Effects of concomitant usage of milrinone and catecholamine for weaning from cardiopulmonary bypass

Inotropic agents and vasodilator strategies for acute myocardial infarction complicated by cardiogenic shock or low cardiac output syndrome

BACKGROUND

The recently published German-Austrian S3 Guideline for the treatment of infarct related cardiogenic shock (CS) revealed a lack of evidence for all recommended therapeutic measures.

OBJECTIVES

To determine the effects in terms of efficacy, efficiency and safety of cardiac care with inotropic agents and vasodilator strategies versus placebo or against each other for haemodynamic stabilisation following surgical treatment, interventional therapy (angioplasty, stent implantation) and conservative treatment (that is no revascularization) on mortality and morbidity in patients with acute myocardial infarction (AMI) complicated by CS or low cardiac output syndrome (LCOS).

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), EMBASE (Ovid) and ISI Web of Science, registers of ongoing trials and proceedings of conferences in January 2013. Reference lists were scanned and experts in the field were contacted to obtain further information. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials in patients with AMI complicated by CS or LCOS.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the published protocol. All trials were analysed individually. Hazard ratios (HRs) and odds ratios with 95% confidence intervals (CI) were extracted but not pooled because of high heterogeneity between the control group interventions.

MAIN RESULTS

Four eligible, very small studies were identified from a total of 4065 references. Three trials with high overall risk of bias compared levosimendan to standard treatment (enoximone or dobutamine) or placebo. Data from a total of 63 participants were included in our comparisons, 31 were treated with levosimendan and 32 served as controls. Levosimendan showed an imprecise survival benefit in comparison with enoximone based on a very small trial with 32 participants (HR 0.33; 95% CI 0.11 to 0.97). Results from the other similarly small trials were too imprecise to provide any meaningful information about the effect of levosimendan in comparison with dobutamine or placebo. Only small differences in haemodynamics, length of hospital stay and the frequency of major adverse cardiac events or adverse events overall were found between study groups.Only one small randomised controlled trial with three participants was found for vasodilator strategies (nitric oxide gas versus placebo) in AMI complicated by CS or LCOS. This study was too small to draw any conclusions on the effects on our key outcomes.

AUTHORS' CONCLUSIONS

At present there are no robust and convincing data to support a distinct inotropic or vasodilator drug based therapy as a superior solution to reduce mortality in haemodynamically unstable patients with CS or low cardiac output complicating AMI.

Enhanced Vasodilatory Responses to Milrinone in Catecholamine-Precontracted Small Pulmonary Arteries

Beta-adrenergic agonists (e.g., epinephrine [E] and norepinephrine [NE]) and phosphodiesterase-III inhibitors (e.g., milrinone) are often used in combination to augment ventricular function in the perioperative period. In the myocardium, milrinone acts synergistically with beta-adrenergic agonists to increase contractility. However, the potential interaction between catecholamines with combined alpha- and beta-adrenergic activity and milrinone in the pulmonary circulation has not been determined. We evaluated the vasodilatory effects of milrinone and nitroglycerine on large elastic and small muscular porcine pulmonary vascular rings precontracted with catecholamines with beta-adrenergic agonist activity (E and NE), the alpha-adrenergic agonist phenylephrine, and a nonadrenergic agonist, the thromboxane analog U46619. In small pulmonary arteries, the vasorelaxation with milrinone was significantly enhanced in rings precontracted with E or NE compared with those precontracted with phenylephrine or U46619. However, in large pulmonary arteries, the vasorelaxation with milrinone was similar in all vessel rings and was not influenced by the agonist used to induce precontraction. In marked contrast, the vasorelaxant responses to nitroglycerine were not altered by the specific agonist used for precontraction in either small or large pulmonary vascular rings. Thus, the pulmonary vascular effects of milrinone are enhanced when combined with drugs with beta-adrenoreceptor agonist activity. The vasodilatory interactions exhibited by phosphodiesterase-III inhibitors and the catecholamines NE and E suggest that their combined use might be beneficial in circumstances in which ventricular dysfunction and increased pulmonary vascular resistance occur.

