Bruce Spiess

Virginia Commonwealth University | VCU · Department of Anesthesiology

Background: Antithrombin (AT) activity is reduced during cardiac operations with cardiopulmonary bypass (CPB), which is associated with adverse outcomes. Preoperative AT supplementation, to achieve >58% and <100% AT activity, may potentially reduce postoperative morbidity and mortality in cardiac operations with CPB. This prospective, multicenter,...

The World Health Organization (WHO) has declared Coronavirus Disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVI...

Purpose Hydroxocobalamin, or vitamin B12 (V-B12), is frequently used to treat smoke inhalation and cyanide poisoning. Recent reports have also described its use to treat vasoplegia in cardiac surgery and liver transplantation. This narrative review discusses this “off-label” indication for V-B12, focusing on the potential biochemical mechanisms of...

Background Trauma‐induced coagulopathy (TIC) is a common and deadly bleeding disorder. Platelet dysfunction is present during TIC, but its mechanisms remain unclear. Platelets are currently thought to become “exhausted”, a state in which they have released their granule contents and can no longer aggregate or contract. Methods This prospective obs...

Background: Coagulopathy and inflammation induced by hemorrhagic shock and traumatic injury are associated with increased mortality and morbidity. Vitamin C (VitC) is an antioxidant with potential protective effects on the pro-inflammatory and pro-coagulant pathways. We hypothesized that high-dose VitC administered as a supplement to fluid resusci...

Purpose: Vasoplegia is a clinical syndrome marked by severe arteriolar vasodilatation, hypotension, and low systemic vascular resistance refractory to multiple vasopressor treatment. We report our experience with hydroxocobalamin (B12) infusion as a potential rescue adjunct for refractory vasoplegia during cardiopulmonary bypass (CPB). Methods:...

Topical hemostatic agents are used in conjunction with conventional procedures to reduce blood loss. They are often used in cardiothoracic surgery, which is particularly prone to bleeding risks. Variation in their use exists because detailed policy and practice guidelines reflecting the current medical evidence have not been developed to promote be...

Background: Clinical trial success depends on appropriate management, but practical guidance to trial organisation and planning is lacking. The Incident Command System (ICS) is the 'gold standard' management system developed for managing diverse operations in major incident and public health arenas. It enables effective and flexible management thr...

Background: Viscoelastic thromboelastography tests such as TEG™ are now routine for assessing the coagulation status of cardiac surgery patients. We compared TEG™ with a new technology, sonic estimation of elasticity via resonance (SEER) sonorheometry, to compare measures of coagulation dynamics of whole blood and assess its potential for rapid, n...

Gaps remain in our understanding of the contribution of bypass-related practices associated with red blood cell (RBC) transfusions after cardiac surgery. Variability exists in the reporting of bypass-related practices in the peer-reviewed literature. In an effort to create uniformity in reporting, a draft statement outlining proposed minimal criter...

Cinnamic acid-based oligomers and therapeutic uses thereof are provided. The oligomers are used as anti-inflammation agents, inhibitors of elastase and anti-oxidants, and in some cases (e.g. the treatment of lung disorders such as lung cancer) all three activities are simultaneously beneficial. Subsets of the oligomers (e.g. β-O4 and β-5 trimers an...

Perfluorocarbons (PFC) are compounds with high gas solubility that could help deliver O2 to tissues and have been suggested as adjunct therapy to ischemia. Using a newly designed in vitro system, we tested the hypothesis that a third generation PFC emulsion (Oxycyte) increased O2 transport of blood by measuring changes in O2 extraction ratio. The s...

Arterial gas embolism (AGE) is a clinical problem that occurs directly in cardiopulmonary bypass machines in open-heart surgeries, or indirectly (through cardiac or pulmonary right to left shunts) in dive accidents, resulting in serious morbidity and even death. Perfluorocarbon (PFC) emulsions have been used for the treatment of AGE in an animal mo...

This invention provides for methods of treating a subject suffering from central nervous system injury, including traumatic brain injury, comprising administering to the subject an amount of a perfluorocarbon. This invention also provides for use of a perfluorocarbon in the manufacture of a medicament for treating a subject suffering from central n...

