Persistent endocrine stress response in patients undergoing cardiac surgery

Analysis of Efficacy and Safety of Laparoscopy Plus Choledochoscopy Combined With Holmium Laser Lithotripsy for Choledocholithiasis and Hepatolithiasis

Background

With the advancement of laparoscopic technology, the combination of laparoscopy, choledochoscopy, and holmium laser lithotripsy has emerged as an effective treatment modality for both choledocholithiasis and hepatolithiasis. This study aimed to assess the efficacy and safety of this approach.

Methods

Retrospective analysis was conducted on the medical records of 76 patients diagnosed with choledocholithiasis and hepatolithiasis between April 2021 and March 2023. Patients were divided into two groups based on the treatment plan: the control group, which underwent traditional laparotomy and choledochoscopy lithotripsy (n = 38), and the experimental group, which underwent laparoscopy combined with choledochoscopy and holmium laser lithotripsy (n = 38). Comparative analysis was performed on various operation-related parameters, stone-free rate, complication rates, and changes in biochemical, liver function, inflammatory, stress response indicators, and pain scores between the two groups.

Results

The experimental group demonstrated significantly shorter stone removal time, reduced intraoperative bleeding, and shorter hospital stay compared to the control group (P < 0.05). Moreover, the experimental group exhibited lower incidence of postoperative complications and lower pain scores at 2 weeks to 3 months post-operation (P < 0.05). Biochemical indicators including total bile acid (TBA), total bilirubin (TBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and glutamyl transpeptidase (GGT) were significantly lower in the observation group compared to the control group (P < 0.05). Additionally, stress and inflammation indicators were also lower in the experimental group (P < 0.05).

Conclusions

The combination of laparoscopy, choledochoscopy, and holmium laser lithotripsy presents favorable therapeutic outcomes in the management of choledocholithiasis and hepatolithiasis, indicating its potential for widespread clinical application.

Reduction of postoperative nausea and vomiting risk in the second stage during bilateral total knee arthroplasty with a 1-week interval

PURPOSE

Total knee arthroplasty (TKA) is often performed sequentially on both sides during a single hospital stay. Patients who experience postoperative nausea and vomiting (PONV) after the first operation are concerned about PONV recurrence after the second operation. However, there are few studies regarding the incidence of PONV in staged bilateral TKA with a ≥ 1-week interval. This study aimed to identify the differences in (1) PONV incidence, (2) use of rescue antiemetics, and (3) the amount of opioid consumption between the first and second operations for staged bilateral TKA with a 1-week interval. Based on our anecdotal experience, the hypothesis of this study was that during staged bilateral TKA at a 1-week interval, the PONV incidence and rescue antiemetic requirement after the second operation will be lower than those after the first operation, regardless of opioid consumption.

METHODS

Fifty-eight consecutive patients who underwent staged bilateral TKA with a 1-week interval were retrospectively reviewed. All second-stage operations were performed with the same anaesthesia protocol and perioperative patient management protocol as the first-stage operation. PONV incidence was the primary outcome. The requirement for rescue antiemetic drugs and the amount of opioid consumption were secondary outcome variables. The outcome variables were recorded during three postoperative days (Days 0-2) for each stage and were compared between the first and second operations.

RESULTS

The incidence rates of nausea and vomiting on Day 0 (p = 0.001 and p = 0.004, respectively) and nausea on Day 1 (p = 0.008) were significantly lower after the second operation. Rescue antiemetic use on Day 0 was significantly lower after the second operation (p = 0.001). The total opioid consumption 72 h after surgery was significantly higher after the second operation (61.76 vs. 34.28 mg, p < 0.001).

CONCLUSION

During staged bilateral TKA with a 1-week interval, PONV incidence was lower after the second operation, even with increased opioid consumption.

LEVEL OF EVIDENCE

III.

Effects of Preoperative Psychological Interventions on Catecholamine and Cortisol Levels After Surgery in Coronary Artery Bypass Graft Patients: The Randomized Controlled PSY-HEART Trial

OBJECTIVE

The aim of the study was to examine whether preoperative psychological interventions targeting patients' expectations are capable of influencing the biological stress response after coronary artery bypass graft (CABG) surgery and could thus improve recovery after heart surgery.

METHODS

Randomized controlled trial with assessments 10 days before surgery, after psychological intervention (day of hospital admission, but before surgery), postoperative (6-8 days later), and at follow-up (6 months after surgery). Eligible patients (N = 124) scheduled for elective on-pump CABG or CABG with valve replacement surgery were approached before hospital admission. Standard medical care (SMC) was compared with two additional preoperative psychological interventions: (a) an expectation manipulation intervention to optimize patients' expectations about course and outcomes or (b) supportive therapy, containing the same amount of therapeutic attention, but without specifically focusing on expectations. Postoperative plasma adrenaline, noradrenaline, and cortisol levels were a secondary outcome of our study (primary outcome patients' disability 6 months after surgery and other secondary patient-reported or clinical outcomes were reported elsewhere).

RESULTS

Expectation manipulation intervention (3.68 ln pg/mL, 95% confidence interval = 3.38-3.98, p = .015) and supportive therapy (3.70 ln pg/mL, 95% confidence interval = 3.38-4.01, p = .026) led to significantly lower postoperative adrenaline levels compared with SMC (4.26 ln pg/mL, 95% confidence interval = 3.99-4.53) only. There were no treatment effects of the preoperative intervention for noradrenaline (p = .90) or cortisol (p = .30). Higher postoperative adrenaline levels predicted disability 6 months after surgery (r = .258, p = .018).

CONCLUSIONS

In addition to SMC, preoperative psychological interventions seem to buffer psychobiological stress responses and could thus facilitate recovery from CABG surgery. Patients' postoperative stress responses could be an important factor for explaining trajectories of long-term outcomes.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov(NCT01407055).

Addressing the Global Burden of Trauma in Major Surgery

Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.

Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review

BACKGROUND

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

METHODS

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

RESULTS

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

CONCLUSION

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

The role of different anesthetic techniques in altering the stress response during cardiac surgery in children: a prospective, double-blinded, and randomized study

OBJECTIVES

Our goal was to evaluate the role of three anesthetic techniques in altering the stress response in children undergoing surgery for repair of congenital heart diseases utilizing cardiopulmonary bypass in the setting of fast tracking or early tracheal extubation. Furthermore, we wanted to evaluate the correlation between blunting the stress response and the perioperative clinical outcomes.

DESIGN

Prospective, randomized, double-blinded study.

SETTING

Single center from December 2008 to May of 2011.

PATIENTS

Forty-eight subjects (low-dose fentanyl plus placebo, n = 16; high-dose fentanyl plus placebo, n = 17; low-dose fentanyl plus dexmedetomidine, n = 15) were studied between ages 30 days to 3 years old who were scheduled to undergo repair for a ventricular septal defect, atrioventricular septal defect, or Tetralogy of Fallot.

METHODS

Children undergoing surgical repair of congenital heart disease were randomized to receive low-dose fentanyl (10 mcg/kg; low-dose fentanyl), high-dose fentanyl (25mcg/kg; high-dose fentanyl), or low-dose fentanyl plus dexmedetomidine (as a 1 mcg/kg loading dose followed by infusion at 0.5mcg/kg/hr until separation from cardiopulmonary bypass. In addition, patients received a volatile anesthetic agent as needed to maintain hemodynamic stability. Blood samples were tested for metabolic, hormonal and cytokine markers at baseline, after sternotomy, after the start of cardiopulmonary bypass, at the end of the procedure and at 24 hours postoperatively.

MEASUREMENTS AND MAIN RESULTS

Forty-eight subjects (low-dose fentanyl plus placebo, n = 16; high-dose fentanyl plus placebo, n = 17; low-dose fentanyl plus dexmedetomidine, n = 15) were studied. Subjects in the low-dose fentanyl plus placebo group had significantly higher levels of adrenocorticotropic hormone, cortisol, glucose, lactate, and epinephrine during the study period. The lowest levels of stress markers were seen in the high-dose fentanyl plus placebo group both over time (adrenocorticotropic hormone, p= 0.01; glucose, p = 0.007) and at individual time points (cortisol and lactate at the end of surgery, epinephrine poststernotomy; p < 0.05). Subjects in the low-dose fentanyl plus dexmedetomidine group had lower lactate levels at the end of surgery compared with the low-dose fentanyl plus placebo group (p < 0.05). Although there were no statistically significant differences in plasma cytokine levels between the three groups, the low-dose fentanyl plus placebo group had significantly higher interleukin-6:interleukin-10 ratio at 24 hours postoperatively (p < 0.0001). In addition, when compared with the low-dose fentanyl plus placebo group, the low-dose fentanyl plus dexmedetomidine group showed a lower norepinephrine level from baseline at poststernotomy, after the start of cardiopulmonary bypass, and at the end of surgery (p ≤ 0.05). Subjects in the low-dose fentanyl plus placebo group had more postoperative narcotic requirement (p = 0.004), higher prothrombin time (p ≤ 0.03), and more postoperative chest tube output (p < 0.05). Success of fast tracking was not significantly different between groups (low-dose fentanyl plus placebo 75%, high-dose fentanyl plus placebo 82%, low-dose fentanyl plus dexmedetomidine 93%; p = 0.39).

CONCLUSIONS

The use of low-dose fentanyl was associated with the greatest stress response, most coagulopathy, and highest transfusion requirement among our cohorts. Higher dose fentanyl demonstrated more favorable blunting of the stress response. When compared with low-dose fentanyl alone, the addition of dexmedetomidine improved the blunting of the stress response, while achieving better postoperative pain control.

Statin withdrawal after major noncardiac surgery: risks, consequences, and preventative strategies

BACKGROUND

A growing body of research suggests that statins improve perioperative cardiac outcomes by attenuating inflammation. Conversely, some studies suggest that withdrawal of statins after surgery results in an upsurge of inflammation and adverse cardiac outcomes.

METHODS

We performed a literature search using multiple medical databases to examine the basic, clinical, and experimental evidence supporting the existence of a statin withdrawal state. Studies examining outcomes associated with statin withdrawal were narratively synthesized.

RESULTS

Published evidence suggests that statin withdrawal is associated with worse cardiac outcomes in a variety of scenarios, including acute coronary syndrome, ischemic stroke, and surgery. Although certain reasons for postoperative statin cessation are difficult to avoid (eg, ileus after surgery), we posit that many perioperative clinicians may be unaware of the importance of statin resumption in a timely fashion. This lack of awareness translates into preventable harm and an opportunity for outcome improvement. We introduce innovative practices through which perioperative practitioners may prevent statin discontinuation.

CONCLUSIONS

Ensuring the resumption of statins after surgery should become routine practice for perioperative providers. We highlight knowledge gaps and identify a research agenda aimed at better understanding this practice.

Modulation of the cellular and humoral immune response to pediatric open heart surgery by methylprednisolone

BACKGROUND

With the intention to reduce overshooting immune response, glucocorticoids are frequently administered perioperatively in children undergoing open heart surgery. In a retrospective study we investigated extensively the modulation of the humoral and cellular immune response by methylprednisolone (MP).

METHODS

This study was carried out on blood samples from two groups of children who had undergone surgical correction of atrial or ventricular septal defects, either without (MP⁻, n = 10), or with MP administration (MP+, n = 23, dose median 11 (IQR 10-16) mg kg⁻¹ body weight) before cardiopulmonary bypass (CPB, duration median 42 (IQR 36-65) min). EDTA blood was obtained 24 h preoperatively, after anesthesia, at CPB begin and end, 4, 24, and 48 h after surgery, at discharge and at out-patient follow-up (median 8.2 (IQR 3.3-12.2) months after surgery). Complex blood analysis including clinical chemistry and flow cytometry were performed to monitor humoral immune response, differential blood count, lymphocyte subsets, and the degree of activation of various leukocyte subpopulations.