IMPLICATIONS

This study demonstrated that milrinone had enhanced vasodilator effects when combined with drugs with beta-adrenoreceptor agonist activity in small pulmonary artery segments removed from pigs.

The Variable Effects of Dopamine Among Human Isolated Arteries Commonly Used for Coronary Bypass Grafts

The direct actions of dopamine on human arterial coronary bypass grafts are not well known. We investigated its effects on isolated rings cut from radial arteries (RA), gastroepiploic arteries (GEA), and internal mammary arteries (IMA) harvested from patients undergoing coronary artery bypass surgery. Dopamine produced dose-dependent contractile responses in RA, an effect independent of the presence of a functional endothelium. The contractions were enhanced by the dopamine A(1) (DA(1))-receptor antagonist SCH23390, whereas they were blocked by an alpha(1)-adrenergic antagonist, prazosin. Results qualitatively similar to these were obtained in both GEA and IMA, although the contractile responses were far smaller. In RA, DA enhanced the norepinephrine (NE)-induced contraction, and this action of dopamine was enhanced by SCH23390. In GEA, small concentrations (<10(-7) mol/L) of DA attenuated the NE-induced contraction but larger concentrations did not. In IMA, DA induced a vasorelaxation on the NE-contraction only at higher concentrations (10(-6)-10(-5) mol/L). In both GEA and IMA, the dopamine-induced vasorelaxations on the NE contraction were completely inhibited by SCH23390. These results suggest that the affinities of DA for DA(1)- and alpha(1)-adrenergic receptors may explain its variable contractile and vasorelaxant effects among these arteries.

IMPLICATIONS

Differing affinities of dopamine for dopamine A(1)- and alpha(1)-adrenergic receptors may lead to it having variable contractile and vasorelaxant effects among the arteries supplying grafts for coronary bypass surgery.

Effect of sevoflurane on human neutrophil apoptosis

BACKGROUND AND OBJECTIVE

Both chronic occupational exposure to volatile anaesthetic agents and acute in vitro exposure of neutrophils to isoflurane have been shown to inhibit the rate of apoptosis of human neutrophils. It is possible that inhibition of neutrophil apoptosis arises through delaying mitochondrial membrane potential collapse. We assessed mitochondrial depolarization and apoptosis in unexposed neutrophils and neutrophils exposed to sevoflurane in vivo.

METHODS

A total of 20 mL venous blood was withdrawn pre- and postinduction of anaesthesia, the neutrophils isolated and maintained in culture. At 1, 12 and 24 h in culture, the percentage of neutrophil apoptosis was assessed by dual staining with annexin V-FITC and propidium iodide. Mitochondrial depolarization was measured using the dual emission styryl dye JC-1.

RESULTS

Apoptosis was significantly inhibited in neutrophils exposed to sevoflurane in vivo at 24 (exposed: 38 (12)% versus control: 28 (11)%, P = 0.001), but not at 1 or 12 h, in culture. Mitochondrial depolarization was not delayed in neutrophils exposed to sevoflurane.

CONCLUSIONS

The most important findings are that sevoflurane inhibits neutrophil apoptosis in vivo and that inhibition is not mediated primarily by an effect on mitochondrial depolarization.

Opioid-induced respiratory depression is associated with increased tidal volume variability

BACKGROUND AND OBJECTIVE

mu-agonistic opioids cause concentration-dependent hypoventilation and increased irregularity of breathing. The aim was to quantify opioid-induced irregularity of breathing and to investigate its time-course during and after an opioid infusion, and its ability to predict the severity of respiratory depression.

METHODS

Twenty-three patients breathing spontaneously via a continuous positive airway pressure (CPAP) mask received an intravenous (i.v.) infusion of alfentanil (2.3 microg kg(-1) min(-1), 14 patients) or pirinitramide (piritramide) (17.9 microg kg(-1) min(-1), nine patients) until either a cumulative dose of 70 microg kg(-1) for alfentanil or 500 microg kg(-1) for pirinitramide had been achieved or the infusion had to be stopped for safety reasons. Tidal volumes (VT) and minute ventilation were measured with an anaesthesia workstation. For every 20 breaths, the quartile coefficient was calculated (Qeff20V(T)).