Massive arteriolar gas embolism (AGE) has never been evaluated in vivo using intravital microscopy and previous perfluorocarbon (PFC) emulsions were only effective in AGE when administered before AGE. We implemented a new system for quantitative studies of massive AGE using brightfield microscopy and tested a treatment with a third-generation PFC e...

In 2008, we saw the withdrawal of aprotinin from the US markets after preliminary results from a large, randomized clinical trial in Canada. This drug, a potent antifibrinolytic, was used primarily in complex and/or redo cardiac surgery as an adjunct to decrease postoperative bleeding and complications. The Canadian study raised questions previousl...

Decompression sickness (DCS) results from a decrease in ambient pressure leading to supersaturation of tissues with inert gas and bubble formation. Perfluorocarbons (PFCs) are able to dissolve vast amounts of non-polar gases. Intravenous (IV) PFC emulsions reduce both morbidity and mortality associated with DCS, but the mechanism of this protective...

Microvascular hemodynamic responses to arterial gas embolism (AGE) and local oxygen tensions (PO2) have never been evaluated in vivo using intravital microscopy. A system was implemented to study AGE in real time using brightfield and phosphorescence microscopy as well as laser-induced microvessel occlusion. Bubble dynamics, microhemodynamics and o...

The microcirculation can be defined as those vascular structures where respiratory gas flux occurs. These are generally the arterioles, venules, and capillaries. Larger vascular conduits tend to have thicker walls, are at considerable distance from cellular sites of oxygen utilization, and therefore contribute little to oxygen flux. The microcircul...

Human error in medicine is a significant cause of patient mortality. While there has been increased attention to safety in medicine since the Institute of Medicine publication To Err is Human, the profession at large has not progressed to the same degree as other highly complex industries such as aviation and nuclear power. The Flawless Operative C...

Blood management is an evolving field of reducing transfusions of allogeneic blood by maximizing multi-modality therapy to optimize red cell mass, reduce red cell loss, and harvest red cells that would have otherwise been discarded. These techniques are highly dependent upon teams working together. The programs are not just focused upon red cells b...

The 2007 Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Clinical Practice Guideline for Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery was recently promulgated and has received much attention. Using a survey of cardiac anesthesiologists and perfusionists' clinical practice, we aimed to as...

Gaseous anaesthesia has been a great boon for medicine. These drugs form a foundation from which modern surgery has sprung, yet their mechanism(s) of actions remains poorly understood. Inert gas narcosis is a limitation of deep sea diving, and its mechanisms also remain poorly understood. In this review article we summarise what is known about the...

Platelets are active metabolising cells that are evolved for the tasks of haemostasis, inflammatory reactions and wound healing. When platelet products are stored in the blood bank a complex series of changes occur, leading to partial activation, up-regulation of inflammatory mediators, cellular morphology changes, loss of cell membrane lipids and...

Knowledge of central venous pressure (CVP) is considered valuable in the assessment and treatment of various states of critical illness and injury. We tested a noninvasive means of determining CVP (NICVP) by monitoring upper arm blood flow changes in response to externally applied circumferential pressure to the upper arm veins. Thirty-six patients...

Formation of bubbles in tissue and vasculature from a sudden reduction in ambient pressure is likely an underlying cause of the clinical symptoms of decompression sickness (DCS). Thus, tools detecting bubbles in the vasculature may be important for evaluating DCS. Sheep were air-compressed to 6.0 ATA (30 minutes bottom time) then rapidly decompress...

As the practice of cardiothoracic surgery continues to evolve in the face of an aging population and increasing comorbidities, patients are being offered options that once may have been considered off limits, often without guidelines or consensus available to guide the surgeon or the patient. A case report of a high-risk aortic procedure is present...

Perfluorocarbon emulsions have been shown to improve outcomes in stroke models. This study examined the effect of Oxycyte, a third-generation perfluorocarbon emulsion (04RD33; Synthetic Blood International, Inc., Costa Mesa, CA) treatment on cognitive recovery and mitochondrial oxygen consumption after a moderate lateral fluid percussion injury (LF...

Heparin resistance occurs in up to 22% of patients undergoing cardiac surgery requiring cardiopulmonary bypass and it is associated with decreased levels of antithrombin. Treatment options for heparin resistance include administration of antithrombin or fresh frozen plasma. A systematic review revealed no clinical trials directly comparing antithro...

