Axilloaxillary cardiopulmonary bypass: a practical alternative to femorofemoral bypass

BACKGROUND: Peripheral arterial and venous cannulation for cardiopulmonary bypass is used increasingly for patients undergoing minimally invasive cardiac operations, complex reoperations, or repair of aortic dissection or aneurysm, and for patients with extensive arteriosclerotic aortic disease in whom aortic cannulation is a prohibitive embolic risk. The common femoral artery and vein are most commonly used for peripheral cannulation, but these sites may be predisposed to complications, primarily because the femoral vessels are commonly involved with arteriosclerotic disease. We have recently begun to use the axillary artery and axillary vein as alternative cannulation sites, achieving full cardiopulmonary bypass, providing antegrade aortic flow, and avoiding many of the complications associated with other sites. METHODS: Seven patients with peripheral vascular or aortic disease, or both, prohibiting safe aortic or femoral cannulation underwent cardiopulmonary bypass through axillary artery and axillary vein cannulation, approached through a small single subclavicular incision. RESULTS: All patients were successfully cannulated and axilloaxillary cardiopulmonary bypass was possible without the need for additional cannulas. All axillary vessels were closed primarily without complication. CONCLUSION: For an expanding population of patients with peripheral vascular and aortic disease, axilloaxillary bypass is a safe and practical alternative to aortic or femoral cannulation.     

Establishment of total cavopulmonary connection without use of cardiopulmonary bypass

OBJECTIVE: To minimize deleterious postoperative influences of cardiopulmonary bypass on the pulmonary circulation immediately after the Fontan type procedure, total cavopulmonary connection was achieved without use of cardiopulmonary bypass. METHODS: Since April 1996, 15 patients including five patients with visceral heterotaxy, in whom no intracardiac procedure was needed, have undergone this operative maneuver. Age at operation ranged from 1.2 to 44.6 years. Construction of a systemic to pulmonary shunt had been previously employed in seven patients, banding of the pulmonary trunk in two patients, and the Norwood procedure in one patient. The superior caval vein was initially anastomosed to the pulmonary arteries in bidirectional fashion under temporary bypass from the superior caval vein to the atrium. The channel for draining the inferior caval vein was subsequently constructed with the aid of temporary bypass from the inferior caval vein to the atrium, using a Goretex tube in ten patients, using a pedicled autologous pericardial roll in four patients, and directly anastomosing the pulmonary trunk to the orifice of the inferior caval vein in one patient. In patients with visceral heterotaxy and an independent hepatic venous drainage, redirection of the blood flow via the caval vein as well as the hepatic vein could be successfully achieved by placing dual temporary bypasses into these veins. RESULTS: Postoperative courses were excellent in all patients. Superior caval venous pressure was 11 +/- 2 mmHg at 12 h after the operation. No blood transfusion was needed in nine patients(60%). CONCLUSION: This alternative operative procedure is undoubtedly attractive when establishing the Fontan circulation in patients undergoing no intracardiac maneuvers.     

Extraction and replacement of permanent pacemaker leads through occluded vessels: use of extraction sheaths as conduits--balloon venoplasty as an adjunct

Patients (pts) may present for lead extraction with symptomatic or asymptomatic subclavian vein or superior vena cava thrombosis. Replacement of permanent pacemaker leads (PPLs) in these pts may be difficult and may require accessing a new site. We examined the utility of replacing PPLs through completely occluded vessels using extraction sheaths as conduits through the total occlusion. Over six years, a total of 210 atrial and/or ventricular PPLs were extracted from 137 pts. Two pts presented with angiographically documented thrombotic occlusion of the subclavian vein. One additional pt. who had presented with a superior vena cava (SVC) syndrome, had a totally occluded innominate vein and SVC occlusion. Balloon venoplasty was used as an adjunct to dilate the SVC. In all pts, after PPLs were removed via a subclavian extraction sheath through the occluded vessel, the retained sheath was used to place a guide wire, then a peel away dilating sheath, to insert new PPLs, in each case on the side of total venous occlusion. Seven PPLs and two lead fragments were extracted, and five new PPLs replaced, ipsilateral to the venous occlusion. These data show that extraction of PPLs through thrombosed veins may be performed successfully and may not require replacing the leads through a new site. This technique spares the pt the need to access the opposite subclavian vein, and it avoids an excessive number of PPLs in the subclavian vein and SVC. The procedure illustrates an efficient means to reintroduce new PPLs with the potential to reduce associated morbidity, since repeat puncture of the subclavian vein is not required. Safety of the procedure as a whole must be considered with regard to the known risks of lead extraction, some complications of which may be substantial using current techniques.     

