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Mechanisms of injury and methods of protection of the brain during cardiac surgery in neonates and infants

Published online by Cambridge University Press:  19 August 2008

William J. Greeley ,
Frank H. Kern ,
James R. Mault ,
Lynn A. Skaryak  and
Ross M. Ungerleider
William J. Greeley*
Affiliation:
From the Departments of Anesthesiology, Surge and Pediatrics, Duke Children's Hospital, Durham
Frank H. Kern
Affiliation:
From the Departments of Anesthesiology, Surge and Pediatrics, Duke Children's Hospital, Durham
James R. Mault
Affiliation:
From the Departments of Anesthesiology, Surge and Pediatrics, Duke Children's Hospital, Durham
Lynn A. Skaryak
Affiliation:
From the Departments of Anesthesiology, Surge and Pediatrics, Duke Children's Hospital, Durham
Ross M. Ungerleider
Affiliation:
From the Departments of Anesthesiology, Surge and Pediatrics, Duke Children's Hospital, Durham
*
Dr. William J. Greeley, Department of Anesthesiology, Duke Medical Center, Durham, NC 27710, USA. Tel. 919-681-3543.
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Extract

With substantial effort and research devoted to improving surgical techniques and myocardial protection, superb results have been achieved for repair of complex congenital heart defects in children. As a result, investigative efforts now have begun to examine the quality of life for patients surviving these operations. Because these neonates and infants are exposed to severe physiologic extremes of temperature (15–18 °C) and severe alterations from normal perfusion (total circulatory arrest), the nature of long-term neuropsychological outcome has been a prominent concern. Recent preliminary reports suggest that transient and permanent neuropsychologic injury occur in as many as 25% of all infants undergoing hypothermic cardiopulmonary bypass with circulatory arrest.'Since improved surgical techniques have significantly reduced rates of operative mortality and cardiac morbidity, one of the greatest risks remaining for the patient with congenital heart disease may be long term neuropsychologic and developmental abnormalities.

Keywords

Cerebral metabolismdeep hypothermic arrestbypass at low flowinjury to the brain
Type
World Forum for Pediatric Cardiology Symposium on Cardiopulmonary Bypass (Part 1)
Information
Cardiology in the Young , Volume 3 , Issue 3 , July 1993 , pp. 317 - 330
Copyright
Copyright © Cambridge University Press 1993

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References

1.Ferry, PC. Neurologic sequelae of open-heart surgery in children. An ‘irritating question’. Am J Dis Child 1990; 144: 369–73.CrossRefGoogle ScholarPubMed
2.Wright, J, Hicks, R. Deep hypothermic arrest. Observation on later development in children. J Thorac Cardiovasc Surg 1979; 86: 466–468.CrossRefGoogle Scholar
3.Dickinson, D, Sambrooks, J. Intellectual performance in children after circulatory arrest with profound hypothermia in infancy. Arch Dis Child 1979; 54: 1–6.CrossRefGoogle ScholarPubMed
4.Clarkson, P, Barton, M, MacArthur, A. Developmental progress after cardiac surgery in infancy using hypothermia and circulatory arrest. Circulation 1980; 62: 855–861.CrossRefGoogle ScholarPubMed