Decompression illness (DCI) results from sudden changes in ambient pressure leading to super-saturation and bubble formation in tissues and the blood stream. Perfluorocarbon emulsions (PFC) increase both oxygen and nitrogen solubility when infused into the blood stream. This study hypothesized that PFC would increase N(2) removal as well as O(2) de...

This study assessed the use of bivalirudin as an alternative anticoagulant in patients with heparin-induced thrombocytopenia-thrombotic syndrome (HIT/TS) or antiplatelet factor four-heparin (anti-PF4/H) antibodies undergoing off-pump coronary artery bypass (OPCAB). In a prospective, open-label, multicenter study, fifty-one patients with documented...

A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes. We reviewed all a...

The coronary artery bypass grafting (CABG) heparin-induced thrombocytopenia thrombosis syndrome (HITTS) on- and off-pump safety and efficacy (CHOOSE-ON) trial was designed as a safety and efficacy trial of bivalirudin for use in anticoagulation during cardiopulmonary bypass (CPB) in patients with confirmed or suspected HIT and (or) antiplatelet fac...

Blood transfusion utilization continues to rise, yet it has never undergone prospective safety and efficacy testing. Recent data regarding oxygen delivery, microcirculation, and inflammation all point toward potential problems with allogeneic transfusion. Outcome data from retrospective data bases are sobering, calling to question the present pract...

Inappropriate activation of hemostasis and inflammation may contribute to postoperative morbidity and mortality. The serine protease inhibitor, aprotinin, has been shown to prevent tissue and organ injury in laboratory and animal studies. In this retrospective analysis, we evaluated the relationship of aprotinin therapy with organ dysfunction in hu...

In the EVOLUTION OFF trial, we evaluated the safety and efficacy of bivalirudin during off-pump coronary artery bypass grafting as compared with heparin-protamine. In this subanalysis of EVOLUTION OFF data of bivalirudin-treated patients, we assessed the pharmacokinetics (PK) and effectiveness of bivalirudin anticoagulation to achieve target activa...

Knowledge of central venous pressure (CVP) is considered valuable in the assessment and treatment of various states of critical illness and injury. We tested a noninvasive means of determining CVP (NICVP), by monitoring forearm volume changes in response to externally applied circumferential pressure to the upper arm veins. Sixteen patients who wer...

The beneficial effects of blood transfusions have been described and widely accepted. Multiple factors, including shortages, costs, infectious risks, immunologic risks, and the risk/benefit ratio to the patient, have made the medical community reassess the guidelines for transfusion. Cardiac surgery presents a unique subset of patients, because int...

Unfractionated heparin has been a near universal anticoagulant for cardiac surgery; however it is contraindicated in heparin-induced thrombocytopenia type II. Alternative anticoagulants such as bivalirudin (a direct thrombin inhibitor) are being utilized. Bivalirudin was successfully used in an immunologically complex patient (diagnoses of heparin-...

Standard formulae used for calculating outcome measures.

Unfractionated heparin and its antidote, protamine sulfate, allow for rapid and reversible anticoagulation during cardiac surgery with cardiopulmonary bypass, yet limitations exist, including a variable dose-response, dependence on a cofactor for anticoagulant effect, and antigenic potential. This trial was performed to evaluate the safety and effi...

Unfractionated heparin has many shortcomings, including indirect and partial inhibition of thrombin, antibody formation, and platelet activation. Bivalirudin, a short-acting direct thrombin inhibitor, avoids these limitations and has superior outcomes during percutaneous revascularization. This trial was performed to evaluate the safety and efficac...

Cardiopulmonary bypass (CPB) induces hemodilutional anemia, which frequently requires the transfusion of blood products. The objective of this study was to evaluate oxygen delivery and consumption and clinical outcome in low risk patients who were allocated to an hematocrit (Hct) of 20% versus 25% during normothermic CPB for elective coronary arter...

Clinicians now realize the limitations of the physical examination in detecting compensated shock states, the severity of uncompensated states, and in determining the adequacy of resuscitation in order to prevent subsequent post-traumatic multisystem organ failure and death. A renewed interest has developed in interrogating the state of oxygen tran...

