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Dobson GP, Morris JL, Letson HL. Adenosine, lidocaine and Mg 2+ update: teaching old drugs new tricks. Front Med (Lausanne) 2023; 10:1231759. [PMID: 37828944 PMCID: PMC10565858 DOI: 10.3389/fmed.2023.1231759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
If a trauma (or infection) exceeds the body's evolutionary design limits, a stress response is activated to quickly restore homeostasis. However, when the injury severity score is high, death is often imminent. The goal of this review is to provide an update on the effect of small-volume adenosine, lidocaine and Mg2+ (ALM) therapy on increasing survival and blunting secondary injury after non-compressible hemorrhagic shock and other trauma and infective/endotoxemic states. Two standout features of ALM therapy are: (1) resuscitation occurs at permissive hypotensive blood pressures (MAPs 50-60 mmHg), and (2) the drug confers neuroprotection at these low pressures. The therapy appears to reset the body's baroreflex to produce a high-flow, hypotensive, vasodilatory state with maintained tissue O2 delivery. Whole body ALM protection appears to be afforded by NO synthesis-dependent pathways and shifting central nervous system (CNS) control from sympathetic to parasympathetic dominance, resulting in improved cardiovascular function, reduced immune activation and inflammation, correction of coagulopathy, restoration of endothelial glycocalyx, and reduced energy demand and mitochondrial oxidative stress. Recently, independent studies have shown ALM may also be useful for stroke, muscle trauma, and as an adjunct to Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Ongoing studies have further shown ALM may have utility for burn polytrauma, damage control surgery and orthopedic surgery. Lastly, we discuss the clinical applications of ALM fluid therapy for prehospital and military far-forward use for non-compressible hemorrhage and traumatic brain injury (TBI).
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Affiliation(s)
- Geoffrey P. Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Kramer AM, Kiss A, Heber S, Chambers DJ, Hallström S, Pilz PM, Podesser BK, Santer D. Normothermic blood polarizing versus depolarizing cardioplegia in a porcine model of cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 2022; 35:ivac152. [PMID: 35640544 PMCID: PMC9199933 DOI: 10.1093/icvts/ivac152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/30/2022] [Accepted: 05/25/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We have previously demonstrated beneficial cardiac protection with hypothermic polarizing cardioplegia compared to a hyperkalemic depolarizing cardioplegia. In this study, a porcine model of cardiopulmonary bypass was used to compare the protective effects of normothermic blood-based polarizing and depolarizing cardioplegia during cardiac arrest. METHODS Thirteen pigs were randomized to receive either normothermic polarizing (n = 8) or depolarizing (n = 5) blood-based cardioplegia. After initiation of cardiopulmonary bypass, normothermic arrest (34°C, 60 min) was followed by 60 min of on-pump and 90 min of off-pump reperfusion. Primary outcome was myocardial injury measured as arterial myocardial creatine kinase concentration. Secondary outcome was haemodynamic function and the energy state of the hearts. RESULTS During reperfusion, release of myocardial creatine kinase was comparable between groups (P = 0.36). In addition, most haemodynamic parameters showed comparable results between groups, but stroke volume (P = 0.03) was significantly lower in the polarizing group. Adenosine triphosphate levels were significantly (18.41 ± 3.86 vs 22.97 ± 2.73 nmol/mg; P = 0.03) lower in polarizing hearts, and the requirement for noradrenaline administration (P = 0.002) and temporary pacing (6 vs 0; P = 0.02) during reperfusion were significantly higher in polarizing hearts. CONCLUSIONS Under normothermic conditions, polarizing blood cardioplegia was associated with similar myocardial injury to depolarizing blood cardioplegia. Reduced haemodynamic and metabolic outcome and a higher need for temporary pacing with polarized arrest may be associated with the blood-based dilution of this solution.