RESULTS

The patients' postoperative courses and follow-up were uneventful. Release of IL-6 and IL8 was reduced and that of the anti-inflammatory cytokine IL-10 upregulated by MP. Significant increase of circulating neutrophils and monocytes as inflammatory reaction to surgery and CPB contact was detected in both groups. However, invasion of monocytes to the periphery was delayed with MP. CD4+ and CD8+ T-lymphocyte counts were lower with MP treatment. B-lymphocyte count increased significantly after surgery in MP+ but remained constant in MP⁻ group.

CONCLUSIONS

MP treatment partially decreased the pro-inflammatory effect of CPB surgery and induced anti-inflammatory effect on the cellular and humoral level.

Perioperative beta-blockers for major noncardiac surgery: Primum Non Nocere

Recent studies have called into question the benefit of perioperative beta blockade, especially in patients at low to moderate risk of cardiac events. Once considered standard of care, the role of beta-blocker therapy now lies mired in conflicting data that are difficult to apply to the at-risk patient. We provide an overview of the evolution of perioperative beta blockade, beginning with the physiology of the adrenergic system, with emphasis on the biologic rationale for the perioperative implementation of beta-blockers. Although initial studies were small in size and statistically limited, early data showed cardiac benefit with the use of perioperative beta-blockers. However, larger, more recent studies now suggest a lack of benefit and potential harm from this practice. This paradigm holds true especially in those at low-to-moderate cardiovascular risk profiles. Potential explanations for these paradoxical results are discussed, stressing the key differences between earlier and current studies that may explain these divergent outcomes. We conclude by commenting on performance measures as they relate to perioperative beta-blockers and make recommendations for the continued safe implementation of this practice.

Sedation practice in the intensive care unit: a UK national survey

INTRODUCTION

The purpose of this study was to evaluate sedation practice in UK intensive care units (ICUs), particularly the implementation of daily sedation holding, written sedation guidelines, sedation scoring tools and choice of agents.

METHODS

A national postal survey was conducted in all UK ICUs.

RESULTS

A total of 192 responses out of 302 addressed units were received (63.5%). Of the responding ICUs, 88% used a sedation scoring tool, most frequently the Ramsey Sedation Scale score (66.4%). The majority of units have a written sedation guideline (80%), and 78% state that daily sedation holding is practiced. A wide variety of sedating agents is used, with the choice of agent largely determined by the duration of action rather than cost. The most frequently used agents were propofol and alfentanil for short-term sedation; propofol, midazolam and morphine for longer sedation; and propofol for weaning purposes.

CONCLUSIONS

Most UK ICUs use a sedation guideline and sedation scoring tool. The concept of sedation holding has been implemented in the majority of units, and most ICUs have a written sedation guideline.

Sedation and analgesia in the intensive care unit

PURPOSE OF REVIEW

Sedation and analgesia are important means of providing care for the critically ill patient.

RECENT FINDINGS

It is now clear that posttraumatic stress disorders resulting from an intensive care unit stay may be prevented by the right level of sedation. New drug developments but also recent findings in new ventilation strategies allow for a sedation management that is better tailored to an individual's need. Most importantly, regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level will help to avoid over- and undersedation and may ultimately improve the outcome of the patient and reduce costs.

SUMMARY

Sedation and analgesia are now regarded as an integral part of treatment on the intensive care unit instead of being an unpleasant but necessary and minor issue. The importance of monitoring the level of sedation and analgesia has only recently been realized. It remains to be shown that new management strategies including an evaluation of the patient, planned interventions and the choice of drugs will further improve the care for the critically ill.

Intraoperative Management of Hyperglycemia in the Cardiac Surgical Patient

The stress response of cardiac surgery leads to hyperglycemia, and undergoing cardiopulmonary bypass magnifies this response greatly. Counter-regulatory hormones, the cytokine response, and the automatic nervous system are all part of the coordinated host response that can lead to hyperglycemia. Postoperative hyperglycemia is associated with worsened perioperative outcomes, and there are data demonstrating this to also be true for the intraoperative period. Many factors affect intraoperative glucose control, including cardiopulmonary pump (CPB) prime fluid composition, temperature while on CPB, and medications such as catecholamines and glucocorticoids. Intraoperative glucose control has a significant impact on postoperative outcomes. No optimal intraoperative insulin regimen has been identified, but continuous intravenous infusions appear to be superior to intermittent sliding scale dosing. In addition, the technique of hyperinsulinemic glucose clamp shows the greatest promise of achieving normoglycemia while on CPB.

Systemic Stress Hormone Response in Patients Undergoing Open Heart Surgery With or Without Cardiopulmonary Bypass

BACKGROUND

Cardiopulmonary bypass often causes a stress hormonal response with subsequent changes in hemodynamics and organ perfusion. Leptin, an adipocyte-derived factor, has been proposed to play a role in systemic inflammation. We examined perioperative release of leptin and cortisol in patients undergoing open heart surgery with or without cardiopulmonary bypass.

METHODS

Forty-nine patients were enrolled in this prospective study. Conventional coronary artery bypass grafting was performed in 19 patients (ONCABG; group I), and heart valve surgery in 15 patients (group II). Fifteen patients (group III) received off-pump coronary artery bypass grafting (OPCABG). Blood samples were collected preoperatively and for as long as 72 hours postoperatively. Plasma levels of leptin and cortisol were measured by enzyme-linked immunosorbent assay.

RESULTS

Leptin serum levels decreased during the operation, reaching 73.2% of the baseline in group I, 85.3% in group II, and 38.9% in group III (p < 0.05), 2 hours postoperatively. Thereafter, leptin levels increased gradually to 218.6% of the baseline in group I and 313.7% in group II 24 hours after the operation (p < 0.01). However, patients in the OPCABG group showed only a moderate increase in serum leptin levels. Plasma cortisol levels rose to a maximum of 532.9% of baseline in group I, 526.4% in group II, and 280% in group III 12 hours postoperatively (p < 0.01).

