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Barker T, May HT, Doty JR, Lappe DL, Knowlton KU, Carlquist J, Konery K, Inglet S, Chisum B, Galenko O, Anderson JL, Muhlestein JB. Vitamin D supplementation protects against reductions in plasma 25-hydroxyvitamin D induced by open-heart surgery: Assess-d trial. Physiol Rep 2021; 9:e14747. [PMID: 33580636 PMCID: PMC7881347 DOI: 10.14814/phy2.14747] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/28/2022] Open
Abstract
Low vitamin D (serum or plasma 25‐hydroxyvitamin D (25(OH)D)) is a global pandemic and associates with a greater prevalence in all‐cause and cardiovascular mortality and morbidity. Open‐heart surgery is a form of acute stress that decreases circulating 25(OH)D concentrations and exacerbates the preponderance of low vitamin D in a patient population already characterized by low levels. Although supplemental vitamin D increases 25(OH)D, it is unknown if supplemental vitamin D can overcome the decreases in circulating 25(OH)D induced by open‐heart surgery. We sought to identify if supplemental vitamin D protects against the acute decrease in plasma 25(OH)D propagated by open‐heart surgery during perioperative care. Participants undergoing open‐heart surgery were randomly assigned (double‐blind) to one of two groups: (a) vitamin D (n = 75; cholecalciferol, 50,000 IU/dose) or (b) placebo (n = 75). Participants received supplements on three separate occasions: orally the evening before surgery and either orally or per nasogastric tube on postoperative days 1 and 2. Plasma 25(OH)D concentrations were measured at baseline (the day before surgery and before the first supplement bolus), after surgery on postoperative days 1, 2, 3, and 4, at hospital discharge (5–8 days after surgery), and at an elective outpatient follow‐up visit at 6 months. Supplemental vitamin D abolished the acute decrease in 25(OH)D induced by open‐heart surgery during postoperative care. Moreover, plasma 25(OH)D gradually increased from baseline to day 3 and remained significantly increased thereafter but plateaued to discharge with supplemental vitamin D. We conclude that perioperative vitamin D supplementation protects against the immediate decrease in plasma 25(OH)D induced by open‐heart surgery. ClinicalTrials.gov Identifier: NCT02460211.
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Affiliation(s)
- Tyler Barker
- Precision Genomics, Intermountain Healthcare, St. George, Utah, USA.,Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA
| | - Heidi T May
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - John R Doty
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Donald L Lappe
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kirk U Knowlton
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - John Carlquist
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Kristin Konery
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Shannon Inglet
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ben Chisum
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Oxana Galenko
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Jeffrey L Anderson
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joseph B Muhlestein
- Heart Institute, Intermountain Healthcare, Salt Lake City, Utah, USA.,School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Yao YT, He LX, Fang NX, Ma J. Anesthetic Induction With Etomidate in Cardiac Surgical Patients: A PRISMA-Compliant Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2020; 35:1073-1085. [PMID: 33384231 DOI: 10.1053/j.jvca.2020.11.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This meta-analysis aimed to systematically review the effects of etomidate (ETM) during anesthetic induction on patients undergoing cardiac surgery. DESIGN Systematic review and meta-analysis. SETTING Operating room. PARTICIPANTS Patients undergoing cardiac surgery. INTERVENTIONS ETM or control drugs. MEASUREMENTS AND MAIN RESULTS PubMed, Cochrane Library, OVID, and EMBASE were searched through August 31, 2020. Primary outcomes included hemodynamic profiles and stress responses. Secondary outcomes included morbidity, mortality, and postoperative recovery. For continuous/dichotomous variables, treatment effects were calculated as weighted mean difference (WMD)/odds ratio (OR) and 95% confidence interval (CI). A database search yielded 18 randomized controlled trials including 1,241 patients. The present meta-analysis demonstrated that ETM-anesthetized patients had lower heart rates (WMD, -3.31; 95% CI -5.43 to -1.19; p = 0.002), higher blood pressures (systolic blood pressure: WMD, 12.02; 95% CI 6.24 to 17.80; p < 0.0001; diastolic blood pressure: WMD, 5.23; 95% CI 2.39 to 8.08; p = 0.0003; mean arterial pressure (MAP): WMD, 8.64; 95% CI 5.85 to 11.43; p < 0.00001), less requirement for vasopressor (OR, 0.26; 95% CI 0.15 to 0.44; p < 0.00001), and more nitroglycerin usage (OR, 14.89; 95% CI 4.92 to 45.08; p < 0.00001) during anesthetic induction. Current meta-analysis also demonstrated that single-dose ETM lowered cortisol levels transiently and did not have a significant effect on endogenous norepinephrine and epinephrine levels and was not associated with increased postoperative inotrope and/or vasopressor requirement. Additionally, the meta-analysis suggested that ETM anesthesia was associated with neither increased mortality nor morbidity, except a higher incidence of transient adrenal insufficiency in ETM recipients. CONCLUSION The present meta-analysis suggested that single-dose ETM during anesthetic induction could be associated with more stable hemodynamics, transient and reversible lower cortisol levels, and a higher adrenal insufficiency incidence, but not worse outcomes in cardiac surgical patients.
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Affiliation(s)
- Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Neng-Xin Fang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Ma
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Koyuncu A, Yava A, Yamak B, Orhan N. Effect of family presence on stress response after bypass surgery. Heart Lung 2020; 50:193-201. [PMID: 33278754 DOI: 10.1016/j.hrtlng.2020.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is a major surgery that may cause severe surgical stress response (SR). Although the presence of family members in intensive care unit (ICU) is known to benefit intensive care patients socially and emotionally, its effects on surgical SR are unknown. OBJECTIVES To investigate the effect of an informed family member (IFM)'s presence in the awakening process in ICU on patients' SR after CABG. METHODS A nonrandomized controlled clinical study was completed with a total of 73 patients: 37 patients in the control (CG) and 36 in the intervention group (IG) underwent CABG surgery. In the CG patients, no family members were taken into the ICU during the awakening process and routine care and treatment practices were continued. In the IG patients, besides routine care and treatment practices, an IFM was taken into the ICU during the awakening process in accordance with the research method. Groups were statistically compared in terms of serum cortisol level which is the one of the main indicators of surgical SR, state anxiety, sedative drug requirements, and duration of intubation, sedation, and ICU stay. A p value <0.05 was accepted as statistically significant. RESULTS Presence of an IFM in the ICU was found to be effective in decreasing serum cortisol level, state anxiety, sedative drug requirements, and the duration of intubation, sedation, and ICU stay (p<0.05). CONCLUSIONS In CABG, the presence of IFM in ICU is effective in reducing SR.
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Affiliation(s)
- Aynur Koyuncu
- Nursing Department, Hasan Kalyoncu University, Faculty of Health Sciences, Gaziantep, Turkey.
| | - Ayla Yava
- Nursing Department, Hasan Kalyoncu University, Faculty of Health Sciences, Gaziantep, Turkey.
| | - Birol Yamak
- Gaziantep Medikal Park Hospital, Gaziantep, Turkey.
| | - Nuri Orhan
- Gaziantep Medikal Park Hospital, Gaziantep, Turkey.
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Kaushik A, Kapoor A, Agarwal SK, Pande S, Kashyap S, Sinha A, Khanna R, Kumar S, Garg N, Tewari S, Goel PK. Effect of statin on perioperative myocardial injury in isolated valve surgery. Asian Cardiovasc Thorac Ann 2020; 29:369-375. [PMID: 33197319 DOI: 10.1177/0218492320974514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Statins have known pleiotropic effects that confer protection from ischemia-reperfusion injury. Because cardiopulmonary bypass is a potentially reversible ischemia-reperfusion sequence, we aimed to assess whether statin loading could help to limit myocardial injury in patients undergoing isolated heart valve replacement under cardiopulmonary bypass. METHODS One hundred patients with rheumatic valvular heart disease undergoing valve replacement received either a loading dose of rosuvastatin (40 mg initiated 7 days before surgery; loaded group) or no statins (non-loaded group). Cardiac troponin I, creatine kinase MB, and brain natriuretic peptide were measured at 8, 24, and 48 hours postoperatively. The primary endpoint was the extent of perioperative myocardial injury measured by the area under the curve for each biomarker. RESULTS Despite similar baseline levels, all biomarkers at 8, 24, and 48 h were significantly lower in the loaded group. The area under the curve of each biomarker was significantly lower in the loaded group than in the non-loaded group (troponin I: 31.43 vs. 77.21 ng·h·mL-1, creatine kinase MB 309.31 vs. 429.12 ng·h·mL-1, brain natriuretic peptide 5176.11 vs. 16119.31 pg·h·mL-1, all p < 0.001). The mean changes from baseline to peak levels were also significantly lower in the loaded group. The loaded group had a shorter hospital stay but no significant difference was seen in ventilator time, inotrope time, aortic crossclamp time, cardiopulmonary bypass time, or intensive care unit stay. CONCLUSION In patients undergoing valve replacement, high-dose statin loading before surgery had a favorable impact on the release kinetics of various cardiac biomarkers.
