By F. Curtis. Dakota State University.
Awake intubation has been used to secure the airway without the danger of loss of airway during the procedure generic 250 mcg seroflo with mastercard, but it can be a traumatic experience for both the patient and the anesthesiologist order 250mcg seroflo with amex, accompanied by pain discount seroflo line, bradycardia seroflo 250 mcg overnight delivery, breath holding, desaturation, and tissue trauma. However, this technique is usually reserved for patients with severe hemodynamic compromise, an extraordinarily distended and tense abdomen, or a presumed difficult airway, especially the newborn with micrognathia. In the latter situation, the addition of sedation with an opioid or topical application of local anesthetic can help decrease some of the trauma of the procedure. It has also been suggested that an awake intubation may be best for the anesthesiologist who is not very experienced in intubating newborns. It may be better to have a more experienced clinician, if available, attend to the airway in that situation. If there is concern about the difficulty of intubation, it may be prudent to induce anesthesia, ensure adequacy of mask ventilation, and then give the muscle relaxant. Positioning for intubation is based on the known differences in the neonatal airway. No changes in position are usually needed, although additional extension of the head may be accomplished by a shoulder roll. Sliding the blade down the right side of the mouth allows the blade to be seated with minimal overlap by the tongue (Fig. The tip of the blade is advanced to lift the epiglottis directly instead of placing it in the vallecula, as is commonly done with older patients. Every patient’s anatomy is different, but if the laryngoscope is advanced in the direction parallel to the handle, one will get the best visualization. If the 2971 glottis is not easily seen, cricoid pressure can be applied with the little finger of the hand holding the handle or by an assistant, often improving the view (Fig. Uncuffed tubes have traditionally been used in newborns to minimize cuff pressure on the subglottic larynx, especially at the level of the cricoid cartilage. Modern cuffed endotracheal tubes make minimal sacrifice in tube diameter to allow for the presence of a cuff, which has renewed interest in cuffed endotracheal tubes. Although various formulas have been proposed for how far to advance an uncuffed tube, it is prudent to use the depth markers at the end of the tube to ensure under direct vision that the tip is advanced 2 or 3 cm past the vocal cords. Once inserted, the presence of a positive capnograph tracing, bilateral expansion of the thorax, and bilateral breath sounds are used to ensure proper placement. Although some anesthesiologists prefer to advance the endotracheal tube past the carina and then withdraw until bilateral breath sounds are heard, there are two major disadvantages to the technique: trauma to the airway and lack of a guarantee that the tip of the tube is not sitting right at the carina, increasing the chance of migration into a bronchus with head movement. Finally, listen for an air leak at an airway pressure of about 20 cm H O to2 ensure that the tube is not too large for the airway, increasing the chances of subglottic edema and damage. Fiberoptic laryngoscopy, the most flexible of intubating tools routinely used in older children and adults, can also be used in the newborn. After establishing a baseline of acceptable ventilation, it is important to continuously monitor the peak airway pressures, chest expansion, return volume, pulse oximetry, and capnograph tracings for changes. Initial tidal volumes of 6 to 7 mL/kg and rates of 20 to 25 breaths per minute are a reasonable starting point for most patients. With this rate 2973 and volume setting, it would be expected that peak airway pressures be approximately 20 cm H O. Of course, this strategy must be modified for some patients with severe coexisting disease. Mechanical ventilation of the neonate can be challenging for the anesthesiologist. Modern anesthetic systems make ventilation much easier than in the past, even in the smallest patients. Although the standard has been to use pressure control ventilation in this population, all modes of ventilation are now readily available on modern anesthesia machines. Table 42-4 shows the modes of ventilation and breath synchronization most commonly used in neonates. Use of high frequency ventilation in the operative setting will require use of a specialized ventilator and close consultation with a critical care physician and respiratory therapist. Table 42- 5 lists some of the advantages and disadvantages to use of pressure control, volume targeted, and high frequency