RESULTS

Both the decrease of minute volume and the increase of Qeff20V(T) during and after opioid infusion were highly significant (P < 0.001, ANOVA). Patients in which the alfentanil infusion had to be terminated prematurely had lower minute volumes (P = 0.002, t-test) and higher Qeff20V(T) (P = 0.034, t-test) than those who received the complete dose. Changes in the regularity of breathing measured as Qeff20V(T) parallel those of minute ventilation during and after opioid infusion.

CONCLUSIONS

Opioids cause a more complicated disturbance of the control of respiration than a mere resetting to higher PCO2. Furthermore, Qeff20V(T) appears to predict the severity of opioid-induced respiratory depression.

Intravenous patient-controlled analgesia after thoracotomy: a comparison of morphine with tramadol

BACKGROUND AND OBJECTIVE

This study examined the quality of analgesia together with the side-effects produced by tramadol compared with morphine using intravenous patient-controlled analgesia during the first 24 h after thoracotomy.

METHODS

Forty-four patients scheduled for thoracotomy were included in the study. Morphine 0.3 mg kg(-1) was given interpleurally 20 min before a standard general anaesthetic. In the postanaesthetic care unit, the patients were randomly allocated to one of two groups to self-administer tramadol or morphine using a patient-controlled analgesia device throughout a 24 h period. The patient-controlled analgesia device was programmed to deliver tramadol 20 mg as an intravenous bolus or morphine 2 mg with a lockout time of 10 min.

RESULTS

Mean cumulative morphine and tramadol consumption were 48.13 +/- 30.23 and 493.5 +/- 191.5 mg, respectively. There was no difference in the quality of analgesia between groups. Five (26.3%) patients in the tramadol group and seven (33%) in the morphine group had nausea, and three of the latter patients vomited. The incidence rate of vomiting with tramadol was 5.2%. All vital signs were within safe ranges. Sedation was less in the tramadol group, but not statistically significant.

CONCLUSIONS

In this clinical setting, which includes interpleural morphine pre-emptively, postoperative analgesia provided by tramadol was similar to that of morphine at rest and during deep inspiration. Side-effects were slight and comparable between the patients receiving morphine and tramadol.

Effects of ropivacaine on human neutrophil function: comparison with bupivacaine and lidocaine

BACKGROUND AND OBJECTIVE

Neutrophils are important both for the immunological defence system and for the inflammatory tissue autoinjury mechanism. However, many local anaesthetics impair certain neutrophil functions. The aim was to assess the effects of ropivacaine, bupivacaine and lidocaine on human neutrophils from adult volunteers.

METHODS

Chemotaxis, phagocytosis, reactive oxygen species production, intracellular calcium ion ([Ca2+]i) concentrations and protein kinase C activity were measured in the absence and presence of ropivacaine, bupivacaine or lidocaine. The lowest concentrations of the local anaesthetics were similar to those clinically observed in the plasma.

RESULTS

Bupivacaine did not affect any neutrophil function (P > 0.05). Ropivacaine failed to change chemotaxis or phagocytosis, while lidocaine suppressed both these neutrophil functions. Ropivacaine (15, 150 microg mL(-1)) and lidocaine (20, 200 microg mL(-1)) impaired neutrophil production of O2-, H2O2 and OH- (P < 0.05) at similar rates (by 7-10%). These same concentrations of ropivacaine and lidocaine suppressed [Ca2+1i elevation. Finally, neither ropivacaine nor bupivacaine inhibited protein kinase C activity, while lidocaine did.