5.Wells, F, Coghill, S, Caplan, H. Duration of circulatory arrest does influence the psychological development of children after cardiac operation in early life. J Thorac Cardiovasc Surg 1983; 86: 823–831.CrossRefGoogle ScholarPubMed
6.Blackwood, M, Haka-Ikse, K, Steward, D. Developmental outcome in children undergoing surgery with profound hypothermia. Anesthesiology 1986; 65: 437–440.CrossRefGoogle ScholarPubMed
7.Ferry, PC. Impairment of cerebral function following cardiac and other major surgery. Eur J Cardiothorac Surg 1989; 3: 216–221.Google Scholar
8.Greeley, WJ, Ungerleider, RM, Smith, LR, Reves, JG. The effects ofdeep hypothermic cardiopulmonasy bypass and total circulatory arrest on cerebral blood flow in infants and children. J Thorac Cardiovasc Surg 1989; 97: 737–745.CrossRefGoogle Scholar
9.Greeley, WJ, Kern, FH, Ungerleider, RM, Boyd, JLI, Quill, T, Smith, LR, Baldwin, B, Reves, JG. The effect of hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral metabolism in neonates, infants, and children. J Thorac Cardiovasc Surg 1991; 101: 783–794.CrossRefGoogle ScholarPubMed
10.Fisk, G, Wrighr, J, Hicks, R, Anderson, M, Turner, B, Baker, W, Lawrence, J, Stacey, R, Lawrie, G, Kalnins, I. The influence of duration of circulatory arrest at 20°C on cerebral changes. Anaesth miens Care 1976; 4: 126–134.CrossRefGoogle Scholar
11.Watanabe, T, Orita, H, Kobayashi, M, Washio, M. Brain tissue pH, oxygen tension, and carbon dioxide tension in profoundly hypothermic cardiopulmonasy bypass. Comparative study of circulatory arrest, nonpulsatile low-flow perfusion, and pulsa tile low-flow perfusion [see comments]. J Thorac Cardiovasc Surg 1989; 97: 396–401.CrossRefGoogle Scholar
12.Swainj, A, Robbins, RC, Balaban, RS, McDonald, TJJ, Schneider, B, Groom, RC. The effect ofcardiopulmonary bypass on brain and heart metabolism, a 31 p NMR study. Magn Reson Med 1990; 15: 446–455.CrossRefGoogle Scholar
13.Rossi, R, van d, LJ, Ekroth, R, Scallan, M, Thompson, RJ, Lincoln, C. No flow or low flow? A study of the ischemic marker creatine kinase BB after deep hypothermic procedures. J Thorac Cardiovasc Surg 1989; 98: 193–199.CrossRefGoogle ScholarPubMed
14.Rossi, R, Ekroth, R, Lincoln, C, Jackson, A, Thompson, R, Scallan, M, Tsang, V, Jackson, A, Thompson, R. Detection of cerebral injury after total circulatory arrest and profound hypothermia by estimation of specific creatinine kinase isoen zyme levels using monoclonal antibody techniques. Am J Cardiol 1987; 59: A12.Google Scholar
15.Miyamato, K, Kawahima, Y, Matsuda, H, Okuda, A, Maeda, S, Hirose, H. Optimal perfusion flow rate for the brain during deep hypothermic cardiopulmonary bypass at 20°C. J Thorac Cardiovasc Surg 1986; 92: 1065–1070.CrossRefGoogle Scholar
16.Perna, A, Gardner, T, Tabaddor, K, Brawley, R, Gott, V. Cerebral metabolism and blood flow after circulatory arrest during deep hypothermia. Ann Surg 1973; 178: 95–101.CrossRefGoogle ScholarPubMed
17.Fish, KJ, Helms, KN, Sarnquist, FH, van, SC, Linet, OI, Hilberman, M, Mitchell, RS, Jamieson, SW, Miller, DC, Tinklenberg, JS. The effect of low-flow cardiopulmonary bypass on cerebral function: an experimental and clinical study. Ann Thorac Surg 1987; 43: 391–396.Google Scholar