ventilation. Table 42-4 Common Ventilator Strategies in Neonates Impact of Surgical Requirements on Anesthetic Technique Every procedure has its own unique challenges. With any surgery, issues related to presurgical resuscitation, perioperative fluid and blood loss, 2974 heat loss from the surgical field, likely perioperative complications, and the likely need for postoperative intubation and ventilation should be anticipated, both on the basis of experience and communication about the unique needs of the upcoming procedure. There is a dramatic increase in the use of laparoscopic and thoracoscopic approaches to lesions, even in the smallest neonates. There may be less blood, fluid, and heat loss, but there are additional issues related to positioning, insufflation pressures in the chest and abdomen, and prolonged surgical time. As new techniques evolve, close communication between the anesthesiologist and the surgeon is necessary to ensure adequate preparation, monitoring, and resolution of problems or complications. One not well-recognized factor that may result in higher concentrations of volatile anesthetics being administered to infants has to do with the use of nonrebreathing systems such as the Bain or a Mapleson “D” circuit. When an adult circle system is used with infant tubes and bag, the clinician experienced with this equipment is used to reading the inspired, end-tidal, and dialed concentrations of the volatile anesthetic. In the circle system, the inspired concentration is a result of the combination of the end-tidal concentration that is rebreathed through the soda lime absorber and the dialed concentration. The inspired concentration is always lower than the dialed concentration, unless the flow rates are so high that a nonrebreathing system has been created. In the nonrebreathing system, the dialed concentration is the inspired concentration. However, if the clinician switches back and forth between the circle system and a nonrebreathing circuit, but does so infrequently, there is a danger of not recognizing the possibility of excessive overpressure of volatile anesthetics with the nonrebreathing systems. The newborn infant has elevated progesterone levels, similar to those of the mother. Elevated levels of β-endorphin and β-lipotropin have been demonstrated in infants in the first few days of postnatal life. Regional Anesthesia 2976 There has been a tremendous increase in the use of regional anesthesia in infants and children. In general, regional techniques are combined with general anesthesia to permit early extubation and provide postoperative pain relief. Useful regional anesthesia techniques include spinal anesthesia, caudal anesthesia, epidural analgesia, penile block, and other peripheral nerve blocks (Table 42-6). Regional anesthesia may even have other applications outside surgery, including management of neonatal limb ischemia. The use of ultrasonography has revolutionized the use of regional anesthesia as vascular structures can be easily avoided while still providing a regional blockade. The use of sole regional anesthesia in neonates and infants is for avoidance of general anesthetics, for either theoretical decreased risk of apnea or decreased risk of neurotoxicity. Although neurotoxicity trials are still ongoing, it has been shown that spinal anesthesia decreases early apnea following surgery in premature neonates, but does not decrease the risk of overall apnea following surgery in premature neonates. Some patients may benefit from providing a caudal block in addition to the spinal anesthetic. Total spinal anesthesia, produced either with a primary spinal technique or secondary to an attempted epidural puncture, will present as apnea, rather than as hypotension, because of the lack of sympathetic tone in infants. The exact mechanism for the lack of cardiovascular change with spinal anesthesia in infants and young children is not clear. Consequently, the first indication of a high spinal is falling oxygen saturation rather than a falling blood pressure. Sedation can be added to regional anesthesia but may cause problems with apnea in ex-premature infants. The landmarks are the coccyx, the two sacral cornua, and the posterior superior iliac spines (Fig. Several needle types may be used, but the “pop” through the sacrococcygeal ligament is best observed with a blunt-tipped needle, whereas an intravenous catheter advanced over a needle may provide additional confirmation of sacral canal entry. The caudal space is identified by “pop” through the sacrococcygeal ligament, ease of local anesthetic injection, and absence of subcutaneous swelling upon dose delivery. Once the sacrococcygeal ligament is penetrated and there is a loss of resistance, gentle aspiration is applied to the needle to determine if there is blood or cerebrospinal fluid. If there is difficulty in injecting the solution, and the tip of the needle is not in the caudal space and it needs to be repositioned. The needle is not advanced up the sacral canal after proper placement in the caudal epidural space has been accomplished, this avoids dural puncture and accidental intrathecal injection.