CONCLUSIONS

Suppression of the [Ca2+]i response in neutrophils by ropivacaine may represent one of the mechanisms responsible for the impairment of neutrophil functions. It should be emphasized that the inhibitory effects of ropivacaine are minor and are attained only at high concentrations, which may minimize the clinical implication of ropivacaine-associated impairment of reactive oxygen species production. Further studies using in vivo systems are required to identify the inhibitory effects of ropivacaine on reactive oxygen species production in clinical settings.

Neural nets and prediction of the recovery rate from neuromuscular block

BACKGROUND AND OBJECTIVE

The aim was to train artificial neural nets to predict the recovery of a neuromuscular block during general anaesthesia. It was assumed that the initial/early neuromuscular recovery data with the simultaneously measured physical variables as inputs into a well-trained back-propagation neural net would enable the net to predict a rough estimate of the remaining recovery time.

METHODS

Spontaneous recovery from neuromuscular block (electrically evoked electromyographic train-of-four responses) were recorded with the following variables known to affect the block: multiple minimum alveolar concentration, end-tidal CO2 concentration, and peripheral and central temperature.

RESULTS

The mean prediction errors, mean absolute prediction errors, root-mean-squared prediction errors and correlation coefficients of all the nets were significantly better than those of average-based predictions used in the study. The root-mean-squared prediction error of the net - employing minimum alveolar concentrations from the whole recovery period (the recovery time from E2/E1 = 0.30 to E4/E1 = 0.75; E1 = first response of train-of-four, E2 = second response of train-of-four, etc.)--were significantly smaller than those of other nets, or the same net employing minimum alveolar concentrations only from the initial recovery period (from E2/E1 = 0.30 to E4/E1 = 0.25).

CONCLUSIONS

Neural nets could predict individual recovery times from the neuromuscular block significantly better than the average-based method used here, which was supposed to be more accurate than guesses by any clinician. The minimum alveolar concentration was the only monitored variable that influenced the recovery rate, but it did not aid neural net prediction.

Sevoflurane but not isoflurane can reduce prostacyclin production of endothelial cells

BACKGROUND AND OBJECTIVE

Little is known about the interaction of newer volatile anaesthetics with endothelial eicosanoid production. Sevoflurane may possibly reduce prostacyclin formation. Thus, we compared the influences of sevoflurane and isoflurane on endothelial prostacyclin production.

METHODS

Production of prostacyclin of human umbilical vein endothelial cells was measured by the ELISA technique under basal conditions and after stimulation with calcium ionophore A 23187 10 micromol or histamine 0.1 micromol in the absence and presence of 1 and 2 minimal alveolar concentrations (MAC) of sevoflurane or isoflurane.

RESULTS

The basal production of prostacyclin was unaffected by the volatile anaesthetics. Stimulation of endothelial cells increased prostacyclin formation 3-5-fold. Sevoflurane at 2 MAC, but not at 1 MAC, could reduce stimulated prostacyclin production by about half (P < 0.05). Isoflurane had no inhibitory effect. Inhibition of cyclo-oxygenase function by acetylsalicylic acid abolished the induced burst of prostacyclin formation completely.

CONCLUSIONS

Sevoflurane, but not isoflurane, can reduce stimulated endothelial prostacyclin production in a concentration-dependent manner. Because at least 2 MAC of sevoflurane were required, this effect should be of minor importance under clinical conditions of balanced anaesthesia.

Adsorption of sufentanil to epidural filters and catheters

BACKGROUND AND OBJECTIVE

Stable drug concentrations must be administered to provide adequate patient-controlled epidural analgesia. This study investigated the stability of sufentanil after the epidural delivery system had been flushed with solutions containing the drug.

METHODS

Sufentanil citrate, 5 microg mL(-1) was injected through an epidural catheter system into a glass container. The concentrations of the drug leaving the system, in 1 mL aliquots (1-5 mL) were measured using high-performance liquid chromatography. In the same manner, sufentanil samples were analysed after flushing the filter, as well as after priming the filter and catheter.