18.Treasure, T, Naftel, D, Conger, K, Garcia, J, Kirklin, J, Blackstone, E. The effect of hypothermic circulatory arrest time on cere bral function, morphology, and chemistry: An experimental study. J. Thorac Cardiovasc Surg 1983; 86: 761–770.CrossRefGoogle Scholar
19.Molina, J, Einzig, S, Mastri, A, Bianco, R, Marks, J, Rasmussen, T, Clark, R. Brain damage in profound hypothermia: Perfusion versus circulatory arrest. J Thorac Cardiovasc Surg 1984; 87: 596–600.CrossRefGoogle ScholarPubMed
20.Mault, JR, Ohtake, S, Klingensmith, ME, Heinle, JS, Greeley, WJ, Ungerleider, RM. Cerebral metabolism following variable periods of hypothermic circulatory arrest: Effects of duration and strategies for protection. Ann Thorac Surg 1993; 55: 57–64.CrossRefGoogle Scholar
21.Hillier, S, Burrows, F, Bissorinette, B, Taylor, R. Cerebral hemodynamics in neonates and infants undergoing cardiopulmonary bypassand profound hypothermic circulatory arrest: Assessment by transcranial Doppler sonography. Anesth Analg 1991; 72: 723–728.CrossRefGoogle ScholarPubMed
22.Lundar, T, Lindberg, H, Lindegaard, KF, Tjnneland, S, Rian, R, Nornes, H. Cerebral perfusion during major cardiac surgery in children. Pediatr Cardiol 1987; 8: 161–165.CrossRefGoogle ScholarPubMed
23.Willems, CE, Salisbury, DM, Lumley, JS, Dillon, MJ. Serial measurement of arterial and internal jugular venous creatine kinase isoenzyme BB (CK-BB) after deep hypothermic total circulatory arrest in pediatric cardiac surgely. Thorac Cardiovasc Surg 1986; 34: 223–225.Google Scholar
24.Rossi, R, Ekroth, R, Lincoln, C, Jackson, AP, Thompson, RJ, Scallan, M, Tsang, V, Jackson, A, Thompson, R. Detection of cerebral injury after total circulatory arrest and profound hypothermia by estimation of specific creatine kinase isoen zyme levels using monoclonal antibody techniques. Am J Cardiol 1986; 58: 1236–1241. [Published erratum appears in AmJ Cardiol 1987; 59:A12.]CrossRefGoogle Scholar
25.Greeley, W, Ungerleider, R, LR, S, Reves, J. Cardiopulmonary bypass alters cerebral blood flow in infants and children during and after cardiovascular surgery. Circulation 1988; 78(Suppl II): II 356–II 363.Google Scholar
26.Greeley, WJ, Ungerleider, RM, Kern, FH, Brusino, FG, Smith, LR, Reves, JG. Effects of cardiopulmonary bypass on cerebral blood flow in neonates, infants, and children. Circulation 1989; 80: 1209–1215.Google ScholarPubMed
27.Greeley, W, Bracey, V, Ungerleider, R, Greibel, J, Kern, F, Reves, J, Piantadosi, C. Recovery of cerebral metabolism and mitochrondrial oxidation state are delayed after hypothermic circulatory arrest. Circulation 1991; 82: 412–418.Google Scholar
28.Civalero, LA, Moreno, JR, Senning, A. Temperature conditions and oxygen consumption during deep hypothermia. Acta Chir Scand 1962; 123: 179–188.Google ScholarPubMed
29.Tanaka, J, Shiki, K, Asou, T, Yasui, H, Tokunaga, K. Cerebral autoregulation during deep hypothermic nonpulsatile cardio pulmonary bypass with selective cerebral perfusion in dogs. J Thoracic Cardiovasc Surg 1988; 95: 124–132.CrossRefGoogle Scholar