Primary bidirectional superior cavopulmonary shunt in infants between 1 and 4 months of age

The performance of a primary bidirectional superior cavopulmonary shunt procedure in early infancy is attractive because it minimizes the number of operations needed before a Fontan procedure, avoids ventricular volume overload and its sequelae, and eliminates pulmonary artery distortion. However, concerns over elevated or labile pulmonary vascular resistance have limited its use in the first few months of life. Nine patients aged 1 to 4 months (5 patients, < 2 months) have undergone a primary bidirectional superior cavopulmonary shunt procedure between October 1992 and March 1994. Primary diagnoses were tricuspid atresia (n = 4), asplenia syndrome (n = 2), polysplenia syndrome (n = 1), double-outlet right ventricle (n = 1), and double-inlet left ventricle (n = 1). Associated lesions of immediate surgical importance were total anomalous pulmonary veins (n = 2), a restrictive atrial septum (n = 4), bilateral superior venae cavae (n = 5), and patent ductus arteriosus (n = 5). The surgical procedure consisted of unilateral (n = 4) or bilateral (n = 5) bidirectional superior cavopulmonary shunt and the repair of associated lesions. Of significance, in 4 of our first 5 patients a very limited additional source of pulmonary blood flow was provided because of a low arterial oxygen tension immediately after cardiopulmonary bypass. Pleural effusions developed in 2 of these 4 patients. In subsequent patients cardiopulmonary bypass was not used whenever possible or, if it was needed, use of an extra source of pulmonary blood flow was avoided.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reconstruction of large veins for nonmalignant venous occlusive disease

To evaluate the effectiveness of venous grafting, we reviewed the management and clinical course of 28 patients (21 males and seven females) who underwent 29 reconstructions of large veins for benign disease. There were 12 patients with superior vena cava (SVC) syndrome, two with subclavian vein thrombosis, and 15 with occlusion of the inferior vena cava (IVC) or iliac veins. One of these patients underwent both IVC and SVC reconstructions. Reconstruction of the SVC was performed with spiral saphenous vein graft (SSVG) in nine patients and expanded polytetrafluoroethylene (ePTFE) in three. All seven straight SSVGs had documented patency at a median of 7 months (2 weeks to 5 years) after reconstruction. Six patients had complete relief of symptoms. Two patients with bifurcated SSVG had early occlusion of one graft limb. Two of the three ePTFE grafts needed early thrombectomy. One graft reoccluded at 6 months and two were patent at 2 and 5 years. The two subclavian vein reconstructions with axillary-jugular ePTFE grafts with an arteriovenous fistula had documented early patency. Both patients had rapid resolution of symptoms. The IVC or iliac vein was reconstructed with ePTFE graft in 11 patients, SSVG in three, and Dacron in one. A femorofemoral arteriovenous fistula was added in eight patients with ePTFE grafts. Seven of the 11 ePTFE grafts had documented patency at the last follow-up (median 9 months; range 2 weeks to 5 years). None of the three SSVGs had documented long-term patency. The one Dacron cavoatrial graft occluded at 3 years. A straight SSVG continues to be our first choice for SVC replacement. Short, large-diameter ePTFE grafts perform the best in the abdomen. Femorocaval or long iliocaval grafts need an arteriovenous fistula to maintain patency. Long-term patency after closure of the fistula is still unknown. Femorocaval grafts with poor venous inflow have limited chance of success. Failed or failing grafts may be salvaged by early thrombectomy. Venous reconstruction to treat selected patients with symptoms with large vein occlusion continues to be a viable option.     

Anesthesia for tracheobronchial stent insertion

We experienced nine cases of general anesthesia for tracheobronchial stent insertion. As far as possible, we anesthetized the patients under spontaneous respiration with inhalation anesthesia, depending on the types of the tracheobronchial stent (Dumon stent or expandable metallic stent), or respiratory status of the patient. Having experienced a case requiring PCPS (percutaneous cardiopulmonary support) to recover from severe ventilatory insufficiency due to tracheal perforation, we, in advance, inserted 18- or 20-gage cannulas into the femoral artery and vein for PCPS standby, and could manage general anesthesia safely for tracheobronchial stent insertion.     