RESULTS

ANOVA for repeated measurements demonstrated that sufentanil concentrations remained constant as long as the catheter had been adequately flushed. However, the concentration of sufentanil in the solution exiting the filter was reduced significantly. Hardly any sufentanil could be detected (0.09 +/- 0.01 microg mL(-1), P < 0.001) in the first 1 mL aliquot (probe) leaving the filter. Altogether, 3 mL sufentanil solution was needed to pass through the filter before the baseline values were restored (P > 0.05). The greatest decrease occurred when the whole epidural delivery apparatus (catheter and filter) was primed; to regain baseline values, as much as 4 mL solution was needed to flush the system.

CONCLUSIONS

Sufentanil citrate is adsorbed by the materials used to manufacture systems (catheters, filters) used in epidural anaesthesia. Hence, the epidural catheter system should be primed with sufentanil before connecting it to the patient so as to deliver reliable concentrations.

Nitrous oxide/oxygen mixture and the prevention of pain during injection of propofol

BACKGROUND AND OBJECTIVE

The incidence of pain associated with the injection of propofol still remains a problem. This study sought to examine the analgesic effects of inhaled nitrous oxide in oxygen on the prevention of propofol injection pain.

METHODS

Nitrous oxide in oxygen was compared with a lidocaine (20 mg)-propofol mixture and with propofol alone (control) in a prospective, randomized, observer-blinded study. ASA I and II patients (n = 135) scheduled for elective surgical procedures were studied. A standard propofol injection technique and scoring system to measure the pain on injection was used.

RESULTS

Demographic variables were similar between the study groups. Without analgesia (control) 26 of 45 patients (58%) reported pain on injection compared with 11 of 45 patients (24%) in both the nitrous oxide (95% CI: 14-52%, P = 0.001) and lidocaine groups (95% CI: 14-52%, P = 0.001).

CONCLUSIONS

The inhalation of a nitrous oxide/oxygen mixture significantly reduces the incidence of pain during propofol injection. This therapeutic stratagem was as effective as a lidocaine-propofol mixture.

Effects of repeated anaesthesia on central cholinergic function in the rat cerebral cortex

BACKGROUND AND OBJECTIVE

General anaesthesia may contribute to postoperative cognitive decline in the elderly. The aim was to determine the effects of repeated pentobarbital anaesthesia throughout life on central cholinergic function in the rat.

METHODS

Young Lewis rats were randomly allocated to two groups. The anaesthesia group (n = 15) was anaesthetized with pentobarbital 20 mg kg(-1) intraperitoneally at 6, 8.5, 11, 13.5, 16, 18.5, 21 and 23.5 months of age. The control group (n = 12) was treated identically, apart from the anaesthesia. At 26 months of age, the animals were killed and the brain dissected and stored for analysis. Central cholinergic function in the cortex and hippocampus was assessed by measuring [3H]-epibatidine and [125I]alpha-bungarotoxin binding to nicotinic receptors and choline acetyltransferase (ChAT) activity.

RESULTS

Tissue from nine rats in the anaesthesia group and eight in the control group was available for analysis. There was a significant reduction in alpha-bungarotoxin binding in the anaesthetized compared with the control group in the superior cortex (P < 0.0002) and molecular cortex (P < 0.04). There were no significant differences between the groups for epibatidine binding or ChAT.

CONCLUSIONS

Repeated anaesthesia in rat reduces central nicotinic cholinergic binding in the cortex. The findings may have implications for postoperative cognitive function studies.

Induced arterial hypotension for interventional thoracic aortic stent-graft placement: impact on intracranial haemodynamics and cognitive function

BACKGROUND AND OBJECTIVE

The study investigated the impact of induced arterial hypotension for the facilitation of endovascular stent-graft placement in patients with thoracic aortic aneurysm on cerebral blood flow velocity and neurological/neurocognitive outcome.

METHODS

In 27 ASA III patients, cerebral blood flow velocity was recorded during induced arterial hypotension for endovascular stent-graft placement using transcranial Doppler sonography and the Folstein Mini Mental State Examination and the National Institute of Health Stroke Scale were performed before and after the intervention.