30.Kern, FH, Ungerleider, RM, Quill, TJ, Baldwin, B, White, WD, Reves, JG, Greeley, WJ. Cerebral blood flow response to changes in PaCO2 during hypothermic cardiopulmonary by pass in children. J Thorac Cardiovasc Surg 1991; 101: 618–22.CrossRefGoogle Scholar
31.Michenfelder, JD, Theye, RA. Hypothermia. Effect of canine brain and whole-body metabolism. Anesthesiology 1968; 29: 1107.CrossRefGoogle ScholarPubMed
32.Milde, LN. Clinical use of mild hypothermia for brain protection—a dream revisited. J Neurosurg Anesthesiol 1992; 4: 211–215.CrossRefGoogle ScholarPubMed
33.Bering, F.A Jr. Effect of body temperature change on cerebral oxygen consumption during hypothermia. Am J Physiol 1961; 200: 417.CrossRefGoogle Scholar
34.Croughwell, N, Smith, LR, Quill, I, Newman, M, Greeley, WJ, Kern, FH, Lu, J, Revesj, G. The effect of temperature on cerebral metabolism and blood flow in adults during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1992; 103: 549–554.CrossRefGoogle ScholarPubMed
35.Kety, SS. The determination of cerebral blood flow in man by the use of nitrous oxide in low concentrations. Am J Physiol 1945; 143: 53.CrossRefGoogle Scholar
36.Michenfelder, JD. In: Michenfelder, JD (ed). Anesthesia and The Brain. Churchill Livingstone Inc., New York, Edinburgh, London, Melbourne, 1988, pp 7–8.Google Scholar
37.Michenfelder, JD. In: Michenfelder, JD (ed). Anesthesia and The Brain. Churchill Livingstone Inc., NewYork, Edinburgh, London, Melbourne, 1988, pp 7–8.Google Scholar
38.Rosenberg, AA, Jones, MD, Traystman, RJ, Simmons, MA, Molteni, RA. Response of cerebral blood flow to changes in PCO2 in fetal, newborn and adult sheep. Am J Physiol 1982; 242: H862–H866.Google ScholarPubMed
39.Murkin, JM, Farrar, JK, Tweed, WA, McKenzie, FN, Guiraudon, G. Cerebral autoregulation and flow/metabolism coupling duringw cardiopulmonary bypass: the influence of PaCO2. Anesth Analg 1987; 66: 825–832.CrossRefGoogle ScholarPubMed
40.Govier, AV, Reves, JG, McKay, RD, Karp, RB, Zorn, GL, Morawetz, RB, Smith, LR, Adams, M, Freeman, AM. Factors and their influence on regional cerebral blood flow during nonpulsatile cardiopulmonary bypass. Ann Thorac Surg 1984; 38: 592–600.CrossRefGoogle ScholarPubMed
41.Prough, D, Stump, D, Roy, R, Gravlee, G, Williams, T, Mills, S, Hinshelwood, L, Howard, G. Response of cerebral blood flow to changes in carbon dioxide tension during hypothermic cardiopulmonary bypass. Anesthesiology 1986; 64: 576–581.CrossRefGoogle ScholarPubMed
42.Murkin, J, Farrar, J, Tweed, W, McKenzie, F, Guiraudon, G. Cerebral autoregulation and flow/metabolism coupling dur ing cardiopulmonary bypass: The influence of PaCO2. Anesrh Analg 1987; 66: 825–832.Google Scholar
43.Swan, H. The importance ofacid-base management for cardiac and cerebral preservation during open heart operations. Surg Gynecol Obstet 1984; 158: 391–414.Google ScholarPubMed
44.Somero, GN, White, FN. Enzymatic consequences under alpha stat regulation. In: Rahn, H, Prakash, O (eds). Acid-Base Regulation and Body Temperature. Nijhoff, Boston, 1985.Google Scholar
45.Slogoff, S, Girgis, KZ, Keats, AS. Etiologic factors in neuropsy chiatric complications associated with cardiopulmonary by pass. Anesth Analg 1982; 61: 903–911.CrossRefGoogle Scholar