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Affiliation(s)
- Atul Kaushik
- Department of Cardiology, AIIMS, Jodhpur, Rajasthan, India
| | - Aditya Kapoor
- Department of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Surendra Kumar Agarwal
- Department of Cardiovascular and Thoracic Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Shantanu Pande
- Department of Cardiovascular and Thoracic Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | | | - Roopali Khanna
- Department of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Sudeep Kumar
- Department of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Naveen Garg
- Department of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Satyendra Tewari
- Department of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Pravin K Goel
- Department of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh, India
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Wu H, Tang J, Pan J, Han M, Cai H, Zhang H. Effects of dexmedetomidine on stress hormones in patients undergoing cardiac valve replacement: a randomized controlled trial. BMC Anesthesiol 2020; 20:142. [PMID: 32505177 PMCID: PMC7275125 DOI: 10.1186/s12871-020-00993-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/27/2020] [Indexed: 12/24/2022] Open
Abstract
Background Stress response always occurs in cardiac valve replacement patients undergoing cardiopulmonary bypass (CPB). Methods 60 patients undergoing cardiac valve replacement were recruited and randomized into control and Dex groups. Dex group received 1.0 μg·kg-1 of Dex for 10 min intravenously before anesthesia, followed by 0.5 μg·kg-1·h-1 of Dex, steadily administered throughout the procedure. And controlled group received the identical velocity of saline as Dex group. Plasma level of cortisol (Cor), epinephrine (E), norepinephrine (NE), and serotonin (5-HT) were evaluated at four timepoints: Before administration (T0), sawn sternum (T1), end of extracorporeal circulation (T2), and 24 h post operation (T3). General data of operation and recovery such as heart rate (HR), mean arterial pressure (MAP), intraoperative bispectral index (BIS), and hospitalization time in the intensive care unit (ICU) were also compared. Results Increase of Cor, E, NE, and 5-HT for the Dex group was significant lesser than that in the control group (P < 0.05), and ICU hospitalization time and ventilator support time was significantly shorter in the Dex group. The proportion of patients discharged from the hospital with better prognosis was significantly higher than that in the control group, while there were no significant differences in hospitalization costs and vasoactive drugs use between the two groups. Conclusions Dex reduces plasma Cor, E and NE elevations in patients after CPB, alleviates the stress reaction of the body, shortens the hospitalization time and ventilator support time in ICU, and plays a positive role in the rehabilitation of patients undergoing cardiac valve replacement. Trial registration China Clinical Trial Registry (No. ChiCTR-IPR-17010954) March 22rd, 2017.
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Affiliation(s)
- Hanhua Wu
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Jinqing Tang
- Department of Anesthesiology, Third Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, Guizhou Province, China
| | - Jiamei Pan
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Ming Han
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Huijun Cai
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Hong Zhang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, No. 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China.
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Saracevic A, Medved I, Hrabric Vlah S, Kozmar A, Bilic-Zulle L, Simundic AM. The association of systemic inflammatory markers with indicators of stress and cardiac necrosis in patients undergoing aortic valve replacement and revascularization surgeries. Physiol Res 2020; 69:261-274. [PMID: 32199011 DOI: 10.33549/physiolres.934243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim was to investigate: changes of inflammatory, stress and cardiac response in patients undergoing open heart surgeries up to five days after the procedure; the association between inflammatory, stress and cardiac response and whether changes in a certain marker can predict short-term patient outcome. Ninety patients were divided into three groups, 30 participants each (on-pump,off-pump revascularization and valve replacement group). The following markers were measured:complete blood count, CRP, IL-6, IL-10, leptin, resistin, monocyte chemoattractant protein-1 (MCP-1), cortisol, CK and hsTnT in 5 points. Resistin increased in all three groups. Lower IL-10 levels were found after the surgery and higher levels of leptin and MCP-1 in the off-pump than in the on-pump group. Off-pump group had higher values of IL-6, IL-10, leptin, resistin and MCP-1 and lower levels of CK and hsTnT 24 after surgery than the on-pump group. We found significant correlation between MCP-1 and resistin. The difference between resistin at time points 2 and 3 significantly predicted transfusion needs; while the difference between CRP and resistin before and at the end of the surgery together with the difference between leukocytes at the end and 24 hours after the surgery predicted the use of inotropic agents/vasopressors. Cardiac surgeries cause an increase of inflammatory, stress and cardiac markers. Only resistin correlated with MCP-1 which confirms the link between resistin secreted form infiltrated macrophages and enhanced release of MCP-1.
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Affiliation(s)
- A Saracevic
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", Zagreb, Croatia.
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Assessment of adrenal reserve and secretion of cortisol in patients over 60 years of age undergoing cardiac surgery. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 16:118-123. [PMID: 31708984 PMCID: PMC6836633 DOI: 10.5114/kitp.2019.88600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/20/2019] [Indexed: 12/02/2022]
Abstract
Introduction Cortisol level affects the prognosis of patients after cardiac surgery. Meanwhile, there are no clear guidelines for steroid supplementation after a cardiac operation. The relationship between age and blood cortisol levels has not been finally clarified. Aim Assessment of adrenal reserve and secretion of cortisol in patients over 60 years of age undergoing cardiac surgery. Material and methods The study included 20 patients of both sexes referred for cardiac surgery. A short ACTH synthetic stimulation test was carried out. Assessment of cortisol secretion was carried out in the morning on the day of surgery and the 1st, 2nd and 4th days after surgery in blood samples. Results A result within the normal range for the adrenal reserve was found in 19 of the 20 patients enrolled in the study. The short Synacthen test predicted postoperative secretion of cortisol (p = 0.04, r = 0.047). A relationship between secretion of cortisol and patients’ age was observed (p = 0.03, r = 0.48). The concentration of cortisol on the 1st postoperative day was correlated with the total dose of dopamine (p = 0.006, r = 0.58) and adrenaline (p = 0.04, r = 0.47). The concentration of cortisol on the day of the surgery correlated with the lactate concentration on day 2 (p = 0.04, r = 0.45). The concentration of lactates on day 1 correlated with total dose of dopamine (p = 0.01, r = 0.54). Conclusions A short Synacthen test allows one to predict secretion of cortisol after cardiac surgery. Greater secretion of cortisol after cardiac surgery may be associated with a more difficult postoperative course. There was no decrease in cortisol secretion with age.
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Kumar A, Das S, Chauhan S, Kiran U, Satapathy S. Perioperative Anxiety and Stress in Children Undergoing Congenital Cardiac Surgery and Their Parents: Effect of Brief Intervention—A Randomized Control Trial. J Cardiothorac Vasc Anesth 2019; 33:1244-1250. [DOI: 10.1053/j.jvca.2018.08.187] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Indexed: 11/11/2022]
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Bangalore H, Checchia PA, Ocampo EC, Heinle JS, Minard CG, Shekerdemian LS. Cortisol Response in Children After Second Cardiopulmonary Bypass. Pediatr Cardiol 2019; 40:47-52. [PMID: 30167750 DOI: 10.1007/s00246-018-1959-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/09/2018] [Indexed: 12/29/2022]
Abstract
A surge in cortisol levels is seen after surgery with cardiopulmonary bypass (CPB). Based on evidence of attenuation of the cortisol response to repeated stress in other settings, we hypothesized that the magnitude of cortisol increase in children after a second exposure to CPB would be reduced. Serial cortisol levels were measured at three time points after each CPB: immediately (day 0), on the first morning (day 1), and second morning (day 2). Forty-six children underwent two surgeries with CPB during the study period. The mean age (standard deviation) at first and second surgery was 3.5 (6.3) months and 10.4 (9.9) months, respectively. Cortisol levels at the first surgery were 109 (105) µg/dl, 29 (62) µg/dl, and 17 (12) µg/dl on day 0, 1, and 2, respectively; similarly at second surgery, it was 61 (57) µg/dl on day 0 to 20 (16) µg/dl and 11 (10) µg/dl on day 1 and 2, respectively. After log-transformation and adjusting for time interval between surgeries, cortisol levels at the second surgery were lower by 42% on day 0 (p = 0.02), and 46% lower on day 2 (p = 0.02). A second exposure to CPB in children with congenital heart disease is associated with an attenuated cortisol release.
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Affiliation(s)
- Harish Bangalore
- Department of Pediatrics, Section of Critical Care, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St. Suite W6006, Houston, TX, 77030, USA
| | - Paul A Checchia
- Department of Pediatrics, Section of Critical Care, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St. Suite W6006, Houston, TX, 77030, USA
| | - Elena C Ocampo
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Lara S Shekerdemian
- Department of Pediatrics, Section of Critical Care, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St. Suite W6006, Houston, TX, 77030, USA.