The majority of patients undergoing surgical treatment for ST-elevation myocardial infarction receive antifibrinolytic therapy to limit blood loss. This approach appears counterintuitive to the accepted medical treatment of the same condition--namely, fibrinolysis to limit thrombosis. Despite this concern, no independent, large-scale safety assessm...

This study was conducted to determine whether perfluorocarbons (PFCs) improve brain oxygenation and reduce ischemic brain damage in an acute subdural hematoma (SDH) model in rats. Forty adult male Sprague-Dawley rats were allocated to four groups: (1) controls, acute SDH treated with saline and 30% O2; (2) 30-PFC group, acute SDH treated with PFC i...

Although heparin/protamine has been the standard anticoagulation regimen in cardiac surgery for decades, it induces negative reactions within the vasculature. Heparin-induced thrombocytopenia (HIT) is a highly prothrombotic immune reaction to heparin that may result in death, limb ischemia leading to amputation, graft occlusion, and other severe th...

Bivalirudin has been successfully used as a replacement for heparin during on-pump coronary artery bypass grafting. This study was conducted to assess the effects of the currently suggested protocol for bivalirudin on hemostatic activation during cardiopulmonary bypass with and without cardiotomy suction. Ten patients scheduled for coronary artery...

We assessed the systemic effects of exchanges with blood or hemoglobin (Hb) raffimer under conditions of critical oxygen delivery (Do(2)crit). We compared Do(2)crit in animals receiving Hb-based oxygen carrier (HBOC; Hemolink), fresh blood (collected <24 h), or stored blood (10 days) before hemodilution. Rats were randomized to control, blood, or H...

Systemic variables were evaluated with respect to O(2) delivery to test the hypothesis that critical O(2) delivery and critical Hb can be estimated by multiple variables collected simultaneously. Rats were subjected to transfusion with either fresh or stored blood and then subjected to stepwise isovolemic hemodilution. Critical levels were measured...

In summary, the data on outcomes and transfusion are worrisome. There are few if any articles that support transfusion actually improving patient outcome. The only article from a large database showing improved outcome is flawed and should not be generalized. The majority of database papers show associations between transfusion utilization and with...

There remains controversy as to when patients undergoing cardiac surgery should receive a transfusion and whether a low hematocrit and its treatment with a transfusion of red cells influences outcome. The data related to this controversy are reviewed. Although the risk of known viral transmission is currently low, stored red cells do not function n...

t- 3 The improvement in viral transmission risk has come at a considerable cost. New plagues await the blood-banking industry, and today the country has just survived the scare of West Nile virus infestation of the United States blood supply (11800-114,000 units). In 1 year, a nucleic acid test (NAT) for West Nile virus has been instituted, now ren...

Platelet (PLT) transfusions are administered in cardiac surgery to prevent or treat bleeding, despite appreciation of the risks of blood component transfusion. The current analysis investigates the hypothesis that PLT transfusion is associated with adverse outcomes associated with coronary artery bypass graft surgery (CABG). Data originally collect...

Cerebral ischemia is a common secondary sequela of traumatic brain injury (TBI). Experimental models of stroke have demonstrated reductions in ischemia after perfluorocarbon (PFC) administration; however, there are no published reports of PFC efficacy after TBI. The current study analyzed the effect of the PFC emulsion Oxygent (AF0144; Alliance Pha...

We investigated the use of bivalirudin as an anticoagulant therapy during cardiopulmonary bypass in 20 patients who underwent coronary artery bypass grafting. Primary end points consisted of clinical outcome data, whereas secondary end points focused on blood loss, transfusions, pharmacokinetics, and monitoring. Our data provide the first evidence...

Cardiopulmonary bypass (CPB) results in many physiologic derangements, including activation of the hemostatic and fibrinolytic pathways. Deep hypothermic circulatory arrest (DHCA) adds a further insult to the coagulation systems because it involves more extreme hypothermia and organ ischemia related to blood stasis. The abnormalities induced by CPB...

Implications: Bivalirudin is a new, direct thrombin inhibitor. We investigated the extracorporeal elimination rate of different hemofilters and one plasmapheresis filter for bivalirudin. Our data show that bivalirudin can be effectively eliminated via hemofiltration and plasmapheresis, although there were significant differences in the elimination...