Integrilin prevents prolonged bleeding times after cardiopulmonary bypass

BACKGROUND: Cardiopulmonary bypass reduces platelet number and function, increases postoperative bleeding time, and is the major, unsolved cause of nonsurgical bleeding after open heart operations. Temporary inhibition of platelet function during cardiopulmonary bypass (platelet anesthesia) protects platelets and reduces postoperative bleeding time and bleeding. METHODS: Integrilin, a short-acting, reversible platelet glycoprotein IIb/IIIa inhibitor was studied in 28 baboons that had 60 minutes of normothermic cardiopulmonary bypass using peripheral cannulas. A control group, two groups that received different doses of Integrilin, and a group that received a combination of Integrilin and low-dose Iloprost were studied. Blood samples for platelet count, aggregation to adenosine diphosphate, beta-thromboglobulin, prothrombin fragment F1.2, thrombin-antithrombin complex, and fibrinopeptide A were obtained at seven time points. Template bleeding times were measured before and at five intervals after cardiopulmonary bypass. RESULTS: Both doses of Integrilin and the combination of Integrilin and Iloprost significantly protected platelet number, inhibited the response to adenosine diphosphate, and reduced postoperative bleeding times, but they did not reduce beta-thromboglobulin release except in the high-dose Integrilin group. Thrombin formation and activity were qualitatively, but not significantly, reduced in all treatment groups. Bleeding times were not significantly different from baseline at the time protamine was given in the combination group and 60 minutes after protamine administration in all treatment groups. CONCLUSIONS: Integrilin alone or in combination with Iloprost significantly reduces platelet activation during cardiopulmonary bypass and produces normal or near-normal bleeding times at the time protamine is given.     

Efficacy of epidural analgesia in minimally invasive direct coronary artery bypass surgery

Minimally invasive direct coronary artery bypass surgery (MIDCAB), coronary bypass grafting with small thoracotomy using no cardiopulmonary bypass (CPB), became popular recently. To attenuate perioperative stress-response, we used epidural analgesia (EPI) with general anesthesia for MIDCAB operation. In this study, we compared retrospectively 11 cases of MIDCAB managed with EPI [ED (+)], and 14 cases of MIDCAB anesthetized without using EPI [ED (-)], concerning extubation time, ICU stay, hospital stay and perioperative complications. The mean time from cessation of general anesthesia to extubation was significantly shorter in ED (+) patients (0.5 hours) when compared to ED (-) patients (18.2 hours). Mean periods of ICU stay and hospital stay were, also, shorter in ED (+) patients (2.1 days, 30.5 days, respectively) when compared to ED (-) (4.3 days, 45.1 days, respectively) patients. We experienced ventricular tachycardia in three patients of ED (-). No major complication occurred in ED (+) patients. These results suggest that EPI shortened extubation time, ICU and hospital stay for MIDCAB patients.     

Consequences of electroencephalographic-suppressive doses of propofol in conjunction with deep hypothermic circulatory arrest

BACKGROUND: Some patients who undergo cerebral aneurysm surgery require cardiopulmonary bypass and deep hypothermic circulatory arrest. During bypass, these patients often are given large doses of a supplemental anesthetic agent in the hope that additional cerebral protection will be provided. Pharmacologic brain protection, however, has been associated with undesirable side effects. These side effects were evaluated in patients who received large doses of propofol. METHODS: Thirteen neurosurgical patients underwent cardiopulmonary bypass and deep hypothermic circulatory arrest to facilitate clip application to a giant or otherwise high-risk cerebral aneurysm. Electroencephalographic burst suppression was established before bypass with an infusion of propofol, and the infusion was continued until the end of surgery. Hemodynamic and echocardiographic measurements were made before and during the prebypass propofol infusion and again after bypass. Emergence time also was determined. RESULTS: Prebypass propofol at 243 +/- 57 micrograms.kg-1.min-1 decreased vascular resistance from 34 +/- 8 to 27 +/- 8 units without changing heart rate, arterial or filling pressures, cardiac index, stroke volume, or ejection fraction. Propofol blood concentration was 8 +/- 2 micrograms/ml. Myocardial wall motion appeared hyperdynamic at the end of cardiopulmonary bypass, and all patients were weaned therefrom without inotropic support. After bypass, vascular resistance decreased further, and cardiovascular performance was improved compared to baseline values. Nine of the 13 patients emerged from anesthesia and were able to follow commands at 3.1 +/- 1.4 h. Three others had strokes and a fourth had cerebral swelling. CONCLUSIONS: Propofol infused at a rate sufficient to suppress the electroencephalogram does not depress the heart or excessively prolong emergence from anesthesia after cardiopulmonary bypass and deep hypothermic circulatory arrest.     