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Glumac S, Kardum G, Karanović N. A Prospective Cohort Evaluation of the Cortisol Response to Cardiac Surgery with Occurrence of Early Postoperative Cognitive Decline. Med Sci Monit 2018; 24:977-986. [PMID: 29453331 PMCID: PMC5960218 DOI: 10.12659/msm.908251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND A recent study reported that patients with higher cortisol levels on the 1st postoperative morning after cardiac surgery exhibited an increased risk of early postoperative cognitive decline (POCD). Therefore, we conducted the current study to gain further insight into the stress response to a surgical procedure as a potential risk factor for early POCD after cardiac surgery. MATERIAL AND METHODS This prospective cohort study enrolled 125 patients undergoing elective cardiac surgery with or without cardiopulmonary bypass (CPB). Patient serum cortisol levels were determined 1 day before surgery (at 08: 00) and on the 1st (at 08: 00, 16: 00 and 24: 00), 3rd (at 08: 00), and 5th (at 08: 00) postoperative days. A battery of 9 neuropsychological tests were used to assess the participants 2 days before the surgical procedure and on the 6th postoperative day. POCD was defined as a decrease in performance of 1 SD or greater between the postoperative and preoperative z scores on at least 1 neuropsychological test. A mixed-design ANOVA was used to determine the correlations of the perioperative cortisol levels with the occurrence of POCD and with the surgical technique performed. RESULTS Mixed-design ANOVA showed no statistically significant differences in the cortisol levels between non-POCD and POCD patients (F=0.52, P=0.690) or between patients with and without CPB (F=2.02, P=0.103) at the 6 perioperative time points. CONCLUSIONS The occurrence of early POCD and the use of CPB were not associated with significantly higher cortisol levels in the repeated measurement design.
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Affiliation(s)
- Sandro Glumac
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Split, Croatia
| | - Goran Kardum
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia
| | - Nenad Karanović
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Split, Croatia.,Department of Anesthesiology and Intensive Medicine, School of Medicine, University of Split, Split, Croatia
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Effects of Preoperative Psychological Interventions on Catecholamine and Cortisol Levels After Surgery in Coronary Artery Bypass Graft Patients: The Randomized Controlled PSY-HEART Trial. Psychosom Med 2017; 79:806-814. [PMID: 28846584 DOI: 10.1097/psy.0000000000000483] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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).
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Ziyaeifard M, Ziyaeifard P. "Effects of Selenium on Stress Response in Coronary Artery Bypass Graft Surgery: A Clinical Trial Study". Anesth Pain Med 2017; 7:e45461. [PMID: 28824865 PMCID: PMC5559665 DOI: 10.5812/aapm.45461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 01/21/2017] [Accepted: 02/15/2017] [Indexed: 12/13/2022] Open
Affiliation(s)
- Mohsen Ziyaeifard
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding author: Mohsen Ziyaeifard, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-2123922152; +98-9128245876, E-mail:
| | - Parisa Ziyaeifard
- Medical Student, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Das D, Sen C, Goswami A. Effect of Vitamin C on adrenal suppression by etomidate induction in patients undergoing cardiac surgery: A randomized controlled trial. Ann Card Anaesth 2017; 19:410-7. [PMID: 27397444 PMCID: PMC4971968 DOI: 10.4103/0971-9784.185522] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Introduction: Etomidate is usually preferred in the induction of cardiac compromised patients due to its relative cardiovascular stability. However, the use of this drug has been limited as etomidate induces suppression of cortisol biosynthesis as a result of blockade of 11-beta-hydroxylation in the adrenal gland, mediated by the imidazole radical of etomidate. This study was carried out to observe the effect of Vitamin C on adrenal suppression after etomidate induction in patients undergoing cardiac surgery. Materials and Methods: A total of 78 patients were randomly distributed into two groups. Group-I received oral Vitamin C (500 mg) twice daily and Group-II received antacid tablet as placebo twice daily instead of Vitamin C for 7 consecutive days prior to surgery till morning of surgery. Patients of both the groups induced with etomidate (0.1–0.3 mg/kg). Blood cortisol was estimated at different points of time till 24th postinduction hour/blood lactate, glucose, hemodynamic parameters, and perioperative outcomes were assessed. Results: Data of seventy patients (n = 35 in each group) were finally analyzed. Cortisol level is statistically significantly higher in Group-I (69.51 ± 7.65) as compared to Group-II (27.74 ± 4.72) (P < 0.05) in the 1st postinduction hour. In Group-II, cortisol was consistently lower for 1st 24 postinduction hour. Total adrenaline requirement was statistically significantly high in Group-II. Time of extubation, length of Intensive Care Unit stay arrhythmia was similar in both the groups. Conclusion: Vitamin C effectively inhibits etomidate-induced adrenal suppression in cardiac patients, thereby etomidate can be used as a safe alternative for induction in cardiac surgery under cardiopulmonary bypass when pretreated with Vitamin C.
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Affiliation(s)
- Deepanwita Das
- Department of Cardiac Anaesthesiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Chaitali Sen
- Department of Cardiac Anaesthesiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Anupam Goswami
- Department of Cardiac Anaesthesiology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
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Chang YL, Tsai YF. Early illness experiences related to unexpected heart surgery: A qualitative descriptive study. Aust Crit Care 2017; 30:279-285. [PMID: 28063723 DOI: 10.1016/j.aucc.2016.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Most studies on patients' experiences following emergency cardiac surgery focus on evaluation of patients after their discharge. Few studies have evaluated patients' experiences after being transferred from intensive care and before being discharged. OBJECTIVE This study aimed to describe patients' experiences in the early stages of recovery following emergency heart surgery. METHODS For this exploratory qualitative descriptive study, 13 patients were recruited from a medical centre in northern Taiwan. Participants had undergone emergency heart surgery and had resided in the cardiothoracic surgical ward for ≥6 days following transfer from the ICU; all expected to be discharged from the hospital within 3 days. Semi-structured, face-to-face interviews were conducted in private after the patients had been transferred to the cardiothoracic surgical wards. Audiotaped interviews were transcribed and analysed using content analysis. FINDINGS Data analysis identified four themes, which represented different recovery stages: sudden and serious symptoms, nightmares and vivid dreams, physical and emotional disturbances, and establishing a new life after emergency surgery. A fifth theme, support for a new lifestyle, occurred between the four stages. CONCLUSION Participants experienced symptoms of physical and psychological stress during the early recovery stages following emergency heart surgery. A lack of understanding of the process of recovery increased these difficulties; participants wanted and needed multidisciplinary care and education. Emergency heart surgery does not allow healthcare professionals to inform patients of what to expect post-surgery. Our findings suggest that rather than waiting until discharge to offer disease information and treatment plans, multidisciplinary care should be initiated as soon as possible to facilitate recovery.
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Affiliation(s)
- Yu-Ling Chang
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Nursing, College of Medicine, Chang Gung University, Taiwan.
| | - Yun-Fang Tsai
- School of Nursing, College of Medicine, Chang Gung University, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Taiwan.
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Yuki K, Matsunami E, Tazawa K, Wang W, DiNardo JA, Koutsogiannaki S. Pediatric Perioperative Stress Responses and Anesthesia. TRANSLATIONAL PERIOPERATIVE AND PAIN MEDICINE 2017; 2:1-12. [PMID: 28217718 PMCID: PMC5310630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Surgical stress responses cause an array of endocrinological, metabolic and immunological changes in patients. The landmark studies in the 1980s showed that adequate anesthesia dramatically improved the outcomes of pediatric surgical patients by attenuating stress hormonal responses, pointing out the harm of 'inadequate' anesthesia. Subsequent studies questioned the role of administering very high-dose anesthetics to further attenuate stress responses. Here we review the feature of surgical stress responses in pediatric patients including their difference from those in adult patients. Overall, pediatric patients show minimal or no resting energy expenditure change postoperatively. In adult patients, increased resting energy expenditure has been described. Pediatric patients demonstrated robust cortisol and catecholamine responses than adult patients. However, the duration of these surges is often short-lived. Systemic proinflammatory and anti-inflammatory cytokine levels have been measured. Pediatric patients showed less proinflammatory cytokine elevation, but had similar anti-antiinflamatory responses. We also review in detail the immunological changes in response to surgical stress. Based on our current knowledge, we attempted to understand the underlying mechanism how adequate anesthesia dramatically improved the outcome of patients. Although more work is needed to be done, understanding how pediatric patients respond to perioperative stress, and its mechanism and consequence will allow us to direct us into a better, perioperative management in this population.
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Affiliation(s)
- Koichi Yuki
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Erika Matsunami
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Kazumasa Tazawa
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Wei Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - James A. DiNardo
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
| | - Sophia Koutsogiannaki
- Department of Anesthesiology, Perioperative and Pain Medicine, Cardiac Anesthesia Division, Boston Children’s Hospital, Boston, USA,Harvard Medical School, Boston, USA
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Sedighinejad A, Imantalab V, Mirmansouri A, Naderi Nabi B, Tarbiat M, Sadeghi AM, Nassiri Sheikhani N, Haghighi M, Sayahe Varag Z. Comparing the Effects of Isoflurane-Sufentanil Anesthesia and Propofol-Sufentanil Anesthesia on Serum Cortisol Levels in Open Heart Surgery with Cardiopulmonary Bypass. Anesth Pain Med 2016; 6:e42066. [PMID: 28975079 PMCID: PMC5560634 DOI: 10.5812/aapm.42066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 10/13/2016] [Accepted: 11/05/2016] [Indexed: 12/19/2022] Open
Abstract
Background Major surgeries such as open-heart surgery with cardiopulmonary bypass are associated with a complexity of stress response leading to post-operative complications. Studies have confirmed that anesthesia can mitigate the surgically induced stress response. Objectives The aim of this study was to compare the effects of propofol and isoflurane, both supplemented with Sufentanil, on the stress response in coronary artery bypass graft surgery with cardiopulmonary bypass, using cortisol as a biochemical marker. Methods This double-blind randomized clinical trial was conducted on 72 patients who underwent coronary artery bypass grafting (CABG) with cardiopulmonary bypass meeting the inclusion criteria. The subjects were randomly divided into two groups of isoflurane (n = 36) and propofol (n = 36) both supplemented with sufentanil. Serum cortisol levels were measured and compared between the groups; 30 minutes before the surgery (T0), at the end of the cardiopulmonary bypass (T1), and 24 hours after the surgery (T2). Results Compared to the baseline (T0), at the end of cardiopulmonary bypass (T1), both groups demonstrated a decrease in plasma cortisol levels with no statistical significant difference (P = 0.4). At T2 measuring time point, the level of plasma cortisol significantly increased in both groups (P = 0.02), however this increase was less in the Isoflurane group. Conclusions In CABG with cardiopulmonary bypass, using plasma cortisol level as a measure, Isoflurane-Sufentanil significantly reduces the stress response to the surgery, when compared to propofol-Sufentanil.
