Letters Article Swipe

of the Journal of Extra-Corporeal Technology.Dr. Brenner is certainly to be congratulated for addressing efforts to react in what is one of the most serious accidents that can occur in and around an open heart operation.However, there are two aspects in his approach with which we differ.First, in the event of massive air embolism into the systemic circulation we would strongly recommend the technique of retrograde perfusion.The technique 1 has been reported in its entirety and only recently another article supports its use in pediatric patients. 2 Second, Number 13 in Dr. Brenner's battle plan advises avoiding profound barbiturate "artificial coma," and "suggests aim for early arousal, the best prognostic indicator."Recent studies indicate that this approach may not indeed be beneficial.In fact, the administration of sufficient thiopental to produce an isoelectric electroencephalogram may be recommended.Nussmeier et a! presented clear data that patients who receive sufficient thiopental (avg.39.5 mg/kg) to silence the EEG during CPB can reduce sensory motor neurologic dysfunction secondary to embolism in patients having true open heart procedures.1 Barbiturate therapy did not appear to reduce the frequency of embolization but rather did reduce its clinical expression, presumbably by decreasing the size of the resulting cerebral infarction.This study represents the first demonstration of cerebral protection by barbiturate in man.It was well done and has received recognition as such.Certainly patients receiving barbiturate therapy may be expected to sleep longer, may require more frequent inotropic support, and will need prolonged ventilation.However, if true injury has occurred, the "aim for early arousal" is unrealistic.This approach is based on a false hope that everything will be OK.Only if there is no significant neurologic injury can early arousal be a reality.If indeed there is therapy (barbiturate coma) which can reduce or alleviate neurologic sequelae after massive air embolism, we feel it is to be indicated rather than avoided.We clearly realize the difficult 198 The Journal of Extra-Corporeal Technology