Ophthalmic surgery with local anesthesia or intubation anesthesia at the Leipzig University Ophthalmology Clinic

BACKGROUND: Different opinions about the reliability and serious complications after regional anesthesia have been reported. The paper describes our experiences in deciding about regional or general anesthesia for ophthalmic surgery. PATIENTS AND METHODS: For this report we analyzed retrospectively our protocols of all operations performed in 1995. Eight categories of procedures were developed to give an insight in our way of decision for local or general anesthesia. We imagine the applied technique of peribulbaranesthesia. RESULTS: 3184 patients were operated on in 1995, in the regional anesthesia group the age ranges from 17 to 96 years, in the general anesthesia group from 3 months to 85 years. In 69.9% of all patients we performed a local anesthesia and in 30.1% we chose general anesthesia. The spread of cases and the surgical procedure corresponding to one of these eight classes below are described in this survey. CONCLUSIONS: Almost 70% of our patients who underwent an ophthalmosurgical procedure were operated on under regional anesthesia. No serious complications have occurred and no procedure had do be stopped off due to an insufficient analgesia or akinesia. We demonstrate some observations concerning the duration of pain after the injection and our indications for general anesthesia in ophthalmic surgery.     

Closed-chest cardiopulmonary bypass and cardioplegia: basis for less invasive cardiac surgery

BACKGROUND: We developed a method of closed-chest cardiopulmonary bypass to arrest and protect the heart with cardioplegic solution. This method was used in 54 dogs and the results were retrospectively analyzed. METHODS: Bypass cannulas were placed in the right femoral vessels. A balloon occlusion catheter was passed via the left femoral artery and positioned in the ascending aorta. A pulmonary artery vent was placed via the jugular vein. In 17 of the dogs retrograde cardioplegia was provided with a percutaneous coronary sinus catheter. RESULTS: Cardiopulmonary bypass time was 111 +/- 27 minutes (mean +/- standard deviation) and cardiac arrest time was 66 +/- 21 minutes. Preoperative cardiac outputs were 2.9 +/- 0.70 L/min and postoperative outputs were 2.9 +/- 0.65 L/min (p = not significant). Twenty-one-French and 23F femoral arterial cannulas that allowed coaxial placement of the ascending aortic balloon catheter were tested in 3 male calves. Line pressures were higher, but not clinically limiting, with the balloon catheter placed coaxially. CONCLUSIONS: Adequate cardiopulmonary bypass and cardioplegia can be achieved in the dog without opening the chest, facilitating less invasive cardiac operations. A human clinical trial is in progress.     

Biocompatibility in cardiopulmonary bypass

Recent advances in surgical techniques and perfusion technology allow cardiac operations to be performed routinely with low mortality rates. However, patients undergoing cardiac operations with cardiopulmonary bypass (CPB) are still associated with bleeding disorders, thrombotic complications, massive fluid shifts, and the activation of blood components that are collectively known as the whole body inflammatory response. In this review, the effect of cardiopulmonary bypass on various humoral and cellular components of blood is examined. Blood activation caused by interaction with artificial materials of extracorporeal circuit and by material-independent stimuli is discussed. Methods to control blood activation during and after cardiopulmonary bypass are described. These include surface modification of extracorporeal circuit, control of flow dynamics in the circuit, pharmacological intervention, and the use of extracorporeal devices to remove inflammatory mediators. Recent findings on the effects of heparin-coated circuits on inflammatory response and clinical outcome are reviewed. It appears that the causes of inflammatory response to cardiopulmonary bypass are multifactorial and that an integrated strategy is needed to control and eliminate the negative effects of CPB.     

Minimally invasive treatment for coronary artery disease

Coronary artery disease is the leading cause of morbidity and mortality in the United States. One advancement in the treatment of this disease is the minimally invasive direct coronary artery bypass (MIDCAB) procedure, which is an alternative to the traditional open heart bypass procedure. The MIDCAB procedure is becoming a viable alternative to the traditional coronary artery bypass grafting procedure for a select group of patients. With further experience and follow-up, this procedure will offer lower hospital costs by decreasing lengths of stay and offering patients the optimal conduit for coronary artery bypass grafting without the complications of cardiopulmonary bypass.     