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Affiliation(s)
- Abbas Sedighinejad
- Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, Iran
| | - Vali Imantalab
- Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, Iran
- Corresponding author: Vali Imantalab, MD, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Guilan, Iran. Tel: +98-9111316138, E-mail:
| | - Ali Mirmansouri
- Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, Iran
| | - Bahram Naderi Nabi
- MD, Associate Professor of Anesthesiology, Fellowship of Anesthesia and Pain (FIPP), Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Masoud Tarbiat
- Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, Iran
| | - Ali Mohammad Sadeghi
- Department of Cardiology, Assistant Professor of Cardiac Surgery, Guilan University of Medical Sciences, Rasht, Iran
| | - Nassir Nassiri Sheikhani
- Department of Cardiology, Assistant Professor of Cardiac Surgery, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammad Haghighi
- Associate Professor of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, Iran
| | - Zahra Sayahe Varag
- Department of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
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Rovai D, Giannessi D, Andreassi MG, Gentili C, Pingitore A, Glauber M, Gemignani A. Mind injuries after cardiac surgery. J Cardiovasc Med (Hagerstown) 2016; 16:844-51. [PMID: 24933202 DOI: 10.2459/jcm.0000000000000133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
After cardiac surgery, delirium, cognitive dysfunction, depression, or anxiety disorders frequently occur, and profoundly affect patients' prognosis and quality of life. This narrative review focuses on the main clinical presentations of cognitive and psychological problems ('mind injuries') that occur postoperatively in absence of ascertainable focal neurologic deficits, exploring their pathophysiological mechanisms and possible strategies for prevention and treatment. Postoperative cognitive dysfunction is a potentially devastating complication that can involve several mechanisms and several predisposing, intraoperative, and postoperative risk factors, which can result in or be associated to cerebral microvascular damage. Postoperative depression is influenced by genetic or psychosocial predisposing factors, by neuroendocrine activation, and by the release of several pro-inflammatory factors. The net effect of these changes is neuroinflammation. These complex biochemical alterations, along with an aspecific response to stressful life events, might target the function of several brain areas, which are thought to represent a trigger factor for the onset of depression.
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Affiliation(s)
- Daniele Rovai
- aCNR, Institute of Clinical Physiology bBiomedicine, CNR, Institute of Clinical Physiology cClinical Psychology, Department of Surgery, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa dCardiothoracic Department, Fondazione Toscana G. Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
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18
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Sedighinejad A, Imantalab V, Mirmansouri A, Mohammadzadeh Jouryabi A, Kanani G, Nassiri Sheikhani N, Haghighi M, Atrkarroushan Z, Biazar G. Effects of Low-dose Selenium on the Inflammatory Response in Coronary Artery Bypass Graft Surgery: A Clinical Trial. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e37918. [PMID: 27795837 PMCID: PMC5070486 DOI: 10.5812/ircmj.37918] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/16/2016] [Accepted: 06/18/2016] [Indexed: 01/06/2023]
Abstract
Background Coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) triggers an inflammatory reaction, leading to the development of myocardial damage and dysfunction. It is suggested that selenium (Se), an essential trace element, has a protective role against oxidative stress. Decreased intraoperative Se levels might be an independent predictive factor for postoperative multiorgan failure. In spite of its proposed advantages, however, the optimal timing and dosage are not well known. Objectives To determine whether 600 µg of intravenous Se administration before induction of anesthesia for CABG surgery could attenuate inflammatory reactions in an Iranian population. Methods This randomized triple-blind clinical trial took place in the department of cardiac surgery of an academic hospital affiliated with Guilan University of Medical Sciences (GUMS) from May 2015 to September 2015. Eighty-eight eligible patients scheduled for elective on-pump CABG surgery were divided into two groups using randomized fixed quadripartite blocks. They received either an intravenous bolus of 600 µg Se before induction of anesthesia, or normal saline as a placebo. We had four measurement time-points: just before induction of anesthesia (T0), immediately after the end of CPB (T1), 24 hours after surgery (T2), and 48 hours after surgery (T3). Interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP) serum levels were measured using the enzyme-linked immunosorbent assay (ELISA). Results Data from a total of 81 patients were analyzed: group S (n = 41) and group C (n = 40). There was no significant difference between the two groups with regard to baseline characteristics. In both groups, CPB caused markedly increased IL-6, TNF-α, and CRP plasma concentrations compared with baseline (P = 0.0001). However, the pattern of changes was not significantly different between group S (P = 0.068) and group C (P = 0.26). The IL-6 and TNF-α change trends were significant in each group (P=0.0001). However, comparing the two groups showed no significant difference. With regard to IL-6, there was no significant difference between the two groups at the time-points of T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056), and the same was found for TNF-α at T1 (P = 0.34), T2 (P = 0.17), and T3 (P = 0.056). With regard to CRP, the trend of the changes was significant in each group (P = 0.0001). However, comparing two groups showed a borderline significant difference between them at T1 (P = 0.039), but not at T2 (P = 0.075) or T3 (P = 0.11). Conclusions This study revealed that the administration of 600 μg of intravenous Se immediately before induction of anesthesia was safe, but when compared to a placebo, no predominant clinical effects or modifications in the systemic inflammatory response induced by on-pump CABG were observed.
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Affiliation(s)
- Abbas Sedighinejad
- MD, Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Vali Imantalab
- MD, Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Guilan University of Medical Sciences, Rasht, IR Iran
- Corresponding Author: Vali Imantalab, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, IR Iran. Tel: +98-9111316138, E-mail:
| | - Ali Mirmansouri
- MD, Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Ali Mohammadzadeh Jouryabi
- MD, Associate Professor of Anesthesiology, Fellowship of Anesthesia in Cardiac Surgery, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Gholamreza Kanani
- MD, Assistant Professor of Cardiac Surgery, Department of Cardaic Surgery, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Nassir Nassiri Sheikhani
- MD, Assistant Professor of Cardiac Surgery, Department of Cardaic Surgery, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Mohammad Haghighi
- MD, Associate Professor of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, IR Iran
| | - Zahra Atrkarroushan
- PhD, Assistant Professor of Biostatistic, Guilan University of Medical Sciences (GUMS), Rasht, IR Iran
| | - Gelareh Biazar
- MD, Assistant Professor of Anesthesiology, Anesthesiology Research Center, Guilan University of Medical Sciences (GUMS), Rasht, IR Iran
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19
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The prothrombotic paradox of severe obesity after cardiac surgery under cardiopulmonary bypass. Thromb Res 2014; 134:346-53. [DOI: 10.1016/j.thromres.2014.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 05/27/2014] [Accepted: 06/05/2014] [Indexed: 11/21/2022]
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Serum cortisol and early postoperative outcome after stage-1 palliation for hypoplastic left heart syndrome. Pediatr Crit Care Med 2014; 15:211-8. [PMID: 24366509 DOI: 10.1097/pcc.0000000000000050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The postoperative cortisol profile and its association with early outcomes are poorly understood in neonates undergoing surgery for complex congenital heart disease. We investigated the postoperative profile of cortisol and its relationship with the clinical course in a cohort of newborns after stage-1 palliation for hypoplastic left heart syndrome. DESIGN Prospective observational study. SETTING Pediatric cardiovascular ICU at a tertiary children's hospital. SUBJECTS Twenty-three neonates after stage-1 palliation for hypoplastic left heart syndrome between 2009 and 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three serial measurements of total serum cortisol after surgery. The first measurement was taken immediately after surgery and the second and third-on the first and second postoperative mornings. The median weight of the infants was 3.0 kg (2.7-3.4 kg), and the age at surgery was 7 days (6-9 d). The median (25th-75th percentile) cortisol levels at admission, day 1, and day 2 were 96.2 μg/dL (51.1-112 μg/dL), 17.3 μg/dL (9.7-25.1 μg/dL), and 10 μg/dL (6.5-17 μg/dL), respectively (p < 0.0001 between admission and day 1). Higher cortisol was associated with greater morbidity, including the need for preoperative ventilation, increased total duration of ventilation, duration of inotropic support, and hospital length of stay. CONCLUSIONS Cortisol levels fell significantly over the first 24 hours after stage-1 palliation for hypoplastic left heart syndrome. A higher postoperative cortisol was associated with increased postoperative morbidity, which warrants further investigation.