46.Nussmeir, NA, Carolee, A, Slogoff, S. Neuropsychiatric compli cations after cardiopulmonary bypass: cerebral protection by barbiturates. Anesthesiology 1986; 64: 165–170.CrossRefGoogle Scholar
47.Glauser, TA, Rorke, LB, Weinberg, PM, Clancy, RR. Acquired neuropathologic lesions associated with the hypoplastic left heart syndrome. Pediatrics 1990; 85: 991–1000.CrossRefGoogle ScholarPubMed
48.Aisen, P. In: Jacobs, A, Warwood, M (eds). Iron in Biochemistry and Medicine. Academic Press, New York, 1980, p. 87.Google Scholar
49.Siesjo, BK, Memezawa, H, Smith, ML. Neurocytotoxicity. Fundam Clin Pharmacol 1991; 5: 755–767.CrossRefGoogle ScholarPubMed
50.Ogata, T, Ida, Y, Nonoyama, A. A comparative study of the effectiveness of pulsatile and nonpulsatile flow in extracorpo real circulation. Arch Jpn Clin 1960; 29: 59.Google Scholar
51.Matsumato, T, Wolferth, CC Jr, Perlman, MH: Effects of pulsatile and non perfusion upon cerebral and con junctival microcirculatiojn in the dog. Am Surg 1960; 37: 61–64.Google Scholar
52.Geha, AS, Salayemeh, MT, Abe, T, Baue, AE. Effect of pulsatile cardiopulmonary bypass on cerebral metabolism. J Surg Res 1972; 12: 381–387.CrossRefGoogle ScholarPubMed
53.Watanabe, T, Miura, M, Kohno, M, Nemoto, H, Orita, H, Nishimura, K, Shimanuki, T, Nakamura, C, Kobayashi, M, Washio, M. Pulsatile assistance for profoundly hypothermic circulatory arrest, low-flow perfusion, and moderate-flow perfusion: comparative study of brain tissue pH, PO2 and PCO2. Nippon Kyobu Geka Gakkai Zasshi 1989; 37: 2449–2455. [In Japanese]Google Scholar
54.Smith, PL. The cerebral complications of coronary artery bypass surgery. Ann R Coil Surg Engl 1988; 70: 212–216.Google ScholarPubMed
55.Shaw, PJ, Bates, D, Cartlidge, NE, French, JM, Heaviside, D, Julian, DG, Shaw, DA. Neurologic and neuropsychological morbidity following major surgery: comparison of coronary artery bypass and peripheral vascular surgery. Stroke 1987; 18: 700–707.CrossRefGoogle ScholarPubMed
56.Oka, Y, Inoue, T, Hong, Y, Sisto, DA, Strom, JA, Frater, RW. Retained intracardiac air. Transesophageal echocardiography for definition of incidence and monitoring by improved techniques. J Thorac Cardiovasc Surg 1986; 91: 329–338.CrossRefGoogle ScholarPubMed
57.Stegman, T, Daniel, W, Bellman, L. Experimental coronary air embolism: Assessment of time course of myocardial ischemia and the protective effect of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1980; 28: 141–148.CrossRefGoogle Scholar
58.Greeley, WI, Kern, FH, Ungerleider, RM, Kisslo, JA. Intramyocardial air causes right ventricular dysfunction after repair of a congenital heart defect. Anesthesiology 1990; 73: 1042– 1046.CrossRefGoogle ScholarPubMed
59.Robbins, RC, Balaban, RS, Swain, JA. Intermittent hypothermic asanguineous cerebral perfusion (cerebroplegia) protects the brain during prolonged circulatory arrest. A phosphorus 31 nuclear magnetic resonance study. J Thorac Cardiovasc Surg 1990; 99: 878–884.CrossRefGoogle ScholarPubMed
60.Todd, MM, Warner, DS. A comfortable hypothesis revisited. Anesthesiology 1992; 76: 161–164.Google Scholar
61.Meldrum, B. Protection against ischemic neuronal damage by drugs acting on excitatory neurotransmission. Cerebrovasc Brain Metab Rev 1990; 2: 27–57.Google ScholarPubMed