Bivalirudin, a new short-acting direct thrombin inhibitor, provides an elimination mechanism independent of specific organ function. We successfully used this new drug, monitored at the point of care via the ecarin clotting time, for anticoagulation during cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia heparin allergy and...

Objective: To assess whether substantial institutional variability exists in red blood cell conservation practices associated with coronary artery bypass graft (CABG) surgery.Design: Prospective, randomized patient enrollment and data collection.Setting: Twenty-four U.S. academic institutions participating in the Multicenter Study of Perioperative...

Objective: To examine the efficacy and safety of shed mediastinal blood (SMB) transfusion in preventing allogenic red blood cell (RBC) transfusion.Design: An observational clinical study.Setting: Twelve US academic medical centers.Participants: Six hundred seventeen patients undergoing elective primary coronary artery bypass grafting.Interventions:...

No data exist regarding "the best" hematocrit value after coronary artery bypass graft surgery. Transfusion practice varies, because neither an optimal hematocrit value nor a uniform transfusion trigger criterion has been determined. To investigate the optimal hematocrit value, we studied 2202 patients undergoing coronary bypass. The hematocrit val...

Background: Acadesine (AICA riboside) (5-amino-1-[beta-D-ribofuranosyl]imidazole-4-carboxamide) is a purine nucleoside analog belonging to a new class of agents generally termed adenosine regulating agents (ARAs) that increase the availability of adenosine locally in ischemic tissues. The effects of acadesine on the incidence of fatal and nonfatal...

Mixed venous oxygen saturation (SvO2) monitoring has been advocated for some critically ill patients. Patients with end-stage hepatic failure have oxygen consumption rates that are lower than normal. Using the Fick equation, oxygen consumption may be calculated if mixed venous and arterial oxygen tensions (and saturations), hemoglobin, and cardiac...

Pre-existing hematologic disturbances present the anesthesiologist with a number of problems. Knowledge of those defects will allow for optimum intraoperative care. This review will highlight recent advances in both erythrocyte abnormalities as well as a number of coagulation problems.

Supraventricular tachydysrhythmias are a commonly encountered clinical problem after cardiothoracic surgery. Current choices for acute drug therapy of these dysrhythmias include intravenous verapamil as well as esmolol, but no data yet exist comparing the relative negative dromotropic (atrioventricular [A-V] nodal blocking) and negative inotropic e...

A prospective study of 324 adult patients undergoing operations requiring cardiopulmonary bypass for heart valve replacement was undertaken to determine the effect of anesthetic technique on outcome. Patients received one of three primary techniques: fentanyl (40–100 μg/kg), sufentanil (4–8 μg/kg), or diazepam (0.4–1 mg/kg) with ketamine (3–6 mg/kg...

The effects of two different anesthetic techniques on postoperative cardiopulmonary events, fluid and vasopressor requirements, and overall intensive care unit (ICU) course were studied in patients undergoing elective myocardial revascularization (CABG) (N = 20) or single cardiac valve replacement (N = 20). Patients were randomized to receive eithe...

Venous air embolism has been reported to occur during total hip arthroplasty. The incidence of venous air embolism, however, has not been previously studied in a large series using Doppler ultrasound and mass spectrometry. Seventy patients undergoing total hip arthroplasty were monitored for venous air embolism with precordial Doppler ultrasound, c...

The protective effects of a perfluorocarbon emulsion (FC-43) against the physiological sequelae of selective coronary air embolism (CAE) were examined in dogs. Animals were randomly assigned to two groups: group 1 received 20 mL/kg of 6% hetastarch in 0.9 normal saline solution with 280 mg/L of CaCl2: group 2 received 20 mL/kg of FC-43 (Oxypherol,...

Postoperative hemorrhage in patients undergoing open-heart surgery is a major cause of morbidity and mortality. Monitoring of coagulation in these patients has routinely involved the activated clotting time. Thromboelastography is currently used as a monitor of coagulation during liver transplantation. The thromboelastogram, by providing informatio...

Cardiopulmonary bypass (CPB) is now 50 years old. Although developed originally to allow correction of congenital and valvular heart disease, CPB has affected all of medicine profoundly. As an artificial circulatory support for systemic and pulmonary functions, CPB has allowed for the development of cardiovascular surgery. Today, coronary artery by...