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Casida JM, Davis JE, Shpakoff L, Yarandi H. An exploratory study of the patients' sleep patterns and inflammatory response following cardiopulmonary bypass (CPB). J Clin Nurs 2013; 23:2332-42. [PMID: 24329980 DOI: 10.1111/jocn.12515] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To describe sleep patterns and inflammatory response postCPB, determine sleep pattern changes and inflammatory response over time and explore relationships between sleep and biomarkers of stress and inflammation. BACKGROUND Despite the numerous citations of the role of sleep in restoration and health maintenance, a paucity of research exists about this phenomenon in patients undergoing CPB. Specifically, there is no research that has explored correlations between sleep patterns and systemic inflammatory response in adult cardiac surgery patients. DESIGN Exploratory, repeated-measures, correlational study. METHOD Subjects were recruited from a Midwestern urban hospital. Of the 25 eligible subjects, 16 males and four females completed the study. Wrist actigraphy was used to measure sleep variables. Salivary cortisol and C-reactive protein (C-RP) levels were measured daily. Data were collected during postoperative nights/days 1 through 4 (T1-T4). RESULTS Subjects' sleep onset latency (SOL) median scores (0 minute) were within normal range across time periods, whereas median scores for wake after sleep onset (WASO > 270 minutes), sleep fragmentation index (SFI >51%), total sleep time (<153 minutes) and sleep efficiency index (SEI <36%) fell outside the normal ranges. Changes in the median sleep scores over time, however, were not significant at p > 0·05. Median cortisol levels were within normal range (0·3-0·8 μg/dl) from T1-T4, but the C-RP level peaked at T2 (median = 2370 pg/ml). Strong correlations were found: (1) between SFI-cortisol (rs = 0·82), C-RP (rs = 0·65) - WBC (rs = 0·69); (2) between SEI-C-RP (rs = 0·58); (3) between WASO-WBC (rs = 0·48), WASO and cross-clamp time (rs = 0·50); and (4) between SOL-age (rs = -0·55) at p < 0·05. CONCLUSIONS Subjects were severely sleep-deprived with inflammatory response exaggerations warranting further investigations using larger sample sizes. RELEVANCE TO CLINICAL PRACTICE This study offers a foundation for developing a conceptual model explaining mechanisms of sleep disturbance and inflammatory response postCPB. This knowledge is crucial for testing sleep-promoting interventions to modulate inflammatory responses essential for preventing complications, and restoring health.
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Affiliation(s)
- Jesus M Casida
- Division of Acute, Critical and Long-Term Care, The University of Michigan School of Nursing, Ann Arbor, MI, USA
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High postoperative serum cortisol level is associated with increased risk of cognitive dysfunction early after coronary artery bypass graft surgery: a prospective cohort study. PLoS One 2013; 8:e77637. [PMID: 24143249 PMCID: PMC3797042 DOI: 10.1371/journal.pone.0077637] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 09/12/2013] [Indexed: 02/02/2023] Open
Abstract
Context Stress response induced by surgery is proposed to play an important role in the pathogenesis of postoperative cognitive dysfunction. Objective To investigate the association between postoperative serum cortisol level and occurrence of cognitive dysfunction early after coronary artery bypass graft surgery. Design Prospective cohort study. Setting Two teaching hospitals. Patients One hundred and sixth-six adult patients who were referred to elective coronary artery bypass graft surgery from March 2008 to December 2009. Intervention None. Main Outcome Measures Neuropsychological tests were completed one day before and seven days after surgery. Cognitive dysfunction was defined using the same definition as used in the ISPOCD1-study. Blood samples were obtained in the first postoperative morning for measurement of serum cortisol concentration. Multivariate Logistic regression analyses were performed to assess the relationship between serum cortisol level and occurrence of postoperative cognitive dysfunction. Results Cognitive dysfunction occurred in 39.8% (66 of 166) of patients seven days after surgery. Multivariate Logistic regression analysis showed that high serum cortisol level was significantly associated with the occurrence of postoperative cognitive dysfunction (odds ratio [OR] 2.603, 95% confidence interval [CI] 1.371-4.944, P = 0.003). Other independent predictors of early postoperative cognitive dysfunction included high preoperative New York Heart Association functional class (OR 0.402, 95% CI 0.207-0.782, P = 0.007), poor preoperative Grooved Pegboard test score of nondominant hand (OR 1.022, 95% CI 1.003-1.040, P = 0.020), use of penehyclidine as premedication (OR 2.565, 95% CI 1.109-5.933, P = 0.028), and occurrence of complications within seven days after surgery (OR 2.677, 95% CI 1.201-5.963, P = 0.016). Conclusions High serum cortisol level in the first postoperative morning was associated with increased risk of cognitive dysfunction seven days after coronary artery bypass graft surgery.
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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Zada G, Tirosh A, Huang AP, Laws ER, Woodmansee WW. The postoperative cortisol stress response following transsphenoidal pituitary surgery: a potential screening method for assessing preserved pituitary function. Pituitary 2013; 16:319-25. [PMID: 22915289 PMCID: PMC5136529 DOI: 10.1007/s11102-012-0423-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The ability to reliably identify patients with new hypocortisolemia acutely following pituitary surgery is critical. We aimed to quantify the postoperative cortisol stress response following selective transsphenoidal adenomectomy, as a marker for postoperative preservation of functional pituitary gland. Records of 208 patients undergoing transsphenoidal operations for pituitary lesions were reviewed. Patients with Cushing's Disease, preoperative adrenal insufficiency, and those receiving intraoperative steroids were excluded. To quantify the postoperative stress response, the ∆ cortisol index was defined as the postoperative day (POD) 1 morning cortisol minus the preoperative morning cortisol level. The incidence of new hypocortisolemia requiring glucocorticoid replacement upon hospital discharge was also recorded. Fifty-two patients met inclusion criteria. The mean preoperative, POD1, and POD2 cortisol levels were 16.5, 29.2, and 21.8 μg/dL, respectively. Morning fasting cortisol levels on POD1 ranged from 4.2 to 73.0 μg/dL. The ∆ cortisol index ranged from -19.0 to +56.2 (mean +12.7 μg/dL). Five patients (9.6%) developed new hypocortisolemia on POD 1-3 requiring glucocorticoid replacement; only one required long-term replacement. The mean ∆ cortisol in patients requiring postoperative glucocorticoids was -2.8 μg/dL, compared with +14.4 μg/dL in patients without evidence of adrenal insufficiency (p = 0.005). Of the 32 patients (61.5%) with a ∆cortisol >25 μg/dL, none developed postoperative adrenal insufficiency. The postoperative cortisol stress response, as quantified by the ∆ cortisol index, holds potential as a novel and complimentary screening method to predict preservation of normal pituitary function and acute development of new ACTH deficiency following transsphenoidal pituitary surgery.
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Affiliation(s)
- Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine, Los Angeles County-USC Medical Center, Los Angeles, CA, USA.
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Guvener M, Ucar HI, Oc M, Pinar A. Plasma leptin levels increase to a greater extent following on-pump coronary artery surgery in type 2 diabetic patients than in nondiabetic patients. Diabetes Res Clin Pract 2012; 96:371-8. [PMID: 22284601 DOI: 10.1016/j.diabres.2012.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Revised: 11/03/2011] [Accepted: 01/03/2012] [Indexed: 10/14/2022]
Abstract
AIMS We aimed to evaluate whether leptin and ghrelin responses to cardiopulmonary bypass (CPB) are dependent on type 2 diabetes and whether these responses are associated with interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP), cortisol and insulin. METHODS We examined stress-response patterns in plasma leptin, ghrelin, hsCRP, IL-6, cortisol and insulin levels before and up to 5 days after cardiopulmonary bypass in 20 patients with type 2 diabetes and 20 patients without diabetes. RESULTS Plasma leptin levels increased significantly in both groups (p<0.05) and rose significantly higher in diabetics when compared with nondiabetic patients (p=0.004). Plasma ghrelin levels increased significantly only in diabetics (p=0.033). Patients with and without diabetes showed significantly elevated serum concentrations of IL-6, hsCRP, cortisol and insulin (p<0.005 for IL-6, hsCRP; p<0.05 for cortisol, insulin) but the difference between the two groups was nonsignificant. Leptin was independently predicted by hsCRP (p<0.05, F=2.9), gender (women p<0.001, F=4.7), body mass index (BMI p<0.0001, F=6.1) whereas ghrelin levels were not associated with any variables in the total patient population. (critical F=2.26, p≤0.05). CONCLUSIONS Acute phase response in diabetics differs by higher leptin levels independent of BMI, gender and IL-6, hsCRP, insulin and cortisol levels.
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Affiliation(s)
- Murat Guvener
- Department of Cardiovascular Surgery, Başkent University Adana Medical Center, Yüreğir, Adana, Turkey.