62.Field, J, Fuhrman, F, Martin, A. Effect of temperature on the oxygen consumption of brain tissue. J Neurophysiol 1944; 7: 117–126.CrossRefGoogle Scholar
63.Bigelow, W, Callaghan, J, Hopps, J. General hypothermia for experimental intracardiac surgery. Ann Surg 1950; 132: 531–539.CrossRefGoogle ScholarPubMed
64.Bellinger, D, Wernovsky, G, Rappaport, L, Lang, P, Hickey, P, Jonas, R, Newburger, J. Rapid cooling of infants on cardiopul monary bypass adversely affects later cognitive function. Circulation 1988; 78: A358.Google Scholar
65.Kern, FH, Jonas, RA, Mayer, JE, Hanley, F, Castafleda, AR, Hickey, PR. Conventional temperature monitoring is a poor correlate of efficient brain cooling. Anesthesiology 1991; 75: 853–859.CrossRefGoogle Scholar
66.Griepp, EV, Griepp, RB. Cerebral consequences of hyporhermic circulatory arrest in adults. J Card Surgery 1992; 7: 134–154.CrossRefGoogle ScholarPubMed
67.Nakajima, T, Kuro, M, Hayashi, Y, Kitaguchi, K, Uchida, O, Takaki, O. Clinical evaluation of cerebral oxygen balance during cardiopulmonary bypass-on-line continuous monitoring of jugular venous oxyhemoglobin saturation. Anesth Analg 1992; 74: 630–635.CrossRefGoogle ScholarPubMed
68.Schell, RM, Kern, FH, Reves, JG. The role of continuous jugular venous saturation monitoring during cardiac Surgery with cardiopulmonary bypass. Anest Analg 1992; 74: 627–629.CrossRefGoogle ScholarPubMed
69.Hindman, BJ, Dexter, F, Cutkomp, J, Smith, T, Todd, MM, Tinker, JH. Brain blood flow and metabolism do not decrease at stable brain temperature during cardiopulmonary bypass in rabbits. Anesthesiology 1992; 77: 342–351.CrossRefGoogle Scholar
70.Kern, FH, Ungerleider, RM, Quill, TJ, Baldwin, B, White, WD, Reves, JG, Greeley, WJ. Cerebral blood flow response to changes in arterial carbon dioxide tension during hypothermic cardiopulmonary bypass in children. J Thorac Cardiovasc Surg 1991; 101: 618–622.CrossRefGoogle ScholarPubMed
71.Bashein, G, Townes, BD, Nessly, BS, Bledsoe, SW, Hornbein, TF, Davis, KB, Goldstein, DE, Coppel, DB. A randomized study of carbon dioxide management during hypothermic cardiopulmonary bypass. Anesthesiology 1990; 72: 7–15.CrossRefGoogle ScholarPubMed
72.Rich, R, Ganz, R, Levy, P. Hemodynamiceffectsofhydralazine, nifedipine and amrinone in primary pulmonary hypertension. Am J Cardiol 1983; 52: 1104–1107.CrossRefGoogle ScholarPubMed
73.Bjork, VO, Hultquist, G. Contraindications to profound hypo thermia. I Thorac Cardiovasc Surg 1962; 44: 1–9.CrossRefGoogle Scholar
74.Egerton, N, Egerton, WS, Kay, JH. Neurologic changes following profound hypothermia. Ann Surg 1963; 157: 366–382.CrossRefGoogle ScholarPubMed
75.Brunberg, JA, Dory, DB, Reilly, EL. Choreoathetosis in infants following cardiac surgery with deep hypothermia and circulatory arrest. J Pediatr 1974; 84: 232–235.CrossRefGoogle ScholarPubMed
76.Norwood, W, Norwood, C, Castaneda, AR. Cerebral anoxia: Effect of deep hypothermia and pH. Surgery 1979; 86: 203209.Google ScholarPubMed
77.Gillino, AM, Redmond, JM, Zehr, KJ, Stuart, RS, Reitz, BA, Baumgartner, WA, Cameron, DE: Superior cerebral protection with profound 5°C vs. deep 20°C hypothermia during hypothermic circulatory arrest. Ann Thorac Surg 1993. In pressGoogle Scholar