CONCLUSIONS

Open heart surgery is associated with acute perioperative changes in plasma levels of neurohormonal stress factors leptin and cortisol. A different pattern of leptin and cortisol release was observed in patients operated on without cardiopulmonary bypass.

Monitoring consciousness in intensive care medicine

Sedation and analgesia are important components of care for critically ill patients. Avoiding over-as well as undersedation is of utmost importance as both states carry considerable risks and may influence outcome. The management of sedation has changed dramatically over the past two decades from providing a dosage level by which the patient was kept in a deep stage of anaesthesia to a current dosing strategy allowing the administration of drugs in line with individual need, resulting in most cases in a slightly sedated, cooperative patient. The importance of monitoring the level of sedation and analgesia has only recently been realised. Most importantly, regularly determining the appropriate level of sedation and analgesia as well as monitoring the desired level of sedation will help to minimise the adverse effects of sedation. Clinical sedation scales are, however, subjective, and most lack proper validation. Thus, an objective measure of sedation, such as the use of processed electroencephalogram (EEG) parameters is desirable. Processed EEG algorithms such as the bispectral index were initially introduced into clinical practice as a tool to assess the depth of anaesthesia objectively in the operating room. However, patients under general anaesthesia differ from those in an intensive care unit. Accordingly, most results from studies evaluating the performance of processed EEG parameters in critically ill patients have not been satisfactory. At present, monitoring sedation with processed EEG parameters cannot generally be recommended. However, in special situations such as deep sedation and neuromuscular blockade, in which clinical sedation scales are prone to failure, the bispectral index may help to assess the level of sedation.

Clinical evaluation of hormonal stress state in medical ICU patients: a prospective blinded observational study

OBJECTIVE

To evaluate whether classification of patients as having low, moderate, or high stress based on clinical parameters is associated with plasma levels of stress hormone.

DESIGN AND SETTING

Prospective, blinded, observational study in an 18-bed medical ICU.

PATIENTS

Eighty-eight consecutive patients.

INTERVENTIONS

Patients were classified as low (n=28), moderate (n=33) or high stress (n=27) on days 0 and 3 of ICU stay, based on 1 point for each abnormal parameter: body temperature, heart rate, systemic arterial pressure, respiratory rate, physical agitation, presence of infection and catecholamine administration. The stress categories were: high: 4 points or more, moderate 2-3 points, low 1 point. Plasma growth hormone (GH), insulin-like growth factor 1 (IGF-1), insulin, glucagon, cortisol were measured on days 0 and 3.

MEASUREMENTS AND RESULTS

Plasma cortisol and glucagon were significantly higher and IGF-1 lower in high vs. low stress patients on days 0 and 3. High stress patients were more likely to have high cortisol levels (odds ratio 5.8, confidence interval 1.8-18.9), high glucagon (8.7, 2.1-36.1), and low IGF-1 levels (5.9, 1.8-19.0) than low stress patients on day 0. Moderate stress patients were also more likely to have high cortisol and glucagon levels than low stress patients. Insulin and GH did not differ significantly. Results were similar for day 3.

CONCLUSIONS

Moderate and severe stress was significantly associated with high catabolic (cortisol, glucagon) and low anabolic (IGF-1) hormone levels. The hormonal stress level in ICU patients can be estimated from simple clinical parameters during routine clinical evaluation.

Acute changes in circulating hormones in older patients with impaired ventricular function undergoing on-pump coronary artery bypass grafting

OBJECTIVES

Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) causes an acute stress response characterized by changes in the levels of several hormones, which might play a role in the high complication rate experienced by older patients after CABG. Thus, the aim of the study was to investigate changes in the circulating levels of anabolic and catabolic hormones in old people undergoing CABG with CPB.

DESIGN

Intervention case study.

METHODS

19 patients (12 males, 7 females) aged 70.1 +/- 6.1 yr (age range 62-80) with coronary artery disease and an ejection fraction <40% who underwent cardiac surgery. Cortisol (Cort), DHEA, DHEAS, LH, estradiol (E2), total testosterone (Te), SHBG, IGF-I were measured the day before, on the day of the procedure and 1, 2, 3, 4, and 30 days after CABG.

RESULTS

After surgery, serum IGF-I levels decreased (p<0.001), while levels of Cort, DHEAS and E2 significantly increased in both men and women. Alterations in Te levels differed between the two sexes with a significant decline in men and a significant increment in women.

CONCLUSION

CABG with CPB resulted in a dramatic drop in Te levels in old men and a significant decline in IGF-I in both sexes. Serum Cort levels also significantly increased in both sexes. These hormonal changes may, at least partially, explain why the elderly need prolonged rehabilitation after CABG.

Cortisol antiinflammatory effects are maximal at postoperative plasma concentrations*

OBJECTIVE

To determine the plasma concentration of cortisol that is needed for maximal suppression of the systemic inflammatory response to cardiac surgery with cardiopulmonary bypass.

DESIGN

Prospective, randomized, double-blind clinical study of cardiac surgical patients.

SETTING

Operating room and inpatient care facility of a university medical center.

SUBJECTS

Sixty elective cardiac surgical patients scheduled for coronary artery bypass graft, cardiac valve replacement, or both.

INTERVENTIONS

Patients were randomized to receive one of three different hydrocortisone doses, by intravenous infusion, for 6 hrs before, during, and immediately after surgery while also receiving etomidate to suppress endogenous cortisol production.

MEASUREMENTS AND MAIN RESULTS

Serial determinations of plasma interleukin-6 were studied as a marker of systemic inflammation. Measurements of interleukin-10 were used as a marker of the compensatory antiinflammatory response. Plasma cortisol concentrations in an untreated control group rose from 17 microg/dL before surgery to a mean of 43 microg/dL by 4 hrs after surgery. A dose of hydrocortisone (4 microg/kg/min for 6 hrs) that maintained plasma cortisol between 40 and 50 microg/dL, starting 60-90 mins before surgery, significantly suppressed plasma interleukin-6 after surgery compared with control while significantly increasing plasma interleukin-10 during surgery. Plasma interleukin-6 after surgery was not suppressed further by increasing the dose of hydrocortisone to 8 microg/kg/min, although the mean peak plasma interleukin-10 concentration increased further compared with the group that received the 4 microg/kg/min hydrocortisone dose.