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The adipocyte-derived hormone leptin has proliferative actions on androgen-resistant prostate cancer cells linking obesity to advanced stages of prostate cancer. JOURNAL OF ONCOLOGY 2012; 2012:280386. [PMID: 22690216 PMCID: PMC3368429 DOI: 10.1155/2012/280386] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 02/22/2012] [Accepted: 03/29/2012] [Indexed: 12/18/2022]
Abstract
Background. Because obesity may be a risk factor for prostate cancer, we investigated proliferative effects of adipocytes-derived hormone leptin on human prostate cancer cells and assessed the role of mitogen-activated protein kinase (MAPK) signaling pathway in mediating these actions. Material and Methods. Three human prostate cancer cell lines were treated with increasing doses of recombinant leptin. Cell growth was measured under serum-free conditions using a spectrophotometric assay. Further, Western blotting was applied to detect the phosphorylation of an ERK1/2, and a specific inhibitor of MAPK (PD98059; 40 μM) was used. Results. In both androgen-resistant cell lines DU145 and PC-3, cell growth was dose-dependently increased by leptin after 24 hrs and 48 hrs of incubation, whereas leptin's proliferative effects on androgen-sensitive cell line LNCaP was less pronounced. Further, leptin caused dose-dependent ERK1/2 phosphorylation in both androgen-resistant cell lines, and pretreatment of these cells with PD98059 inhibited these responses. Conclusions. Leptin may be a potential link between obesity and risk of progression of prostate cancer. Thus, studies on leptin and obesity association to prostate cancer should differentiate patients according to androgen sensitivity.
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Greco F, Hoda MR, Mohammed N, Springer C, Fischer K, Fornara P. Laparoendoscopic Single-Site and Conventional Laparoscopic Radical Nephrectomy Result in Equivalent Surgical Trauma: Preliminary Results of a Single-Centre Retrospective Controlled Study. Eur Urol 2012; 61:1048-53. [DOI: 10.1016/j.eururo.2012.01.043] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 01/24/2012] [Indexed: 01/20/2023]
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ANAESTHETIC ACTION AND BIOCHEMISTRY. Br J Anaesth 2012. [DOI: 10.1093/bja/aer473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Eriksson EA, Willekes CL, McAllen KJ, Romeo OM, Hooker RL, Hoogeboom JE, Barletta JF. Adrenal insufficiency in cardiothoracic patients: an evaluation of the corticotrophin stimulation test and other diagnostic methods. J Crit Care 2012; 27:528.e1-6. [PMID: 22341724 DOI: 10.1016/j.jcrc.2011.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 10/21/2011] [Accepted: 12/19/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use. MATERIALS AND METHODS Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 μg (LD) and 249 μg (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups. RESULTS There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% (κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 [0-180.6] vs 0.6 [0-73.2] hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition. CONCLUSION The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage.
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Affiliation(s)
- Evert A Eriksson
- Medical University of South Carolina, Department of Trauma and General Surgery, Charleston, SC 29425, USA.
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Morel J, Salard M, Castelain C, Bayon M, Lambert P, Vola M, Auboyer C, Molliex S. Haemodynamic consequences of etomidate administration in elective cardiac surgery: a randomized double-blinded study. Br J Anaesth 2011; 107:503-9. [DOI: 10.1093/bja/aer169] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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A comparison of pain measures in newborn infants after cardiac surgery. Pain 2011; 152:1758-1765. [DOI: 10.1016/j.pain.2011.03.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 02/26/2011] [Accepted: 03/15/2011] [Indexed: 11/23/2022]
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Abstract
OBJECTIVES To document preoperative and early postoperative serum cortisol levels among a group of neonates with complex congenital heart disease undergoing cardiopulmonary bypass surgery and to describe the relationship between serum cortisol and hemodynamic variables in the early postoperative period. DESIGN Prospective observational substudy conducted within a randomized controlled trial. SETTING Tertiary-care pediatric cardiac intensive care unit. PATIENTS : We consecutively enrolled neonates undergoing a modified Norwood procedure or repair of interrupted aortic arch with ventricular septal defect in a randomized, placebo-controlled trial of triiodothyronine replacement. Methylprednisolone (30 mg/kg intravenously) was administered at anesthetic induction. MEASUREMENTS AND MAIN RESULTS We measured serum cortisol preoperatively and at 24 and 48 hrs postoperatively. Atrial filling pressures were documented 24 and 48 hrs after surgery. Oxygen consumption was measured and cardiac index was calculated 48 hrs after surgery. Spearman's correlation and linear regression were used to examine the relationship between serum cortisol and postoperative variables. Thirty-eight patients met eligibility criteria. Median serum cortisol levels 24 and 48 hrs postoperatively were 5.0 μg/dL (range 0.4-74.0) and 4.0 μg/dL (range 0.3-17.0), respectively (p = not significant). Greater atrial filling pressures were correlated with higher serum cortisol levels 24 hrs (r = .42, p = .019) and 48 hrs (r = .46, p = .022) after surgery. A lower cardiac index was correlated with higher serum cortisol levels 48 hrs postoperatively (r = -.49, p = .039), and this relationship remained significant after controlling for inotrope score, treatment with triiodothyronine, and atrial filling pressure in bivariate models. Systolic and diastolic BP did not correlate with serum cortisol at 24 or 48 hrs. CONCLUSIONS Serum cortisol levels were low in the majority of subjects, although a wide range was observed. Higher cortisol levels were associated with greater atrial filling pressures and a lower cardiac index. The relationship between serum cortisol and cardiovascular performance after cardiopulmonary bypass in infants warrants further evaluation.
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Garcia X, Bhutta AT, Dyamenahalli U, Imamura M, Jaquiss RDB, Prodhan P. Adrenal insufficiency in hemodynamically unstable neonates after open-heart surgery. CONGENIT HEART DIS 2011; 5:422-9. [PMID: 21087426 DOI: 10.1111/j.1747-0803.2010.00447.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate if the low dose (1 µg) ACTH stimulation test appropriately assesses adrenal responsiveness in neonates undergoing open-heart surgery requiring cardio-pulmonary bypass. DESIGN In this retrospective study, adrenal axis response was assessed on the first post-operative day with the low-dose (1 µg) ACTH stimulation test. Age, gender, weight, RACHS category, inotrope score, and baseline and post-stimulation cortisol levels were collected. The association between basal serum cortisol levels and degree of response to the ACTH stimulation test was also investigated. SETTING Tertiary care referral center. PATIENTS Twenty-one neonates who underwent neonatal cardiac surgery on cardiopulmonary bypass and underwent an ACTH stimulation test. Interventions. Hydrocortisone 50 mg/m(2) bolus in four divided doses daily. OUTCOME MEASURES Response to the low dose (1 µg) ACTH stimulation was assessed. RESULTS All neonates with hemodynamic instability in the immediate post-operative period had low basal serum cortisol levels. The basal mean serum cortisol level for the 21 patients who underwent the low dose ACTH stimulation test was 7.3 µg/dL (median 2.2, range 0.7-42). The mean serum cortisol level increased after the ACTH stimulation test in the 21 patients to 39.6 µg/dL (median 38, range 79-17). The mean inotrope score in the first 24 hours after surgery was 24 (median 17.5, range 7-76.5) and decreased to 17 (median 14, range 5-52.3) 24-48 hours after surgery. At 48 hours post-surgery the mean arterial pressure in the groups with a serum cortisol increase after ACTH stimulation (<30 µg/dL vs. >50 µg/dL) was significantly different (P value 0.026). CONCLUSIONS The low dose (1 µg) ACTH stimulation test is a valid test to assess adrenal responsiveness among neonates after open heart surgery requiring CPB. Traditionally used basal serum cortisol level cutoff of <20 µg/dL used to define relative adrenal insufficiency may not be applicable in neonates undergoing open heart surgery on CPB thus indicating the need for re-defining adrenal insufficiency in this patient population.
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Affiliation(s)
- Xiomara Garcia
- Pediatric Critical Care Medicine, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark 72202, USA.
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Mu DL, Wang DX, Li LH, Shan GJ, Li J, Yu QJ, Shi CX. High serum cortisol level is associated with increased risk of delirium after coronary artery bypass graft surgery: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R238. [PMID: 21192800 PMCID: PMC3219980 DOI: 10.1186/cc9393] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Revised: 10/05/2010] [Accepted: 12/30/2010] [Indexed: 01/28/2023]
Abstract
Introduction The pathophysiology of postoperative delirium remains poorly understood. The purpose of this study was to examine the relationship between serum cortisol level and occurrence of early postoperative delirium in patients undergoing coronary artery bypass graft (CABG) surgery. Methods A total of 243 patients undergoing elective CABG surgery were enrolled. Patients were examined twice daily during the first five postoperative days and postoperative delirium was diagnosed by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Blood samples were obtained between 7 a.m. and 8 a.m. on the first postoperative day and serum cortisol concentrations were then measured. Multivariate logistic regression analyses were performed to identify risk factors of postoperative delirium. Results Postoperative delirium occurred in 50.6% (123 of 243) of patients. High serum cortisol level was significantly associated with increased risk of postoperative delirium (OR 3.091, 95% CI 1.763-5.418, P < 0.001). Other independent risk factors of postoperative delirium included increasing age (OR 1.111, 95% CI 1.065-1.159, P < 0.001), history of diabetes mellitus (OR 1.905, 95% CI 1.001-3.622, P = 0.049), prolonged duration of surgery (OR 1.360, 95% CI 1.010-1.831, P = 0.043), and occurrence of complications within the first day after surgery (OR 2.485, 95% CI 1.184-5.214, P = 0.016). Patients who developed postoperative delirium had a higher incidence of postoperative complications and a prolonged duration of postoperative ICU and hospital stay. Conclusions Delirium was a common complication after CABG surgery. High serum cortisol level was associated with increased risk of postoperative delirium. Patients who developed delirium had outcomes worse than those who did not.