78.Michenfelder, JD. In: Michenfelder, JD ed. Anesthesia and the Brain. Churchill Livingstone Inc., New York, Edinburgh, London, Melbourne, 1988, pp 2334.Google Scholar
79.Lanier, WL, Stangland, KJ, Scheithauer, BW, Milde, JH, Michenfelder, JD. The effects of dextrose infusion and head position on neurologic outcome after complete cerebral ischemia in primates: examination of a model. Anesthesiology 1987; 66: 3948.CrossRefGoogle ScholarPubMed
80.Lanier, WL. Glucose management during cardiopulmonary bypass: cardiovascular and neurologic implications. Anesth Analg 1991; 72: 423427. Editorial commentCrossRefGoogle ScholarPubMed
81.Steward, DJ, Da Silva, CA, Flegel, T. Elevated glucose levels may increase the danger of neurologic deficit following pro found hypothermic cardiac arrest. Anesthesiology 1988; 68: 653.CrossRefGoogle Scholar
82.Metz, S, Keats, AS. Benefits of a glucosecontaining priming solution for cardiopulmonary bypass. Anesth Analg 1991; 72: 428434.CrossRefGoogle ScholarPubMed
83.Brenner, WI, Lansky, Z, Engelman, RM, Stahl, WM. Hyper osmolar coma in surgical patients: an iatrogenic disease of increasing incidence. Ann Surg 1972; 178: 651654.CrossRefGoogle Scholar
84.Mills, NL, Beaudet, RL, Isom, OW, Spencer, FC. Hyperglycemia during cardiopulmonarybypass. Ann Surg 1973; 175: 203205.CrossRefGoogle Scholar
85.Kern, FH, Ungerleider, RM, Reves, JG, Quill, T, Smith, LR, Baldwin, B, Croughwell, N, Greeley, WJ. The effect of altering pump flow rate on cerebral blood flow and cerebral metabolism in neonates, infants and children. Ann Thorac Surg 1993. In pressCrossRefGoogle ScholarPubMed
86.Miyamato, K, Kawashima, Y, Matsuda, H, Okuda, A, Maeda, S, Hirose, H. Optimal perfusion flow rate for the brain during deep hypothermic cardiopulmonary bypass at 20°C. J Thorac Cardiovasc Surg 1986; 92: 1065–1070.CrossRefGoogle Scholar
87.Fox, L, Blackstone, E, Kirklin, J, Bishop, S, Bergdahl, L, Bradley, E. Relationship of brain blood flow and oxygen consumption to perfusion flow rate during profoundly hypothermic car diopulmonary bypass. J Thorac Cardiovasc Surg 1984; 87: 658–664.CrossRefGoogle Scholar
88.Kirklin, JW, Barratt-Boyes, BG eds. Cardiac Surgery. John Wiley Sons, New York, 1986.Google Scholar
89.Swain, JA, McDonald, TJ, Griffith, PK, Balabal, RS, Clark, RE, Ceclder, T. Low flow hypothermic cardiopulmonary bypass protects the brain. J Thorac Cardiovasc Surg 1991; 102: 76–84.CrossRefGoogle ScholarPubMed
90.Watanabe, T, Miura, M, Orita, H, Kobayasi, M, Washio, M. Brain tissue pH, oxygen tension, and carbon dioxide tension in profoundly hypothermic cardiopulmonary bypass. Pulsa tile assistance for circulatory arrest, lowflow perfusion, and moderateflow perfusion. J Thorac Cardiovasc Surg 1990; 100: 274280.CrossRefGoogle Scholar
91.Greeley, WJ. Deep hypothermic circulatory arrest must be used selectively and discretely. J Cardiothorac Vasc Surg 1991; 5: 638–641. CommentGoogle Scholar
92.Stocker, F, Herschkowitz, N, Bossi, E, Stoller, M, Cross, TA, Aue, WP, Seelig, J. Cerebral metabolic studies in situ by3 1 Pnuclear magnetic resonance after hypothermic circulatory arrest. Pediatr Res 1986; 20: 867–871.CrossRefGoogle Scholar