RESULTS

Mean arterial pressure was decreased <50 mmHg, and in 22 patients it was <40 mmHg. Diastolic cerebral blood flow velocity decreased by 59%. Postoperatively, six of 21 patients exhibited changes in the Folstein Mini Mental State Examination and four of these six patients in the National Institute of Health Stroke Scale as indices of new-found neurocognitive dysfunction, but there were no signs of stroke. Loss of the diastolic blood flow profile was detected in two of six patients with new-found neurocognitive dysfunctions and in 18 of 21 patients with no new-found neurocognitive dysfunction. Changes in the Folstein Mini Mental State Examination on postoperative day 1 were correlated to the pre-procedural Folstein Mini Mental State Examination, but not to the time spent with a mean arterial pressure <50 mmHg, <40 mmHg or with a loss of diastolic blood flow profile.

CONCLUSIONS

Transcranial Doppler sonography visualizes the individual effect of induced hypotension and the period of intracranial circulatory arrest during aortic stent-graft placement. However, transient new-found neurocognitive dysfunctions occur independently of the transcranial Doppler data, and are in close correlation to the neurocognitive state before the procedure. The results suggest that induced arterial hypotension is not the major factor for postoperative new-found neurocognitive dysfunction.

Gastric mucosal-to-end-tidal PCO2 difference during major abdominal surgery: influence of the arterial-to-end-tidal PCO2 difference?

BACKGROUND AND OBJECTIVE

Because gastric mucosal PCO2 must be referenced to arterial values via a gastric-to-arterial PCO2 gap (Pg-aCO2), the gastric-to-end-tidal PCO2 difference (Pg-ETCO2) may be proposed as a surrogate method to monitor Pg-aCO2. However, the influence of arterial-to-end-tidal PCO2 (Pa-ETCO2) on its value remains unknown. Pa-ETCO2 may be enhanced by a low cardiac output and subsequent reduced perfusion of the lungs. This study was designed to compare such gaps observed during abdominal surgery in patients with or without preoperative cardiac dysfunction.

METHODS

Haemodynamic, metabolic and tonometric variables were measured in seven patients with Crohn's disease and in five patients with chronic heart failure scheduled for abdominal surgery. Data were collected before skin incision (T0); at extractor placement (T1), 30 (T2) and 60 (T3) min later; at organ extraction (T4), 30 (T5) and 60 (T6) min later, and at the end of surgery (T7).

RESULTS

Gradients appeared larger in the cardiac group. The difference was significant for Pg-ETCO2 during the whole study period, while it was only reached at T1-T2 for Pa-ETCO2 and at T5-T6 for Pg-aCO2. Gaps did not change significantly over the peroperative time points in either group. No major haemodynamic variations were registered in either group.

CONCLUSIONS

In patients with preoperative chronic heart failure, Pg-ETCO2 remained constant throughout a major general surgical procedure and was only moderately influenced by the Pa-ETCO2 gap. In these patients, Pg-ETCO2 may be used as a reliable index of gastrointestinal perfusion after control of PaCO2.

Ondansetron disintegrating tablets of 8 mg twice a day for 3 days did not reduce the incidence of nausea or vomiting after laparoscopic surgery

BACKGROUND AND OBJECTIVE

Although many antiemetic drugs are available for intravenous use in the hospital setting, few are available after patient discharge. Consequently, nausea and vomiting are frequent complaints from patients at home after ambulatory surgery. We tested the hypothesis that the new 8 mg ondansetron disintegrating tablets will decrease the rate of nausea and vomiting at home after laparoscopic surgery.

METHODS

Ninety-six patients were studied in a randomized double-blind study. Starting the first evening after operation and continuing every 12 h for 3 days, patients received either placebo or ondansetron 8 mg disintegrating tablets orally. The patients returned a questionnaire about postoperative nausea and vomiting, other side-effects, e.g. dizziness, headache, nightmare, anxiety and pain, as well as their overall satisfaction at 24 and 72 h after completion of surgery.