CONCLUSIONS

At the doses studied, cortisol-induced suppression of plasma interleukin-6 during and after cardiac surgery appears to be a saturable phenomenon at the concentration of plasma cortisol that is normally achieved after surgery in untreated patients.

Analgesie und Sedierung in der Intensivmedizin

Sedation and analgesia are relevant aspects for the adequate treatment of patients in an intensive care unit. Recent drug developments and new strategies for ventilation provide improved sedation management allowing better adaptation to the clinical background and individual needs of the patient. This article provides an overview on the application of different substance groups. Focus is placed on newly developed pharmaceuticals such as dexmedetomidine. Another aspect is scoring system-related and EEG-based monitoring of depth of sedation. Modern concepts of analgesia and sedation for ICU patients have been developed based on the interaction of different parameters such as adaptive sedation and analgesia management (ASAM).

Perioperative stress response to carotid endarterectomy: The impact of anesthetic modality

OBJECTIVE

Surgery for extracranial carotid artery disease has been challenged by carotid angioplasty stenting because the latter is less invasive and avoids surgical trauma. In fact, the magnitude of the perioperative stress response evoked by carotid endarterectomy (CEA) has never been evaluated. Our aim was to determine the degree of surgical trauma caused by CEA and to define differences related to the use of locoregional or general anesthesia.

METHODS

We prospectively studied 113 consecutive CEAs performed on 109 patients admitted at a community institutional center. Patients were stratified for demographics and risk factors and operated on under locoregional (LA) or general anesthesia (GA) depending on both the surgeon preference and patient's compliance. Selective carotid shunting was performed for patients who manifested neurologic deficits under LA or had stump pressure values </=30 mm Hg under GA. Markers of the stress response, including cortisol, adrenocorticotropic hormone, prolactin, and C-reactive protein, were measured intraoperatively, before and after carotid artery cross-clamping (CACC), and postoperatively up to the third day after surgery. Hemodynamic variability was assessed during surgery and for 24 hours postoperatively. Operative times were also measured. Surgeons were considered as independent variables for stress response. Statistics were run by means of nonparametric tests and univariate and multivariate analysis with a linear regression model.

RESULTS

CEA was performed under GA in 63 cases (55.8%) and under LA in 50 (44.2%). The two groups were comparable in terms of demographics and risk factors. Intraoperatively, cortisol and adrenocorticotropic hormone levels were significantly higher in the LA group (both P <.001). CACC increased the intraoperative cortisol levels in both the GA (P =.019) and the LA groups (P =.006). However, in patients who underwent carotid shunting, this effect was abolished (GA group, P =.779; LA group, P = 1.0). During the early postoperative period there was no difference between the two groups. On postoperative day 1 the stress response was abolished in both groups. Prolactin levels increased intraoperatively in both the LA and GA groups and returned within preoperative values on postoperative day 1. Prolactin levels were higher in the GA group (P =.003 intraoperatively and P <.001 postoperatively). C-reactive protein significantly increased in both GA and LA groups on postoperative days 1 and 2 and started to decrease on day 3 with no differences between the two groups at any time. Hemodynamic variability and considered risk factors including individual surgeon were not significant variables. Gender-related differences were found only in prolactin secretion. The length of surgery had an impact for procedures that lasted >120 minutes. Three patients experienced an intraoperative neurologic event and had higher post-CACC cortisol values as compared to asymptomatic patients.

CONCLUSIONS

Intraoperative surgical stress was higher under LA and was blunted by carotid shunting under both LA and GA. Within 2 hours after surgery the anesthetic modality no longer had any impact on surgical trauma. The stress response to CEA, regardless of the type of anesthesia, was abolished within 24 hours. Intraoperative stress response, namely hypercortisolemia, directly correlated with subclinical and clinical cerebral hypoperfusion/ischemia during CACC. Hence, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events.

Psychological stress and fibromyalgia: a review of the evidence suggesting a neuroendocrine link

The present review attempts to reconcile the dichotomy that exists in the literature in relation to fibromyalgia, in that it is considered either a somatic response to psychological stress or a distinct organically based syndrome. Specifically, the hypothesis explored is that the link between chronic stress and the subsequent development of fibromyalgia can be explained by one or more abnormalities in neuroendocrine function. There are several such abnormalities recognised that both occur as a result of chronic stress and are observed in fibromyalgia. Whether such abnormalities have an aetiologic role remains uncertain but should be testable by well-designed prospective studies.

IL-7-mediated protection of pro and pre-B cells from the adverse effects of corticosterone

The studies herein demonstrate that Interleukin-7 (IL-7) promotes survival of murine pro- and pre-B cells against stress levels of corticosterone (Cs). In short-term, 16-h, bone marrow cultures IL-7 abrogated Cs-induced apoptosis and cell cycle arrest in pro-B cells by decreasing apoptosis 60% and completely restoring the cell cycle. IL-7 also reduced Cs-induced apoptosis by 36% in pre-B cells and 24% in IgM(+) B cells, but did not restore deficits in the cell cycle. Among pro- and pre- B cells, substantial protection against high, pharmacological, levels of Cs was also provided by IL-7. Interestingly, stem cell factor, while reducing spontaneous apoptosis in pro-B cells, did not protect against Cs-induced death, either alone or with IL-7. In conclusion, IL-7 has potential immunotherapeutic value since it provides substantial protection to pro- and pre-B cells against the adverse effects of Cs.