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Affiliation(s)
- Dong-Liang Mu
- Department of Anesthesiology and Surgical Intensive Care, Peking University First Hospital, No, 8 Xishiku Street, Beijing 100034, PR China
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Modan-Moses D, Kanety H, Dagan O, Ehrlich S, Lotan D, Pariente C, Novikov I, Paret G. Leptin and the post-operative inflammatory response. More insights into the correlation with the clinical course and glucocorticoid administration. J Endocrinol Invest 2010; 33:701-6. [PMID: 20386086 DOI: 10.1007/bf03346673] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cardiac surgery involving cardiopulmonary bypass (CPB) causes a systemic inflammatory process which can lead to multiple organ failure and postoperative morbidity. Recent animal and human studies suggested a possible involvement of leptin in the systemic inflammatory response. AIM To characterize the response of leptin to open heart surgery (OHS) and the relationship between the time course of leptin levels and the post-operative clinical course, and to examine the effect of exogenous glucocorticoids. PATIENTS AND METHODS Forty-seven pediatric patients, undergoing OHS for congenital heart disease were studied. Thirty-four patients (Group 1) received methylprednisolone during CPB while 13 (group 2) did not. Serial blood samples were collected perioperatively and up to 24 h after surgery, and assayed for leptin and cortisol. RESULTS All patients' leptin levels decreased significantly during CPB (to 44-48% of baseline, p<0.001); they then increased, peaking at 12 h post-operatively. The levels of groups 1 and 2 were similar up to 8 h post-operatively; thereafter, those of group 1 were significantly higher. Recovery of leptin levels in patients with a more complicated post-operative course was comparatively slower. Cortisol levels of all patients increased significantly during CPB (p<0.001), gradually decreasing afterwards. Cortisol and leptin levels were inversely correlated in both patients' groups. CONCLUSIONS CPB is associated with acute changes in circulating leptin levels. A complicated postoperative course is associated with lower leptin levels which are inversely correlated with cortisol levels. Leptin may participate in post-CPB inflammatory and hemodynamic responses.
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Affiliation(s)
- D Modan-Moses
- Pediatric Endocrinology Unit, the Edmond and Lily Safra Children's Hospital, Tel Aviv, Israel.
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Robley L, Ballard N, Holtzman D, Cooper W. The experience of stress for open heart surgery patients and their caregivers. West J Nurs Res 2010; 32:794-813. [PMID: 20696847 DOI: 10.1177/0193945910361469] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this research was to understand the modern experience of stress among adult coronary artery bypass grafting (CABG) patients who are hospitalized less than 10 days and among their significant caregivers. The naming of stressors and the nature and triggers for the stress response that either contributed to or ameliorated stress were examined. A qualitative research method using hermeneutic phenomenology was used to interpret and understand the experience of stress. The stressors identified by both patient and family participants in this study were shock and disbelief leading to a feeling of being overwhelmed. Among patients, mortality was foremost. Among family caregivers, anger was expressed. The importance of providing information, honesty, and trust were pivotal to alleviating stress. A more thorough knowledge of history and complementary therapies are needed to reduce stress.
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Affiliation(s)
- Lois Robley
- Kennesaw State University, Kennesaw, GA 30144, USA.
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Greco F, Hoda MR, Wagner S, Reichelt O, Inferrera A, Fischer K, Fornara P. Adipocytokine: a new family of inflammatory and immunologic markers of invasiveness in major urologic surgery. Eur Urol 2010; 58:781-7. [PMID: 20691531 DOI: 10.1016/j.eururo.2010.07.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Accepted: 07/15/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Laparoscopic surgery has been proposed to reduce surgical trauma and diminish patients' stress response. OBJECTIVE To investigate the role of the adipocytokine, in combination with changes in other known inflammatory markers, in patients undergoing radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS A total of 580 patients were enrolled in this prospective study. Laparoscopic extraperitoneal radical prostatectomy (LRP) was performed in 286 patients, and open retropubic radical prostatectomy (RRP) in 294 patients. INTERVENTION Blood samples were collected preoperatively and up to 5 d postoperatively. MEASUREMENTS Serum concentrations of acute phase markers, interleukins (IL), and the adipocytokine leptin were measured at each time point by means of enzyme-linked immunosorbent assay. Clinical data were collected and analysed. RESULTS AND LIMITATIONS Patients undergoing LRP had significantly lower IL-6 and adipocytokine levels at all measurement time points. However, biphasic kinetics of adipocytokine serum levels were observed during the postoperative course in all patients. LRP was associated with less adipocytokine and IL-6 release, indicating a smaller degree of surgical insult and the minimal invasive nature of this procedure. The limitation of this study was its nonrandomised design. CONCLUSIONS Adipocytokines might serve as additional immunologic markers of invasiveness in major urologic surgery.
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Affiliation(s)
- Francesco Greco
- Clinic for Urology and Kidney Transplantation Centre, Martin Luther University Medical School of Halle/Saale, Germany.
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Hoda RM, Scharl M, Keely SJ, McCole DF, Barrett KE. Apical leptin induces chloride secretion by intestinal epithelial cells and in a rat model of acute chemotherapy-induced colitis. Am J Physiol Gastrointest Liver Physiol 2010; 298:G714-21. [PMID: 20203064 PMCID: PMC2867420 DOI: 10.1152/ajpgi.00320.2009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The purpose of this study was to investigate whether luminal leptin alters ion transport properties of the intestinal epithelium under acute inflammatory conditions. Monolayers of human intestinal T(84) epithelial cells and a rat model of chemotherapy-induced enterocolitis were used. Cells were treated with leptin and mounted in Ussing chambers to measure basal and secretagogue-induced changes in transepithelial short-circuit current (I(sc)). Furthermore, the role of MAPK and phosphatidylinositol 3-kinase (PI3K) signaling pathways in mediating responses to leptin was investigated. Acute colitis in Sprague-Dawley rats was induced by intraperitoneal injection of 40 mg/kg methotrexate. Leptin (100 ng/ml) induced a time-dependent increase in basal I(sc) in T(84) intestinal epithelial cells (P < 0.01). Moreover, pretreatment of T(84) cells with leptin for up to 1 h significantly potentiated carbachol- and forskolin-induced increases in I(sc). Pretreatment with an inhibitor of MAPK abolished the effect of leptin on basal, carbachol- and forskolin-induced chloride secretion (P < 0.05). However, the PI3K inhibitor, wortmannin, only blunted the effect of leptin on forskolin-induced increases in I(sc). Furthermore, leptin treatment evoked both ERK1/2 and Akt1 phosphorylation in T(84) cells. In the rat model, luminal leptin induced significant increases in I(sc) across segments of proximal and, to a lesser extent, distal colon (P < 0.05). We conclude that luminal leptin is likely an intestinal chloride secretagogue, particularly when present at elevated concentrations and/or in the setting of inflammation. Our findings may provide a mechanistic explanation, at least in part, for the clinical condition of secretory diarrhea both in hyperleptinemic obese patients and in patients with chemotherapy-induced intestinal inflammation.
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Affiliation(s)
- Raschid M. Hoda
- Department of Medicine, University of California, San Diego, School of Medicine, La Jolla, California
| | - Michael Scharl
- Department of Medicine, University of California, San Diego, School of Medicine, La Jolla, California
| | - Stephen J. Keely
- Department of Medicine, University of California, San Diego, School of Medicine, La Jolla, California
| | - Declan F. McCole
- Department of Medicine, University of California, San Diego, School of Medicine, La Jolla, California
| | - Kim E. Barrett
- Department of Medicine, University of California, San Diego, School of Medicine, La Jolla, California
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Iribarren JL, Jiménez JJ, Hernández D, Lorenzo L, Brouard M, Milena A, Mora ML, Martínez R. Relative adrenal insufficiency and hemodynamic status in cardiopulmonary bypass surgery patients. A prospective cohort study. J Cardiothorac Surg 2010; 5:26. [PMID: 20403156 PMCID: PMC2867788 DOI: 10.1186/1749-8090-5-26] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 04/19/2010] [Indexed: 12/13/2022] Open
Abstract
Background The objectives of this study were to determine the risk factors for relative adrenal insufficiency in cardiopulmonary bypass patients and the impact on postoperative vasopressor requirements. Methods Prospective cohort study on cardiopulmonary bypass patients who received etomidate or not during anesthetic induction. Relative adrenal insufficiency was defined as a rise in serum cortisol ≤ 9 μg/dl after the administration of 250 μg of consyntropin. Plasma cortisol levels were measured preoperatively, immediately before, 30, 60, and 90 minutes after the administration of cosyntropin, and at 24 hours after surgery. Results 120 elective cardiopulmonary bypass patients were included. Relative adrenal insufficiency (Δcortisol ≤9 μg/dl) incidence was 77.5%. 78 patients received etomidate and 69 (88%) of them developed relative adrenal insufficiency, (P < 0.001). Controlling for clinical characteristics with a propensity analysis, etomidate was the only independent risk factor associated with relative adrenal insufficiency (OR 6.55, CI 95%: 2.47-17.4; P < 0.001). Relative adrenal insufficiency patients showed more vasopressor requirements just after surgery (P = 0.04), and at 4 hours after surgery (P = 0.01). Pre and post-test plasma cortisol levels were inversely associated with maximum norepinephrine dose (ρ = -0.22, P = 0.02; ρ = -0.18, P = 0.05; ρ = -0.21, P = 0.02; and ρ = -0.22, P = 0.02, respectively). Conclusions Relative adrenal insufficiency in elective cardiopulmonary bypass patients may induce postoperative vasopressor dependency. Use of etomidate in these patients is a modifiable risk factor for the development of relative adrenal insufficiency that should be avoided.