Benzodiazepines have a favorable safety profile and can be reversed by flumazenil to manage excessive sedation or respiratory depression buy cheap seroflo 250 mcg. Midazolam was first discovered in 1976 and is the most widely used benzodiazepine in the perioperative period (Fig buy seroflo 250mcg on-line. Its use as a premedication and anesthetic is largely due to its quick onset cheap 250 mcg seroflo visa, short elimination half-life buy 250 mcg seroflo visa, anterograde amnestic effect, and minimal side-effect profile. Midazolam can be administered intravenously, intranasally, orally,76 rectally, and intramuscularly. Some studies have even found a positive77 behavioral effect 1 week postoperatively in pediatric patients premedicated with oral midazolam. One meta-analysis reported that “infusions of both midazolam and propofol appear to provide similar quality sedation, that extubation time and recovery time is shorter in patients sedated with propofol, and that hemodynamic complications related to either drug regimen are not usually clinically significant. High protein binding renders a smaller free fraction of the drug available to cross the blood–brain barrier, and high lipophilicity results in a larger volume of distribution. Clinically, less drug is free to cross the blood– brain barrier, but the high lipophilicity results in a rapid-onset of action (the peak effect of intravenous midazolam is within 2 to 3 minutes). Midazolam’s high lipid solubility, short duration of action, and short context-sensitive half-time allow this drug to be administered as a continuous infusion, unlike other benzodiazepines. Drugs that inhibit the cytochrome P450 system can result in prolonged duration of benzodiazepines. Favorable properties of midazolam are its high rate of hepatic clearance and relatively short elimination half-life. Midazolam’s active metabolite (1-hydroxymidazolam)82 contributes minimally to its clinical effects (approximately 20% of midazolam’s potency). These properties are influenced by the patient’s age and comorbidities, particularly kidney and liver dysfunction. With continuous infusions of midazolam, the metabolite will accumulate and exert a more pronounced and prolonged effect. Rather than metabolism, redistribution of midazolam results in the termination of its effects. Table 19-8 Benzodiazepine Metabolism and Clearance Table 19-9 Benzodiazepine Pharmacokinetics 1281 Pharmacodynamics and Clinical Uses The three most commonly used parenteral benzodiazepines are lorazepam, diazepam, and midazolam. Lorazepam and diazepam are not soluble in water and often cause vein irritation due to the propylene glycol admixture. Alternative formulations are available as a lipid emulsion, but with a decrease in bioavailability. Midazolam is water-soluble and undergoes conformational change in the bloodstream, becoming more lipophilic. Midazolam is manufactured as an acidic formulation that may produce mild local tissue and vein irritation. The resultant hyperpolarization of the cell ultimately leads to neural inhibition. For example, at 30% to 50% receptor occupancy, sedation is often produced, while at 20% occupancy one usually only achieves anxiolysis. This is in direct contrast to propofol and thiopental, each of which can achieve burst suppression. Thus, the neuroprotectant effect of benzodiazepines is quite limited, but likely not entirely absent. Table 19-10 Midazolam Dosing by Clinical Use Additionally, benzodiazepines are anticonvulsants and are a first-line 1282 therapy in the management of seizures. They can also be used as muscle relaxants, but this spinal cord–mediated response typically requires supratherapeutic doses. Upper airway reflexes may be decreased and central respiratory drive is depressed. This effect is quite minimal as there is some preservation of homeostatic reflexes. Side Effects Aside from their previously discussed systemic effects, benzodiazepines are associated with limited adverse events. More frequently described is pain or thrombophlebitis that ensues following intravenous injection, especially diazepam. Propylene glycol is the organic solvent for diazepam and causes the pain associated with injection. In contrast, midazolam is water- soluble, but may also cause burning with injection secondary to its acidic formulation. Barbiturates Thiopental is one of the earliest