Of 2 such reports from single centers in the 1980s, 1 suggested that the failure to control heart rate to 110 beats per minute was associated with a higher mortality rate, and the other suggested that increasing duration of CPB adversely influenced outcome.52,53 Another observational analysis of data from vascular surgery patients suggested that anesthetic specialization was independently associated with a reduction in mortality rate.54 To meet the challenges of providing care for the increasingly higher-risk patients undergoing CABG, efforts have been di- rected at enhancing the experience of trainees, particularly in the use of newer technologies such as TEE. Cardiac anesthesiolo- gists, in collaboration with cardiologists and surgeons, have implemented national training and certification processes for practitioners in the use of perioperative TEE (Section 2.1.7).164,165 Accreditation of cardiothoracic anesthesia fellow- ship programs from the Accreditation Council for Graduate Medical Education was initiated in 2004, and efforts are ongoing to obtain formal subspecialty certification.18 2.1.2. Use of CPB Several adverse outcomes have been attributed to CPB, including 1) neurological deficits (eg, stroke, coma, postop- erative neurocognitive dysfunction); 2) renal dysfunction; and 3) the Systemic inflammatory Response Syndrome (SIRS). The SIRS is manifested as generalized systemic inflammation occurring after a major morbid event, such as trauma, infection, or major surgery. It is often particularly apparent after on-pump cardiac surgery, during which surgi- cal trauma, contact of blood with nonphysiological surfaces (eg, pump tubing, oxygenator surfaces), myocardial ischemia and reperfusion, and hypothermia combine to cause a dra- matic release of cytokines (eg, interleukin [IL] 6 and IL8) and other mediators of inflammation.55 Some investigators have used serum concentrations of S100 beta as a marker of brain injury56 and have correlated increased serum levels with the number of microemboli exiting the CPB circuit during CABG. 