93.Chopp, M, Knight, R, Tidwell, CD. The metabolic effects of moderate hypothermia on global cerebral ischemia and recirculation in the cat: Comparison to monotherinia and hypothermia. J Cereb Blood Flow Metab 1989; 9: 133–140.CrossRefGoogle Scholar
94.Benveniste, H, Huttemeier, PC. Microdialysistheory and application. Prog Neurobiol 1990; 35: 195–215.CrossRefGoogle ScholarPubMed
95.Rothman, SM, Olney, JW. Glutamate and the pathophysiol ogyofhypoxic-ischemic brain damage. Ann Neurol 1986; 19: 105–111.CrossRefGoogle Scholar
96.Busto, R, Dietrich, WD, Globus, MY, Valdes, I, Scheinberg, P, Ginsberg, MD. Small differences in the intraischemic brain temperature critically determine the extent of ischemic neuronal injury. J Cereb Blood Flow Metab 1987; 7: 729–736.CrossRefGoogle ScholarPubMed
97.Benveniste, H, Drejer, J, Schousboe, A, Diemer, NH. Elevations of the extracellular concentrations of glutamate and aspartate in rat hippocampus during transient cerebral ischemia monitored by intracerebral microdialysis. J Neurochem 1984; 43: 1369–1374.CrossRefGoogle ScholarPubMed
98.Busto, R, Mordecai, YT, Dietrich, D, Martinez, E, Valdes, I, Ginsberg, MD. Effects ofmild hypothermia on brain ischemia. Stroke 1989; 20: 904910.CrossRefGoogle Scholar
99.Rothman, SM, Olney, JW. Excitotoxicity and the NMDA receptor. Ann Neurol 1987; 10: 299–302.Google Scholar
100.Johnson, M, Perry, RH, Chariton, FG, Moses, MA, Court, JA, Perry, EK. Distribution of MK801 binding in the normal aged human hippocampus. Brain Research 1989; 499: 184–187.CrossRefGoogle ScholarPubMed
101.Ment, LR, Stewart, WB, Petroff, OA, Duncan, CC, Montoya, D. Beagle puppy model of perinatal asphyxia: blockade of excitatory neurotransmitters. Pediatr Neurol 1989; 5: 281–286.CrossRefGoogle ScholarPubMed
102.Mault, JR, Whitaker, EG, Heinle, JS, Lodge, AJ, Greeley, WJ, Ungerleider, RM. Intermittent perfusion during hypothermic circulatory arrest: a new and effective technique for cerebral protection. Surgical Forum 1982; 43: 314–317.Google Scholar
103.Watanabe, T, Orita, H, Kobayashi, M, Washio, M: Brain tissue pH, oxygen tension, and carbon dioxide tension in profoundly hypothermic cardiopulmonary bypass. J Thorac Cardiovasc Surg 1989; 97: 396–401.CrossRefGoogle ScholarPubMed
104.Kern, FH, Jonas, RA, Mayer, JE, Hanley, FL, Castañeda, AR, Hickey, PR. Temperature monitoring during infant CPB: Does it predict efficient brain cooling? Ann Thor Surg 1992. [In press]CrossRefGoogle ScholarPubMed
105.Boucher, JK, Rudy, LW, Edmunds, LH Jr. Organ blood flow duringpulsatile cardiopulmonarybypass. J AppI Physiol 1974; 36: 86.CrossRefGoogle Scholar
106.Geha, AS, Salaymeh, MT, Abe, T, Baue, AE. Pressuredepen dent cerebral ischemia during cardiopulmonary bypass. Neu rology 1973; 23: 521–529.Google Scholar
107.Mezrow, CK, Sadeghi, AM, Gandsas, A, Griepp, RB. Cerebral blood flow and metabolism in circulatory arrest. Ann Thorac Surg 1992. [In press]CrossRefGoogle ScholarPubMed
108.Burrows, FA, Hillier, SC, McLeod, ME, Iron, KS, Taylor, MJ. Anterior fontanel pressure and visual evoked potentials in neonates and infants undergoing profound hypothermic cir culatory arrest. Anesthesiology 1990; 73: 632–636.CrossRefGoogle Scholar