intravenous anesthetics used, discovered in the 1930s and first used on human patients in 1934. It has withstood the test of time as an induction agent because of its favorable pharmacokinetic profile (Fig. In 2011, production of thiopental in the United States ceased, leading to a drastic decrease in intraoperative use. Two major classes of barbiturates, oxybarbiturates and thiobarbiturates, are of anesthetic clinical and historical relevance. Both classes contain a pyrimidine center, and either an oxygen or sulfur molecule at position 2. The thiobarbiturate solutions are produced as racemic mixtures, despite unequal potency between their two stereoisomers. Methohexital has two chiral centers and four potential stereoisomers, but not all isomers are included in the final product. Barbiturate solutions are highly alkaline, allowing for formation of water- soluble salts. Addition or reconstitution in acidic solutions leads to 1283 precipitation of these salts, preventing intravenous use. Unlike propofol, barbiturates cannot be stored for an extended period of time at room temperature after reconstitution in solvent. In alkaline solution, thiobarbiturates can be stored up to 2 weeks, and methohexital up to 6 weeks. Pharmacokinetics Primary metabolism of both barbiturate classes is hepatic, yielding water- soluble inactive metabolites that are subsequently eliminated in urine and bile. Oxidation of thiopental and methohexital to their respective hydroxyl derivatives is the most common form of metabolism. Thiopental has a85 relatively long elimination half-life (12 hours), and its clearance rate (3 mL/kg/min) is 10-fold longer than that of propofol. Methohexital elimination half-life (4 hours) is also shorter than thiopental, secondary to a more efficient hepatic extraction of the drug (clearance rate 11 mL/kg/min). A negligible percentage of barbiturates is eliminated without metabolism in the urine. Similar to other intravenous agents, rapid redistribution into highly perfused compartments accounts for the rapid termination of drug action after a single induction dose. After an extended infusion of thiopental, accumulation in poorly perfused compartments and slow elimination play larger pharmacokinetic roles, resulting in a prolonged context-sensitive half-time and delayed recovery. The long context-sensitive half-time of thiopental after high doses is explained by the drug exhibiting zero-order kinetics. The elimination of thiopental becomes independent of both drug plasma concentration and level of compartmental saturation, and remains constant and defined by the slow rate of clearance. At smaller concentrations thiopental has been noted to have proconvulsant properties. Methohexital is considered to have significant proconvulsant effects in patients with epilepsy, and is often the agent of choice for induction of anesthesia prior to electroconvulsive therapy. Other neuroprotective mechanisms90 likely play a role, including barbiturate anticonvulsant properties, improved blood flow to ischemic parts of the brain (reverse steal effect), free-radical scavenging, attenuation of excitatory neurotransmitter release and pathways, and membrane stabilization. At higher doses, the reduction in oxygen consumption in well perfused areas of the brain leads to decreased flow, with subsequent diversion of blood flow to ischemic areas. Historically, barbiturate-induced “brain relaxation” has been utilized as a protective strategy during neurosurgery and after head trauma. Barbiturate neuroprotection is generally considered more effective for focal and incomplete ischemia, rather than global injury.
Over the years incorporation of substances to enhance germination of spores such as horse blood in place of the egg yolk buy seroflo with amex, taurocholate cheap seroflo 250 mcg, and lysozyme have been shown to improve recovery [2 discount seroflo 250 mcg line, 31] order on line seroflo. Whatever medium is chosen, it is important to use prereduced media as the failure to do so can impact the sensitivity of the culture method [33 ]. Other studies have examined the utility of broth enrichment compared to direct plating on solid media as well as spore enrichment techniques. In the former situa- tion, fecal specimens are inoculated to an enrichment broth that contains tauro- cholate, antibiotics, increased carbohydrates and/or lysozyme to reduce normal fecal ﬂora and enhance recovery of small concentrations of C. Several stud- ies have shown enhanced recovery of enrichment broth compared to direct plating on solid media [35–37]. Spore enrichment involves treating the fecal specimen with either heat or ethanol to reduce competing normal ﬂora. With heat shock, an aliquot of the stool specimen is incubated in a 70 °C water