Elimination of cardiopulmonary bypass: a prime goal in reoperative coronary artery bypass surgery

OBJECTIVE: The purpose of this study was to evaluate morbidity and mortality in reoperative coronary artery bypass surgery using the New York State database. METHODS: Patients undergoing reoperative coronary artery bypass between January-1995 and December 1996 were included. Patients were operated using cardiopulmonary bypass (CPB group, n = 184) or without cardiopulmonary bypass (non-CPB group, n = 105) by surgeon preference. Groups were compared for preoperative risk factors, postoperative mortality and major complications. RESULTS: Crude mortality was lower in the non-CPB group, despite a higher expected mortality, resulting in a risk-adjusted mortality of 1.3% versus 2.7% for the CPB group (NS). Of non-CPB patients, 91.4% were without complications, while only 72.1% of CPB patients (P < 0.0001) were complication-free. Major complications were significantly reduced in non-CPB patients compared to CPB patients: stroke 0% versus 3.8% (P < 0.04), cardiovascular complications 4.8% versus 15.8% (P < 0.005), other major complications 1.9% versus 10.4% (P < 0.007). Postoperative IABP support was needed in 1.9% of the non-CPB group patients and in 14.2% of the CPB group (P < 0.0007). CONCLUSIONS: The main object of reoperative CABG is to relieve symptoms, since the survival benefit of the procedure has not been demonstrated. Performance of reoperative coronary artery bypass surgery without cardiopulmonary bypass significantly reduces morbidity. We conclude that cardiopulmonary bypass should be avoided whenever possible in reoperative coronary bypass surgery.     

Temporary gastrostomy as an alternative procedure for nasogastric suction

Based on personal experience with 70 cases of temporary tube gastrostomy - used as an alternative procedure to nasogastric suction in 50 cases and as a double-purpose tube in 20 cases of radical esophagectomy - pertinent problems concerning indication, technique, advantages, and possible complications are presented. The results indicate that temporary gastrostomy is a safe procedure, reduces cardiopulmonary disorders, and increases the patient's comfort. The procedure is therefore strongly recommended for patients with poor cardiopulmonary reserve and for the age group above 60 years. Temporary gastrostomy is also indicated in younger patients, if prolonged gastric distension with the necessity of decompression is anticipated.     

Jugular venous bulb oxyhemoglobin saturation during cardiac surgery: accuracy and reliability using a continuous monitor

Previous studies have demonstrated the feasibility of continuously monitoring jugular venous oxygen saturation (SjO2) with a fiberoptic catheter during hypothermic cardiopulmonary bypass (CPB). In the present study, with patients maintained at either moderate (28 degrees C) or mild (32-34 degrees C) hypothermia during CPB, SjO2 values obtained from a fiberoptic catheter were compared to intermittent samples analyzed by a co-oximeter. Twenty patients scheduled for elective coronary artery or valvular surgery had a 5.5 Fr Opticath catheter inserted into the left internal jugular bulb after induction of general anesthesia. The catheter was calibrated in vitro and in vivo according to the manufacturer's specifications. Catheter and co-oximetry SjO2 values obtained at four time points--1) pre-CPB, 2) target CPB temperature, 3) mid-rewarming, and 4) post-CPB--were compared using linear regression, Bland-Altman analysis, and Shrout-Fleiss interclass correlation coefficient analysis. These statistical methods revealed poor correlation between the catheter and co-oximetry SjO2 values: r = 0.44 by linear regression and 0.32 by interclass correlation coefficient analysis, and was unacceptably discrepant by Bland-Altman analysis. Oxyhemoglobin saturation values obtained continuously from a jugular venous bulb fiberoptic catheter during CPB may not accurately reflect true oxyhemoglobin saturation, and caution is warranted when interpreting SjO2 values obtained from a fiberoptic catheter during CPB.     

A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery. I. Mortality and cardiovascular morbidity

The impact of perfusion technique and mode of pH management during cardiopulmonary bypass has not been well characterized with respect to postoperative cardiovascular outcome. METHODS: This double-blind, randomized study comparing outcomes after alpha-stat or pH-stat management and pulsatile or nonpulsatile perfusion during moderate hypothermic cardiopulmonary bypass was undertaken in 316 patients undergoing coronary artery bypass operations. RESULTS: Cardiovascular morbidity and mortality were not affected by pH management, and the incidence of stroke (2.5%) did not differ between groups. Overall in-hospital mortality was 2.8%, eight of the nine deaths occurring in the nonpulsatile group (5.1% versus 0.6%; p = 0.018). The incidence of myocardial infarction was 5.7% in the nonpulsatile group and 0.6% in the pulsatile group (p = 0.010), and use of intraaortic balloon pulsation was significantly more common in the nonpulsatile group (7.0% versus 1.9%; p = 0.029). The overall percentage of patients having major complications was also significantly higher in the nonpulsatile group (15.2% versus 5.7%; p = 0.006). Duration of cardiopulmonary bypass, age, and use of nonpulsatile perfusion all correlated significantly with adverse outcome. CONCLUSIONS: Use of pulsatile perfusion during cardiopulmonary bypass was associated with decreased incidences of myocardial infarction, death, and major complications.     

