cardiovasc. Surg., August 1, 1994; 108(2): 291 - 301. [Abstract] [Full Text]
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R. M. Ungerleider Direct-vision aortic valvotomy: Predecessor to modern aortic surgery Ann. Thorac. Surg., May 1, 1994; 57(5): 1351 - 1353. [Abstract] [PDF]
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R. A. Jonas Review of current research at Boston Children's Hospital Ann. Thorac. Surg., December 1, 1993; 56(6): 000349759390732W - 349759390732W. [Abstract] [PDF]
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