bath or heat block for 20 min prior to plating . After standing at room temperature for 1 h, the specimen is then plated on selective C. A combination of some type of enrichment (whether it be spore enrichment or broth enrichment) and direct plating on solid media seems to provide the most sensitive approach and should be used in circumstances where low quantities of organisms may be present, as may be the case in an epidemiological study. This method was the comparator against which many of the enzyme immunoassays were assessed. Performance of cytotoxin tests involves multiple steps and lack of adherence to these factors can signiﬁcantly affect perfor- mance. Then the buffered sample is centrifuged to remove debris and the supernatant is ﬁltered. The diluted ﬁltrate is applied to a cell monolayer usually in a macrotiter or microtiter multiwelled plate. After incubation at 37 °C for 24 h the plates are assessed for cytopathic affect that is characterized by rounding of cells. The specimen should be diluted 1:40 to 1:200 to prevent nonspeciﬁc toxicity by substances in fecal samples. The need for more rapid answers in the era of hypervirulent strains and the disappearance of cell culture techniques for viral diagnosis in clinical labs has seen the decrease in availability of this method as a primary diagnostic test. It is also not endorsed by professional societies as a test of choice for direct specimen testing . Toxin Enzyme Immunoassays Enzyme immunoassays became available in the mid to late 1980s to replace the more labor-intensive cell culture cytotoxicity assays. Solid phase microtiter plate formats, that were coated with monoclonal or polyclonal antibodies against toxins A and/or B, allowed for batch testing and the ability to report same day results. Later, rapid immunoassays in chromatographic cassettes, immunocard, and lateral ﬂow membrane formats became available. In some studies the performance of these assays is well below this range as low as 38 and 43 % [47, 48 ]. Two comprehensive reviews of these assays have recently conﬁrmed that these tests are suboptimal as primary diagnostic methods. The results of these studies are summarized in 40 Laboratory Technical Advances in the Diagnosis of Clostridium dif ﬁ cile 775 Table 40. The authors tested each assay in their clini- cal laboratory on the same set of 600 samples. The authors de ﬁ ned acceptability criteria as a sensitivity of 90 % and a positive predictive value of £3 %. Using diagnostic odds ratios (Kruskal–Wallis test) and logistic regression, the authors determined that there was no difference in performance among the various assays [46 ]. None of the assays evaluated fulﬁlled the criteria for acceptability as outlined in the Planche study . This enzyme, also called the common antigen, is present in high levels in all strains of C. Most of these assays used conventional polymerase chain reaction techniques and lengthy cumbersome nucleic acid extraction methods [60, 61]. Later in the decade, reports of improved fecal extraction methods and success with real-time platforms were published . The swab containing specimen is then placed into a sample buffer tube pro- vided by the manufacturer and is vortexed for 1 min. Uninoculated sample buffer is added to a lysis tube with glass beads, then 10 ml of stool in buffer is added to the lysis tube. Following centrifugation and inactivation at 95 °C in a dry heating block, lysed sample is added to a SmartCycler tube (Cepheid, Inc. The SmartCycler tubes are placed in the SmartCycler instrument and after ampliﬁcation, the software provides a qualitative result of “negative,” absence of tcdB or “positive,” tcdB present. Other possible results include the following: “unresolved,” indicating possible inhibition, or “invalid assay run,” indicating that one or both controls failed, and “not deter- mined,” in the case of instrument malfunction. When compared directly to toxigenic culture the sensitivity ranges from 84 to 94 % and the speciﬁcity from 95 to 98 % [42, 43, 45]. In this assay 100 ml of stool is diluted 1:5, then clariﬁed by adding the sample to a proprietary buffer called S. Three controls are required per run—a nega- tive control, a positive matrix control and a negative matrix control. A swab is dipped into the liquid or soft stool spec- imen, and then it is placed into a buffer vial. The vial is vortexed then the sample is pipetted into the sample port of the Xpert™ C difﬁcile assay cartridge. As is true for the other assays mentioned above, this assay has been extensively evaluated in the literature [54–56, 67, 68]. Those studies that have com- pared this assay to toxigenic culture report sensitivities ranging from 94. These observations are important because they can explain, in