Perioperative melatonin secretion in patients undergoing coronary artery bypass grafting

Melatonin, a neurohormone, plays an important role in adjusting the "biological clock" in humans. We sought to describe perioperative patterns of melatonin secretion in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass (CPB). After IRB approval and written informed consent, 12 male patients scheduled for elective coronary artery bypass grafting under hypothermic CPB were enrolled in the study. During anesthesia, patients' eyes were carefully covered to prevent light effects. Blood samples were taken at specific time points during surgery, every 3 h in the immediate postoperative period, and for 24 h from 6:00 PM of Postoperative Day 2 until 6:00 PM of Postoperative Day 3. Plasma melatonin and cortisol concentrations were measured by radioimmunoassay and enzyme-linked immunosorbent assay, respectively. During surgery, plasma melatonin concentrations were below the minimum sensitivity concentration, yet small concentrations, without circadian variation, were detected during the immediate postoperative period. During Postoperative Days 2 and 3, circadian secretion patterns of melatonin were present in 10 patients and showed an inverse correlation with light intensity (r = 0.480; P < 0.01). Plasma cortisol concentrations in the immediate postoperative period were significantly larger than those before the induction of anesthesia (P < 0.01). Only three patients regained circadian secretion of cortisol. We concluded that melatonin and cortisol secretion was disrupted during cardiac surgery with CPB and in the immediate postoperative period. However, circadian rhythms of melatonin were present in most patients from Postoperative Day 2. Only 30% of the patients regained circadian rhythm of cortisol secretion.

IMPLICATIONS

Melatonin is a hormone that plays an important role in adjusting the biological clock in humans and that regulates secretion of various other hormones. We studied melatonin secretion in patients undergoing cardiac surgery with cardiopulmonary bypass. Melatonin secretion was disturbed during and immediately after surgery but had recovered a circadian rhythm 24 h later, raising the question of whether melatonin should be supplemented before cardiac surgery.

Circulating leptin and the perioperative neuroendocrinological stress response after pediatric cardiac surgery

OBJECTIVE

Leptin may be involved in the acute stress response, regulating inflammatory parameters of major importance after cardiopulmonary bypass (CPB) surgery. Critically ill patients demonstrated significant increases in leptin levels in response to stress-related cytokines (tumor necrosis factor, interleukin [IL]-1) and abolishment of the circadian rhythm of leptin secretion. We characterized the pattern of leptin secretion in the acute postoperative period in children undergoing cardiac surgery and compared the changes in leptin levels with concomitantly occurring changes in cortisol levels, IL-8, and clinical parameters.

DESIGN

Investigative study.

SETTING

University-affiliated tertiary care hospital.

PARTICIPANTS AND INTERVENTIONS

Twenty-nine consecutive patients, aged 6 days to 15 yrs, operated upon for the correction of congenital heart defects were studied. Surgery in 20 patients (group 1) involved conventional CPB techniques, and 9 (group 2) underwent closed-heart surgery. The time courses of leptin, cortisol, and IL-8 levels were determined. Serial blood samples were collected preoperatively, on termination of CPB, and at six time points postoperatively. Plasma was recovered immediately, aliquoted, and frozen at -70 degrees C until use.

MEASUREMENTS AND MAIN RESULTS

The leptin levels in group 1 decreased during CPB to 51% of baseline (p <.001), then gradually increased, reaching 120% of baseline levels at 12-18 hrs postoperatively (p <.001), returning to baseline levels at 24 hrs (p <.01). In patients undergoing closed-heart surgery (group 2), leptin levels displayed a pattern resembling the first group: they decreased during surgery to 71% of baseline levels (p =.002) and showed a tendency to return to baseline thereafter. All group 1 patients' cortisol levels increased significantly during the first hour of surgery, then decreased, returning to baseline levels at 18-24 hrs postoperatively. There was a significant negative correlation between leptin and cortisol levels (r = -2.8, p <.01). In group 2, cortisol levels increased during and after surgery, peaking 4 hrs postoperatively and decreasing thereafter. IL-8 levels determined in 15 group 1 patients increased significantly during CPB, peaked at the end of surgery, and then decreased but remained slightly elevated even at 48 hrs postoperatively. There was a significant correlation between cortisol and IL-8 levels (r = 2.55, p <.05). Children with leukocytosis, tachycardia, and hypotension had lower leptin levels and less variation over time as opposed to those with an uncomplicated course.

CONCLUSIONS

CPB is associated with acute changes in circulating leptin levels. These changes parallel those in cortisol, demonstrating an inverse relationship between leptin and cortisol. Further studies of the prognostic and therapeutic roles of leptin after CPB should be investigated.

Blood levels of atrial natriuretic peptide, endothelin, cortisol and ACTH in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass

Previous studies demonstrated a biphasic time course with post-operative dissociation of blood levels of cortisol and ACTH in patients undergoing major surgery and critically ill patients. A possible role of endothelin and atrial natriuretic peptide (ANP) in the dissociation of concentrations of cortisol and ACTH in critically ill patients has been suggested. In the present study, we investigated the perioperative course of blood levels of endothelin, ANP, ACTH, and cortisol in 13 male patients undergoing cardiac surgery with cardiopulmonary bypass (CPB): group 1 consisted of 7 patients with an uneventful perioperative period and group 2 consisted of 6 patients with perioperative complications. Blood samples were taken pre-[T1], intra-[T2], post-operatively (on the day of surgery) [T3], as well as on the first [T4] and second [T5] post-operative days. Blood samples of endothelin, ANP, cortisol, and ACTH were measured using commercially available immunoassays. Perioperatively, a biphasic time course with post-operative dissociation of ACTH and cortisol concentrations was observed in all patients studied. Intraoperatively, during CPB, the highest levels of endothelin were found. Perioperatively, ANP and endothelin levels were elevated compared to pre-operative values up to the second post-operative day. On the second post-operative day, ANP concentrations were significantly higher in patients with complications in the perioperative period compared to those with an uneventful perioperative period. Our results suggest that: 1) plasma levels of ANP increased in patients with perioperative complications; 2) plasma levels of ANP may have prognostic value for patients undergoing cardiac surgery; and 3) the dissociation of ACTH and cortisol cannot solely be explained by the increase in endothelin-1 and ANP concentrations observed in patients undergoing major surgery.