RESULTS

The rates of nausea and vomiting were similar in the two groups, both during the first 24 h (28 versus 48%, placebo and ondansetron, respectively (ns) and during the 24-72 h (21 versus 35% (ns)). The incidence rate of vomiting was 8% (placebo) versus 12% (ondansetron) during the first 24 h (ns) and 9 versus 13% respectively in the 24-72 h (ns). No difference between groups was observed in overall satisfaction, incidence of postoperative pain or other side-effects.

CONCLUSIONS

The use of ondansetron disintegrating tablets of 8 mg twice a day for 3 days did not reduce the incidence of nausea and vomiting in patients undergoing outpatient laparoscopic surgery.

Effects of xenon on mesenteric blood flow

BACKGROUND AND OBJECTIVE

The effects of xenon on mesenteric vascular resistance have not been investigated. Because human beings anaesthetized with xenon show good cardiovascular stability, we believed that the agent would have little or no effect on vascular resistance in the splanchnic bed. We determined the effects of different inhaled xenon concentrations on mesenteric blood flow and mesenteric oxygen consumption in pigs sedated with intravenous propofol.

METHODS

Twenty-three minipigs were instrumented with transit time flow probes around the pulmonary and superior mesenteric arteries as well as with pulmonary artery and portal venous catheters. A 14 h recovery was allowed followed by recordings of baseline values. Xenon was then randomly administered in 0.30, 0.50, and 0.70 end-tidal fractions.

RESULTS

The administration of xenon resulted in an 8% (not dose dependent) decrease in mean arterial pressure (from 99 +/- 15 to 91 +/- 19 mmHg; P < 0.05), a 20% decrease in calculated systemic oxygen consumption (from 0.23 +/- 0.07 to 0.19 +/- 0.04L min(-1); P < 0.01), a 20% reduction in mesenteric oxygen delivery (from 41 +/- 12 to 33 +/- 11 mL min; P < 0.001), a 37% reduction in mesentericmetabolic rate of oxygen (from 11.3 +/- 3.6 to 7.1 +/- 3.2 mL min(-1); P < 0.01) and an 8% decrease in mesenteric artery blood flow (0.22 +/- 0.07 to 0.20 +/- 0.07 L min(-1); P < 0.05) in a dose-dependent fashion. Heart rate, cardiac output, systemic vascular resistance, mesenteric vascular resistance, mesenteric oxygen extraction fraction and portal lactate concentration were not significantly altered by xenon.

CONCLUSIONS

Xenon inhalation in the propofol-sedated pig had no measurable effects on mesenteric vascular resistance. This finding may partly explain the well-known cardiovascular stability observed in patients anaesthetized with xenon. Although mesenteric artery blood flow and mesenteric oxygen delivery decreased during xenon administration, unchanged mesenteric oxygen extraction fraction and portal lactate suggest that metabolic regulation of the splanchnic circulation remained unaltered.

Dopamine stabilizes milrinone-induced changes in heart rate and arterial pressure during anaesthesia with isoflurane

BACKGROUND AND OBJECTIVE

Phosphodiesterase-III inhibitors and dobutamine effectively improve cardiac function in patients with cardiac failure, but they are limited by possible hypotensive effects. We tested the hypothesis that dopamine contributes to stabilizing milrinone-induced haemodynamic changes.

METHODS

Nine patients undergoing major surgery were anaesthetized using nitrous oxide and oxygen supplemented with isoflurane 1-2%. After baseline haemodynamics were recorded, milrinone (25 or 50 microg kg(-1)) was administered over 10min, followed by a continuous infusion (0.5 microg kg(-1) min(-1). The second set of haemodynamic values was measured 50 min after beginning the continuous infusion of milrinone. Dopamine (4 microg kg(-1) min(-1)) was then administered with milrinone.