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Affiliation(s)
- José L Iribarren
- Critical Care Department, Hospital Universitario de Canarias, Ofra s/n, La Cuesta, 38320 La Laguna, Tenerife, España.
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Modan-Moses D, Prince A, Kanety H, Pariente C, Dagan O, Roller M, Vishne T, Efrati O, Paret G. Patterns and prognostic value of troponin, interleukin-6, and leptin after pediatric open-heart surgery. J Crit Care 2009; 24:419-25. [PMID: 19427762 DOI: 10.1016/j.jcrc.2009.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 02/02/2009] [Accepted: 02/12/2009] [Indexed: 01/19/2023]
Abstract
PURPOSE Leptin and interleukin-6 (IL-6) are inversely correlated and associated with decreased survival in critically ill patients. We investigated changes in leptin, IL-6, and troponin in children undergoing open-heart surgery, hypothesizing that IL-6 and troponin will increase after cardiopulmonary bypass (CPB) and will be negatively correlated with leptin. PATIENTS AND METHODS Serial blood samples were collected from 21 patients 24 hours before and up to 48 hours after surgery. RESULTS Leptin levels decreased by 50% during CPB (P < .001), then gradually increased, reaching baseline levels 12 hours after surgery. The IL-6 levels increased (P < .001) during CPB, peaking 2 hours after surgery and remaining slightly elevated at 24 hours after surgery (P < .001). Leptin and IL-6 were negatively correlated (R = -0.448, P < .001). Troponin levels increased during CPB (P < .001). Postoperative leptin and troponin were inversely correlated (r = -0.535, P < .001). Patients with modest elevations in troponin levels (<20 microg/L) had a shorter aortic clamp and CPB time (P < .01), lower IL-6 peak levels (P = .03), and shorter duration of ventilation and inotropic support compared with patients with peak troponin levels greater than 20 microg/L. CONCLUSIONS Lower leptin and higher IL-6 levels correlated with troponin, a marker of myocardial injury. Because leptin may have cardioprotective effects, the postoperative drop in its levels may further contribute to myocardial dysfunction.
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Affiliation(s)
- Dalit Modan-Moses
- Pediatric Endocrinology Unit, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel.
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Morgan TJ, Power G, Venkatesh B, Jones MA. Acid-base effects of a bicarbonate-balanced priming fluid during cardiopulmonary bypass: comparison with Plasma-Lyte 148. A randomised single-blinded study. Anaesth Intensive Care 2009; 36:822-9. [PMID: 19115651 DOI: 10.1177/0310057x0803600611] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fluid-induced metabolic acidosis can be harmful and can complicate cardiopulmonary bypass. In an attempt to prevent this disturbance, we designed a bicarbonate-based crystalloid circuit prime balanced on physico-chemical principles with a strong ion difference of 24 mEq/l and compared its acid-base effects with those of Plasma-Lyte 148, a multiple electrolyte replacement solution containing acetate plus gluconate totalling 50 mEq/l. Twenty patients with normal acid-base status undergoing elective cardiac surgery were randomised 1:1 to a 2 litre prime of either bicarbonate-balanced fluid or Plasma-Lyte 148. With the trial fluid, metabolic acid-base status was normal following bypass initiation (standard base excess 0.1 (1.3) mEq/l, mean, SD), whereas Plasma-Lyte 148 produced a slight metabolic acidosis (standard base excess -2.2 (2.1) mEq/l). Estimated group difference after baseline adjustment was 3.6 mEq/l (95% confidence interval 2.1 to 5.1 mEq/l, P=0.0001). By late bypass, mean standard base excess in both groups was normal (0.8 (2.2) mEq/l vs. -0.8 (1.3) mEq/l, P=0.5). Strong ion gap values were unaltered with the trial fluid, but with Plasma-Lyte 148 increased significantly on bypass initiation (15.2 (2.5) mEq/l vs. 2.5 (1.5) mEq/l, P < 0.0001), remaining elevated in late bypass (8.4 (3.4) mEq/l vs. 5.8 (2.4) mEq/l, P < 0.05). We conclude that a bicarbonate-based crystalloid with a strong ion difference of 24 mEq/l is balanced for cardiopulmonary bypass in patients with normal acid-base status, whereas Plasma-Lyte 148 triggers a surge of unmeasured anions, persisting throughout bypass. These are likely to be gluconate and/or acetate. Whether surges of exogenous anions during bypass can be harmful requires further study.
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Affiliation(s)
- T J Morgan
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Does preoperative statin therapy improve outcomes in patients undergoing isolated cardiac valve surgery? Am J Cardiol 2008; 102:1235-9. [PMID: 18940299 DOI: 10.1016/j.amjcard.2008.06.055] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 06/20/2008] [Accepted: 06/20/2008] [Indexed: 01/31/2023]
Abstract
Preoperative statins have been associated with decreased mortality after coronary artery bypass grafting. Data are limited on whether these benefits extend to patients undergoing cardiac valve surgery. We examined whether preoperative statins decrease morbidity and mortality in patients undergoing isolated cardiac valve surgery. In a retrospective cohort analysis of consecutive patients who underwent surgical valve repair or replacement (excluding concomitant coronary artery bypass grafting, aortic root replacement, or ventricular assist device placement) at St. Luke's Episcopal Hospital, the primary outcome was 30-day mortality. Secondary outcomes included 30-day major adverse events (composite of early mortality, postoperative myocardial infarction, or stroke). Of 825 patients, 31% received preoperative statins (n = 255). Logistic regression analysis revealed that age >65 years (p = 0.02), history of congestive heart failure (p = 0.001), and total bypass time >80 minutes (p = 0.01) were independent predictors of increased 30-day mortality. Preoperative statin therapy was not associated with decreased 30-day mortality (odds ratio 0.89, 95% confidence interval 0.38 to 2.03), major adverse events (odds ratio 1.09, 95% confidence interval 0.61 to 1.96), postoperative myocardial infarction (p = 0.70), or stroke (p = 0.57). At a mean follow-up of 1.57 years, preoperative statin therapy was not associated with decreased mortality (p = 0.81). In the analysis using propensity score matching (354 propensity-matched patients, 177 in each group), preoperative statin was not associated with improved primary or secondary outcomes. In conclusion, preoperative statin therapy was not associated with a decrease in morbidity or mortality in patients undergoing isolated cardiac valve surgery.
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Hoda MR, Popken G. Mitogenic and anti-apoptotic actions of adipocyte-derived hormone leptin in prostate cancer cells. BJU Int 2008; 102:383-8. [PMID: 18341625 DOI: 10.1111/j.1464-410x.2008.07534.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To investigate the proliferative and anti-apoptotic effects of leptin on human prostate cancer cells, and the role of related signalling pathways in mediating these actions, as obesity is a possible risk factor for prostate cancer and leptin, an adipocyte-derived hormone, has mitogenic action in various cell types. MATERIALS AND METHODS Two human prostate cancer cell lines, DU145 and PC-3, were treated with leptin (5-100 ng/mL) for up to 48 h. Under serum-free conditions, cell proliferation was measured using a colorimetric tetrazolium assay and apoptosis by an enzyme-linked immunosorbent assay measuring cell death. Also, the phosphorylation of ERK1/2 and Akt was detected by Western blotting, and specific inhibitors of mitogen-activated protein kinase (MAPK) (PD98059; 40 microm) and phosphatidylinositol 3-kinase (PI3-K, LY294002; 40 microm) were used to evaluate the role of these signalling pathways. RESULTS Leptin dose-dependently increased the cell number in both cell lines for up to 48 h of incubation, the mean (sem) percentage of the control being 189 (4.3)% for DU145 and 173 (7.5)% for PC-3 (100 ng/mL leptin, 48 h; P < 0.01). Leptin also significantly reduced the number of apoptotic cells after 24 h of treatment, dose-dependently caused ERK1/2 and Akt phosphorylation; pretreatment with inhibitors of MAPK and PI3-K inhibited these responses. CONCLUSION These results show that chronic increases in leptin might enhance the growth of prostate cancer via the MAPK and PI3-K pathways. Further studies are needed to investigate whether the ability of leptin to stimulate mitogenic/anti-apoptotic signal transduction pathways could represent a target for anticancer drug discovery.
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Affiliation(s)
- M Raschid Hoda
- Department of Urology, Helios Clinics Berlin-Buch, University Medical School of Charité, Berlin, Germany.
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Current World Literature. Curr Opin Anaesthesiol 2008; 21:85-8. [DOI: 10.1097/aco.0b013e3282f5415f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Gu YJ. Invited commentary. Ann Thorac Surg 2006; 82:2186. [PMID: 17126132 DOI: 10.1016/j.athoracsur.2006.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 08/10/2006] [Accepted: 08/22/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Y John Gu
- University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, 9700 RB The Netherlands.
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