part, geographical variation in assay performance. In this assay, a proprietary sample brush is dipped into the stool specimen then placed into a diluent after which it is vortexed for 10 s. Five drops of the speci- men in diluent is squeezed into an extraction tube, heated to 95 °C for 10 min, then vortexed for 10 s. Fifty microliters of this extracted mixture is then added to a reac- tion buffer tube and vortexed for 10 s. The ﬁnal step involves adding 50 ml of the extracted mixture to both a test vial and a control vial of the ampliﬁcation device. The device is then placed into a small desktop instrument, the run is created and results are generated in 1 h. One is that these assays do not detect the toxins, but the genes that encode for toxins, raising the issue of clinical speciﬁcity. For this reason it is extremely important that physicians not send specimens to the laboratory on patients who do not have diarrhea or otherwise meet a clinical case deﬁnition of C. In addition, laboratories should moni- tor positivity rates and assess their environments for contamination. To reduce the expense that may be incurred with widespread implementation of these assays, several investigators have adopted three step algorithms [54, 55, 71, 72]. Such an algorithm can produce same day results and potentially save money, but this does require maintenance of multiple test methods, training, and the required proﬁciency, and raises other regulatory compliance issues such as whether reimbursement is allowed for multiple test methods [73 ]. Other desirable information includes the impact of rapid molecular testing on infection control and patient management. The increase is multifactorial, but has largely been driven by the emergence of multidrug resistant, toxin variant strains and an increasingly susceptible population. The increased fre- quency of more severe disease and higher mortality rates has forced laboratories to critically evaluate diagnostic testing algorithms. The latter is now perceived as the new “gold standard” against which other methods are compared. More data is needed regarding the impact of molecular assays on infection control and patient management. Kachrimanidou M, Malisiovas N (2011) Clostridium dif ﬁ cile infection: a comprehensive review. Deneve C, Janoir C, Poilane I, Fantinato C, Collignon A (2009) New trends in Clostridium dif ﬁ cile virulence and pathogenesis. Matamouros S, England P, Dupuy B (2007) Clostridium dif ﬁ cile toxin expression is inhibited by the novel regulator TcdC.
Eur J Heart Fail 14(3):319–325 during assisted circulatory support: comparison of the 42 generic 250 mcg seroflo visa. Hayes K buy 250 mcg seroflo amex, Leet A generic seroflo 250 mcg without a prescription, Bradley S cheap seroflo line, Holland A (2012) Efects of total artifcial [corrected] heart with a left ventricu- exercise training on exercise capacity and quality of lar assist device during rehabilitation. J Heart Lung life in patients with a left ventricular assist device: a Transplant 30(11):1207–1213 418 L. J Am walk test after continuous axial fow left ventricular Geriatr Soc 60(1):154–155 device implantation to predict survival. J Am Geriatr Soc 60(12):2270–2276 Rehabilitation, and the Canadian Association of Cardiac 58. J Cardiopulm Rehabil Prev 32(6):327–350 a test of basic functional mobility for frail elderly per- 74. J Am Geriatr Soc 39(2):142–148 E, Iliceto S et al (2013) Efects of short-term exercise 59. 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Int J Integr Care telemonitoring guidance in low to moderate risk 15:e006 patients entering cardiac rehabilitation: short-term 115. As such, a comprehensive approach to mitigating stroke risk and improving recovery Te feld of mechanical circulatory support for post stroke through rehabilitation has evolved children has evolved dramatically over the last from the Berlin Heart experience. Rehabilitation and cannulation prevents easy mobilization of physiotherapy are integral parts to making this patients. Tis paracor- Rehabilitation poreal pulsatile-fow device can be used for right, lef, or biventricular support. A variety of In general, children in end-stage heart failure who pump sizes are available to accommodate all require mechanical circulatory support are signif- sized children, infants to adolescent. Failure to thrive is a com- secure central cannulation technique with mon presentation of heart failure in children, externalization of the cannula through the resulting in a clinical picture of poor growth veloc- upper abdominal wall allows patients to be ity, low weight, low body mass, poor muscle devel- woken up, extubated, fed, mobilized, recondi- opment, and impaired bone density. Te largest ness, multiple hospitalizations, and