Sedative and analgesic practice in the intensive care unit: the results of a European survey

Sedation and analgesia are important aspects of patient care on the intensive care unit (ICU), yet relatively little information is available on common sedative and analgesic practice. We sought to assess international differences in the prescription of sedative and analgesic drugs in western European ICUs by means of a short, self-administered questionnaire. Six hundred and forty-seven intensive care physicians from 16 western European countries replied to the questionnaire. Midazolam was used as a sedative often or always by 63% of respondents and propofol by 35%. There were considerable international variations, with midazolam being preferred over propofol in France, Germany, the Netherlands, Norway and Austria. For analgesia, the drugs most commonly used were morphine (33%), fentanyl (33%) and sufentanil (24%). Morphine was preferred over fentanyl and sufentanil in Norway, UK and Ireland, Sweden, Switzerland, the Netherlands, and Spain and Portugal. Fentanyl was preferred in France, Germany and Italy. Sufentanil was preferred in Belgium and Luxemburg and in Austria. Multivariate analysis showed that the combination of midazolam with fentanyl was most often used in France; propofol with morphine in Sweden, the UK and Ireland, and Switzerland; midazolam with morphine in Norway; and propofol with sufentanil in Belgium and Luxemburg, Germany and Italy. The use of a sedation scale varied from 72% in the UK and Ireland to 18% in Austria. When used, the most common sedation scale was the Ramsay scale. This study demonstrates substantial international differences in sedative and analgesic practices in western European ICUs.

Minimal residual disease in thyroid carcinoma

The detection of disseminated tumor cells in differentiated (DTC) and medullary thyroid carcinomas (MTC) is one of the main topics in current thyroid cancer research. Immunocytochemistry and polymerase chain reaction (PCR) provide the tools for the identification of a small number of thyroid cancer cells in peripheral blood and cervical lymph nodes. Thyroid-specific markers, such as thyroglobulin (Tg) mRNA and thyroid peroxidase (TPO) mRNA, have been detected with RT-PCR in blood samples of tumor patients and healthy control subjects. To prevent false-positive results, quantitative PCR systems were established. Tumor-specific markers, such as telomerase activity and cytokeratin 20 (CK20), have been detected in various epithelial tumors. Amplification products of these markers were found in blood samples and in fine-needle aspiration (FNA) biopsies of patients with thyroid carcinomas. Using molecular detection of disseminated tumor cells in cervical lymph nodes with CK20 RT-PCR, a higher percentage of involved lymph nodes was detected compared to immunohistochemistry. The results of the presented studies may help researchers to develop more sensitive methods for early tumor cell dissemination, and refine risk groups that might benefit from more extensive surgical procedures or adjuvant therapy. However, the prognostic value of minimal residual disease (MRD) in thyroid carcinoma has to be confirmed in large or multicenter prospective studies.

Thoracoscopy as a nonpharmacotherapeutic research modification for limiting postoperative chest pain

Diminished tissue injury and shortened clinical recovery are benefits of using an endoscopic approach for patients needing operative procedure. In the course of developing an experimental model requiring procurement of topographically precise lung biopsy specimens, we sought to apply thoracoscopy as a research alternative to thoracotomy. In addition, we investigated the influence of thoracoscopy on postprocedure recovery practices using rabbits divided into four treatment groups. Rabbit groups 1 and 2 underwent thoracoscopy and lung biopsy while maintained by one-lung anesthesia. Additionally, group 2 had ketoprofen and bupivacaine HCl analgesics injected for treatment during postprocedure recovery. These two groups were compared to control rabbits in groups 3 and 4, which underwent inhalant anesthesia without thoracoscopy. Control group 3 also received the injection analgesic combination. During recovery, rabbit behavior was systematically assessed for evidence of pain. No behavior considered indicative of pain needing intervention was observed regardless of treatment group. Limited changes in plasma corticosterone, catecholamines, and prostaglandin E2 levels measured during recovery were difficult to associate with any treatment. Unexpectedly, significantly different mean corticosterone and catecholamines levels were detected in rabbits given the injection analgesic combination in the absence of thoracoscopic procedure, as compared to other treatment groups. The results highlight the importance of awareness that analgesic drug administration has the potential to alter homeostasis and affect interpretation of some study findings by its own guise. Correlation of the mean pain study results with plasma biochemical data supports preferential use of thoracoscopy as a refinement for limiting postprocedural pain in research models.

Change in circulating blood volume following craniotomy

OBJECT

The importance of monitoring circulating blood volume (CBV) during perioperative management is widely recognized in critically ill patients. The purpose of this study was to investigate the change in CBV following craniotomy by using indocyanine-green pulse spectrophotometry.

METHODS

Circulating blood volume and plasma hormones related to stress and fluid regulation were measured five times: preoperatively, immediately postoperatively, and 1, 2, and 7 days after craniotomy was performed in 17 patients with a brain tumor or an unruptured aneurysm. The mean value of CBV preoperatively was 82 ml/kg, which decreased to 64 ml/kg (78%) immediately postoperatively and gradually recovered to 82 ml/kg on Day 7 postsurgery (p = 0.0069). The mean values of adrenaline, noradrenaline, arginine vasopressin, renin, and aldosterone were highest immediately postoperatively. The mean intraoperative balances of water and sodium were 1,090 ml and 113 mEq, respectively. Partial correlation coefficients of CBV to noradrenaline and serum sodium during the entire study were -0.430 (p = 0.0036) and 0.418 (p = 0.0048), respectively.

CONCLUSIONS

Attention should be paid to decreased CBV following craniotomy, which is caused by the shift of fluid to interstitial spaces due to surgical stress. Hypovolemia can be suspected from a postoperative decrease in serum sodium.