RESULTS

Milrinone significantly increased the heart rate from 81 +/- 8 to 102 +/- 16beats min(-1), but it decreased the mean arterial pressure from 83 +/- 10 to 66 +/- 10 mmHg and systemic vascular resistance (P < 0.05 for each). The pulmonary capillary wedge pressure, cardiac index and pulmonary vascular resistance did not change significantly. The addition of dopamine to the milrinone infusion significantly decreased the heart rate (94 +/- 12 beats min(-1)) and increased the mean arterial pressure (82 +/- 11 mmHg). Dopamine and milrinone, but not milrinone alone, significantly increased the cardiac index and the rate-pressure product.

CONCLUSIONS

The combination regimen of milrinone and dopamine improved cardiac function, and changes in heart rate and mean arterial pressure induced by milrinone were attenuated by dopamine. The results suggest that a combination regimen of milrinone and dopamine rather than milrinone alone should be used to maintain arterial pressure.

Diastolic dysfunction is predictive of difficult weaning from cardiopulmonary bypass

Diastolic function is receiving more attention since echocardiographic measurements were developed and have become widely available. The importance and significance of diastolic dysfunction (DD) observed before cardiac surgery and its relationship with adverse outcomes, such as difficult separation from cardiopulmonary bypass (CPB), have not been fully explored. In this study, we hypothesize that DD can be a predictor for the need of inotropic support to successfully separate from CPB. Ninety-two consecutive patients underwent surgery during the study period. Twenty-six patients were excluded. From the remaining 66 patients, 52 had coronary artery bypass grafting alone and 14 combined procedures, valvular surgery, and reoperations (redo). Systolic and diastolic function was evaluated by two experts blinded as to the clinical data except for the age. The evaluation of diastolic function was done according to published guidelines. The demographic, echocardiographic, and hemodynamic variables were entered in a logistic regression analysis to determine which variables were independent predictors of difficult separation from CPB and the need for postoperative vasoactive support. DD was present in 20 patients (30%). Patients with DD had lower weight (P = 0.046), less frequent coronary artery bypass grafting alone (P = 0.0004), more myocardial infarction before surgery (P = 0.02), higher regional wall motion score index (P = 0.0002), and larger left ventricle (P = 0.03). Total CPB time (P = 0.004) and ischemic time (P = 0.007) were longer in the DD group. Patients with DD required more frequent inotropic support at the end of surgery (P = 0.006) and up to 12 h after surgery (P = 0.003). Multivariate logistic regression identified female sex, DD, and total CPB time as predictive of difficult weaning and inotropic requirements up to 12 h after surgery.

Diastolic dysfunction is predictive of difficult weaning from cardiopulmonary bypass

Diastolic function is receiving more attention since echocardiographic measurements were developed and have become widely available. The importance and significance of diastolic dysfunction (DD) observed before cardiac surgery and its relationship with adverse outcomes, such as difficult separation from cardiopulmonary bypass (CPB), have not been fully explored. In this study, we hypothesize that DD can be a predictor for the need of inotropic support to successfully separate from CPB. Ninety-two consecutive patients underwent surgery during the study period. Twenty-six patients were excluded. From the remaining 66 patients, 52 had coronary artery bypass grafting alone and 14 combined procedures, valvular surgery, and reoperations (redo). Systolic and diastolic function was evaluated by two experts blinded as to the clinical data except for the age. The evaluation of diastolic function was done according to published guidelines. The demographic, echocardiographic, and hemodynamic variables were entered in a logistic regression analysis to determine which variables were independent predictors of difficult separation from CPB and the need for postoperative vasoactive support. DD was present in 20 patients (30%). Patients with DD had lower weight (P = 0.046), less frequent coronary artery bypass grafting alone (P = 0.0004), more myocardial infarction before surgery (P = 0.02), higher regional wall motion score index (P = 0.0002), and larger left ventricle (P = 0.03). Total CPB time (P = 0.004) and ischemic time (P = 0.007) were longer in the DD group. Patients with DD required more frequent inotropic support at the end of surgery (P = 0.006) and up to 12 h after surgery (P = 0.003). Multivariate logistic regression identified female sex, DD, and total CPB time as predictive of difficult weaning and inotropic requirements up to 12 h after surgery.