poor nutri- multicenter prospective study on the Berlin tional status. In adults, the term frailty is used to Heart was conducted in North America for the describe a similar phenotype of patient. Prolonged intubation is associ- evaluation examines all organ systems (neuro- ated with more pronounced deconditioning of logic, pulmonary, renal, hepatic, gastrointestinal, respiratory and skeletal muscles and may lead to musculoskeletal, infectious, immunologic and ventilator-associated pneumonia. In and chest physiotherapy to recruit lung space is a addition, children are evaluated by physiothera- top priority in the early postoperative period. Tese compre- patient is sedated, passive range of motion activi- hensive evaluations help identify defcits that need ties can be completed by physiotherapists or par- focused attention by the care team. Once patients are extubated, mobi- from infants to adolescents, there is a wide spec- lization by sitting up in bed, encouraging play trum of developmental abilities that need to be and ambulation, should be a key priority. Evaluation of gross motor, fne motor, Identifying activities that are age appropriate is language, social skills, and cognition needs to be important. Between 2010 and of developmental capabilities that can be easily 2013, they enrolled 14 patients aged 0. Tey dem- ple caregivers which can limit the number and onstrated no adverse events, with a trend toward duration of time to move around. However, the diference was not statistically For larger children and adolescents, ambula- signifcant and warranted further evaluation with a tion is much easier because of the use of intracor- larger cohort. Am therapists, and rehabilitation physicians will help J Transplant 15(2):453–460 delineate defciencies in functional abilities and 4. Pediatric centers are learning vocational status following a 12 month cardiac exer- from the experiences garnered by adult cardiovas- cise rehabilitation programme. Karapolat H, Engin C, Eroglu M, Yagdi T, Zoghi M, Nalbantgil S et al (2013) Efcacy of the cardiac rehabil- ity of rehabilitation services. Transplant Proc 45(9):3381–3385 children will be an area of tremendous potential for 8. N Engl J Med left ventricular assist devices: the rehab-vad random- 367(6):532–541 ized controlled trial. Balancing the risk of thrombosis and hemor- However, these results were also due to techni- rhage is a major challenge, and there are two key cal improvements, as the introduction of an interactions, which must be understood: the one enhanced coring tool and sintered infow cannula. Jarvik 2000, where the shit of the bearing mecha- nism from pin to cone design resulted in improved survival and reduced incidence of stroke. Te precise causes still and Thrombotic Risk remain unknown, but it has been hypothesized that the level of anticoagulation was insufcient. Tis decreased risk of thrombotic and hemor- rhagic events has been one of the drivers behind the marked increase in the use of continuous-fow 42. However, in light of studies demonstrating that the risk of hemorrhage is greater than throm- 42. Ann Cardiothorac Surg 3:582–584 efect of therapy should be checked with aggrego- 6. Tarzia V, Bortolussi G, Penzo V, Bejko J, Gallo M, Bianco Tis is especially important in the frst month R, Bottio T, Gerosa G (2014) Are all continuous fow post-implant, when the hypercoagulant reaction left ventricular assist devices equal on platelet acti- is oten more pronounced. A comparison of 431 42 Patient- and Device-Tailored Antithrombotic Treatment centrifugal versus axial fow pump. Hamostaseologie assist system for bridge to transplant: combined results 29:279–284 of the bridge to transplant and continued access pro- 13. J Heart Lung Transplant 32:675–683 Multiple electrode aggregometry: a new device to 9. Tarzia V, Di Giammarco G, Di Mauro M, Bortolussi G, measure platelet aggregation in whole blood. Thromb Maccherini M, Tursi V, Maiani M, Bernazzali S, Marinelli Haemost 96:781–788 D, Foschi M, Buratto E, Bejko J, Gregori D, Scuri S, Livi 14. Tarzia V, Bortolussi G, Bianco R, Buratto E, Bejko J, U, Sani G, Bottio T, Gerosa G (2016) From bench to bed- Carrozzini M, De Franceschi M, Gregori D, Fichera D, side: Can the improvements in left ventricular assist Zanella F, Bottio T, Gerosa G (2015) Extracorporeal life device design mitigate adverse events and increase support in cardiogenic shock: impact of acute versus survival? N Engl J Med 370:33–40 Haemost 13:946–955 433 43 Coagulation Monitoring Alexander Stepanenko and Ivan Netuka 43. But it is still a sub- ponents to putting the cellular participants in a ject of debate. Hofman and Monroe proposed in All our struggles of postoperative anticoag- 2001 a so-called “cell-based” model of hemostasis.