Blood levels of corticosteroid-binding globulin, total cortisol and unbound cortisol in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass

Previous studies have demonstrated a persistent rise in serum cortisol concentrations after cardiac surgery. To further investigate this finding and to evaluate the effect of hemodilution that occurs with the onset of cardiopulmonary bypass (CPB), concentrations of cortisol-binding globulin (CBG), total and unbound cortisol, and packed cell volume (PCV) were studied in 28 patients undergoing coronary artery bypass graft surgery. All patients received a standardized general anesthetic using a balanced technique with sufentanil, isoflurane, and midazolam. Blood was collected preoperatively, intraoperatively during CPB, and postoperatively in the evenings on the day of surgery and on the first and second postoperative day. Cortisol and CBG concentrations were measured by radioimmunoassay and were used to calculate the fraction of unbound cortisol. Serum CBG and cortisol concentrations corrected for hemodilution were significantly higher than non-corrected values. Perioperatively, CBG measurements were significantly intercorrelated. Intraoperatively, total and unbound cortisol concentrations were not significantly increased compared to preoperative values. Postoperatively up to the end of the study period serum concentrations of total and unbound cortisol were significantly increased compared to baseline values. Our results suggest that hemodilution occurs in all patients during cardiac surgery and continues up to the second postoperative day. This may lead to an underestimation of serum cortisol and CBG concentrations in patients undergoing heart surgery with CPB. Intraoperatively, concentrations of total and unbound cortisol were not significantly elevated. The postoperative rise in serum total cortisol concentration was accompanied by an increase in unbound cortisol concentration. The postoperative increase of unbound cortisol concentrations in patients undergoing cardiac surgery with CPB was largely due to an increase in cortisol secretion.

The immune-endocrine interaction varies with the duration of the inflammatory process in cardiac surgery patients

The present study investigated the perioperative course of cytokine release and hypothalamic-pituitary-adrenal (HPA) axis activation in relation to the duration of the inflammatory response in cardiac surgery patients. Twelve male patients scheduled for elective coronary artery bypass grafting surgery with cardiopulmonary bypass and general anaesthesia were divided into two study groups: group 1 (n=6) underwent surgery at 13.00 h+/-30 min, group 2 (n=6) at 08.30 h+/-50 min. Blood samples were collected preoperatively and up to the first postoperative day. Postoperatively, on the day of surgery, serum concentrations of the proinflammatory cytokines interleukin (IL)-6, IL-1beta and tumour necrosis factor (TNF)-alpha were not significantly different between the two groups, while blood concentrations of cortisol, adrenocorticotrophic hormone (ACTH) and beta-endorphin in group 2 patients were significantly higher than in group 1 patients. Postoperatively, on the day of surgery, ACTH and cortisol concentrations in group 1 patients were positively correlated to the blood concentrations of IL-1beta, IL-6 and TNF-alpha. By contrast, group 2 patients showed no significant relationship between cytokine release and activation of HPA axis at this time. Our results suggest that in patients undergoing cardiac surgery, the cytokine response is initiated before the HPA axis is fully activated. In the early postoperative period, cytokines appear to be involved in the activation of the HPA axis, while in the later postoperative period, high cortisol concentrations may inhibit the release of IL-6.

Expression of cytokeratin 20 in thyroid carcinomas and peripheral blood detected by reverse transcription polymerase chain reaction

We investigated a nested reverse transcriptase polymerase chain reaction (RT-PCR) system to detect CK20 mRNA in thyroid carcinomas, benign thyroid diseases and peripheral blood to improve diagnosis of thyroid carcinoma and to detect disseminated tumour cells. Frozen tissue samples of 46 thyroid carcinomas and 30 benign thyroid diseases (14 multinodular goiters, 14 follicular adenomas, two Hashimoto's thyroiditis) were obtained intraoperatively. Preoperative blood samples were drawn from 31 patients with thyroid cancer, nine patients with benign thyroid disorders and 20 healthy volunteers. Nine out of nine medullary, 9/12 follicular, 7/19 papillary and 2/6 anaplastic carcinomas expressed CK20 transcripts. CK20 mRNA was undetectable in 30 tissue sections of benign thyroid diseases. Circulating tumour cells were found in the blood of 3/8 patients with medullary carcinoma, 2/8 patients with follicular carcinoma, 2/11 patients with papillary carcinoma and 1/4 patients with an anaplastic carcinoma. Nine blood samples of patients with benign thyroid diseases and 20 healthy volunteers tested negative. For the first time CK20 mRNA could be detected in tissue sections of thyroid carcinomas and peripheral blood samples of patients with thyroid cancer. It was not detectable in benign thyroid diseases. Our results therefore strongly suggest that CK20 RT-PCR assays may improve the diagnosis of thyroid carcinoma and is able to detect circulating tumour cells in peripheral blood of thyroid carcinoma patients.

Perioperative cytokine release during coronary artery bypass grafting in patients of different ages

Surgical interventions and cardiopulmonary bypass (CPB) induce a systemic inflammatory response with cytokine release. Ageing is perceived as a process of impaired immune functions: IL-1beta, IL-6 and tumour necrosis factor-alpha (TNF-alpha) secretion are increased while IL-2 release is reduced in advanced age. At present, little information is available about perioperative immune reactions at different stages of ageing. The aim of the present study was to compare IL-6, IL-1beta, TNF-alpha, IL-10 and soluble IL-2 receptor (sIL-2R) in younger and older patients undergoing cardiac surgery. Male patients (n = 14) undergoing elective coronary artery bypass grafting (CABG) surgery employing CPB with moderate hypothermia were divided into two groups according to their age: group 1 included seven patients < 50 years old, group 2 included seven patients > 65 years old. All patients received general anaesthesia using a balanced technique with sufentanil, isoflurane and midazolam. Blood samples were collected pre-operatively (T1); intra-operatively during CPB (T2); post-operatively on the day of surgery (T3); on the first post-operative day (T4). Blood concentrations of IL-6, IL-1beta, IL-10, TNF-alpha and sIL-2R were measured using commercially available ELISA kits and corrected for plasma cell volume. Statistical analysis was performed by non-parametric analysis of variance and Mann-Whitney U-test. Significance level was set to P<0.05. There were no statistically significant differences in the perioperative release of TNF-alpha, IL-6, IL-1beta, IL-10 and sIL-2R among the two groups. We conclude that the perioperative course of cytokine release in patients undergoing CABG surgery with CPB and comparable perioperative management does not significantly differ in the two age groups.