Right ventricular dysfunction in low output syndrome after cardiac operations: assessment by transesophageal echocardiography

BACKGROUND: Low output syndrome after cardiac operations is associated with high morbidity and mortality rates. The contribution of right ventricular dysfunction to this syndrome has not been fully characterized. The purpose of this study was to evaluate the utility of transesophageal echocardiography to identify the frequency and the in-hospital mortality from right ventricular dysfunction in patients with this syndrome. METHODS: Seventy-five consecutive patients undergoing transesophageal echocardiography for low output syndrome early after cardiac operations were evaluated. The findings from transesophageal echocardiography were correlated with the type of surgical procedure, cross-clamp time, right heart hemodynamics, and coronary angiography. RESULTS: Right ventricular systolic dysfunction occurred in 36 patients (42%); in 17 patients it was isolated and in 19 patients it occurred in combination with left ventricular dysfunction. Postoperative right ventricular dysfunction was not uniformly associated with important right coronary artery disease or with prolonged ischemic time during cardiopulmonary bypass. Hemodynamic data were not useful to distinguish the group with postoperative right ventricular dysfunction. Patients with right ventricular dysfunction had a high (44%) in-hospital mortality rate. CONCLUSIONS: Right ventricular dysfunction occurs frequently in patients with low output syndrome after cardiac operations and is associated with a high in-hospital mortality rate. Better understanding of the mechanisms causing postoperative right ventricular dysfunction may provide insight for preventing this complication.     

Venous valve repair: early results in fifty-two cases

PURPOSE: Chronic deep venous insufficiency, usually secondary to the postthrombotic syndrome, is due to primary valve failure in approximately 15% of cases. In these cases surgical repair of the valvular mechanism may be indicated. METHODS: Fifty-two limbs in 42 patients were treated with superficial femoral vein valvuloplasty after appropriate investigation. Adjunctive operations on the superficial or perforating veins were performed on 49 limbs during the same hospital admission. RESULTS: Of the 27 patients who have completed one year of follow-up, 85% are free of reflux on duplex scanning and 68% have had normalization of venous refilling times. Of 11 limbs with venous ulceration followed up for more than 1 year, only one has had a recurrent ulcer (9%). In patients without ulceration the procedure has been successful in alleviating symptoms of venous insufficiency. CONCLUSIONS: We conclude that the procedure, in conjunction with appropriate superficial venous operation, is effective in selected patients with deep vein reflux whose conditions remain uncontrolled by conservative measures. At 1 year, 85% of valvuloplasties in this series remained competent.     

Dexamethasone decreases the incidence of shivering after cardiac surgery: a randomized, double-blind, placebo-controlled study

Shivering after cardiac surgery is common, and may be a result of intraoperative hypothermia. Another possible etiology is fever and chills secondary to activation of the inflammatory response and release of cytokines by cardiopulmonary bypass. Dexamethasone decreases the gradient between core and skin temperature and modifies the inflammatory response. The goal of this study was to determine whether dexamethasone can reduce the incidence of shivering. Two hundred thirty-six patients scheduled for elective coronary and/or valvular surgery were randomly assigned to receive either dexamethasone 0.6 mg/kg or placebo after the induction of anesthesia. All patients received standard monitoring and anesthetic management. After arrival in the intensive care unit (ICU), nurses unaware of the treatment groups recorded visible shivering, as well as skin and pulmonary artery temperatures. Analysis of shivering rates was performed by using chi2 tests and logistic regression analysis. Compared with placebo, dexamethasone decreased the incidence of shivering (33.0% vs 13.1%; P = 0.001). It was an independent predictor of reduced incidence of shivering and was also associated with a higher skin temperature on ICU admission and a lower central temperature in the early postoperative period. IMPLICATIONS: Dexamethasone is effective in decreasing the incidence of shivering. The effectiveness of dexamethasone is independent of temperature and duration of cardiopulmonary bypass. Shivering after cardiac surgery may be part of the febrile response that occurs after release of cytokines during cardiopulmonary bypass.