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Affiliation(s)
- Anne-Margarethe Kramer
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Attila Kiss
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Stefan Heber
- Institute of Physiology, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - David J Chambers
- Cardiac Surgical Research, The Rayne Institute (King’s College London), Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Seth Hallström
- Division of Physiological Chemistry, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Patrick M Pilz
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - David Santer
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
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Jiang Y, Lin J, Zheng H, Zhu P. The Role of Purinergic Signaling in Heart Transplantation. Front Immunol 2022; 13:826943. [PMID: 35529844 PMCID: PMC9069525 DOI: 10.3389/fimmu.2022.826943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Heart transplantation remains the optimal treatment option for patients with end-stage heart disease. Growing evidence demonstrates that purinergic signals mediated by purine nucleotides and nucleosides play vital roles in heart transplantation, especially in the era of ischemia-reperfusion injury (IRI) and allograft rejection. Purinergic signaling consists of extracellular nucleotides and nucleosides, ecto-enzymes, and cell surface receptors; it participates in the regulation of many physiological and pathological processes. During transplantation, excess adenosine triphosphate (ATP) levels are released from damaged cells, and driver detrimental inflammatory responses largely via purinergic P2 receptors. Ecto-nucleosidases sequentially dephosphorylate extracellular ATP to ADP, AMP, and finally adenosine. Adenosine exerts a cardioprotective effect by its anti-inflammatory, antiplatelet, and vasodilation properties. This review focused on the role of purinergic signaling in IRI and rejection after heart transplantation, as well as the clinical applications and prospects of purinergic signaling.
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Affiliation(s)
| | | | | | - Ping Zhu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Francica A, Vaccarin A, Dobson GP, Rossetti C, Gardellini J, Faggian G, Onorati F. Short-term outcome of adenosine-lidocaine-magnesium polarizing cardioplegia in humans. Eur J Cardiothorac Surg 2021; 61:1125-1132. [PMID: 34751752 DOI: 10.1093/ejcts/ezab466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Hyperkalaemic depolarized myocardial arrest is the cornerstone of myocardial protection, although some potassium-related cytotoxicity has been demonstrated. Polarized arrest has gained interest because of a reported better myocardial protection in preclinical studies. The goal of this study was to analyse the quality of myocardial protection and hospital outcome after normokalaemic adenosine-lidocaine-magnesium (ALM) blood polarizing cardioplegia, compared to hyperkalaemic blood Buckberg depolarizing cardioplegia, in elective routine adult cardiac surgery. METHODS One thousand consecutive elective adult cardiac patients [627 undergoing ALM-polarizing cardioplegia (ALM-POL) vs 373 Buckberg depolarized cardioplegia (BUCK-DEPOL)] who were operated on were analysed. Perioperative leakage of high-sensitivity troponin I (Hs-TnI), peripheral lactate, inotropic and vasoactive daily requirement [maximal vasoactive inotropic score (VISMAX)], hospital mortality and morbidity were collected and compared in the overall population and in the propensity score (PS) matched population (206 pairs). RESULTS A significantly lower leakage of Hs-TnI during hospitalization was detected in patients receiving ALM-POL versus those receiving BUCK-DEPOL (group time P < 0.001 for overall population and PS matched pairs). The maximum value of postoperative Hs-TnI was also lower after ALM-POL (P < 0.001 in both cohorts), and spontaneous recovery of sinus rhythm at aortic declamping was higher (P < 0.001 in favour of ALM-POL). Maximal VISMAX during hospitalization was significantly higher after BUCK-DEPOL in both cohorts (P = 0.019 for overall population; P = 0.031 for PS matched population), with significantly higher VISMAX on the day of surgery in BUCK-DEPOL PS matched patients (P = 0.042). No other significant differences in hospital morbidity and mortality were found. CONCLUSIONS Despite comparable short-term clinical outcomes, ALM-POL cardioplegia proved superior in terms of quality of myocardial protection compared to BUCK-DEPOL cardioplegia in elective routine adult cardiac surgery.
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Affiliation(s)
- Alessandra Francica
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Arianna Vaccarin
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Geoffrey Phillip Dobson
- Heart, Trauma & Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Cecilia Rossetti
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Jacopo Gardellini
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Giuseppe Faggian
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Onorati
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
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Francica A, Tonelli F, Rossetti C, Tropea I, Luciani GB, Faggian G, Dobson GP, Onorati F. Cardioplegia between Evolution and Revolution: From Depolarized to Polarized Cardiac Arrest in Adult Cardiac Surgery. J Clin Med 2021; 10:jcm10194485. [PMID: 34640503 PMCID: PMC8509840 DOI: 10.3390/jcm10194485] [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: 09/04/2021] [Accepted: 09/28/2021] [Indexed: 12/12/2022] Open
Abstract
Despite current advances in perioperative care, intraoperative myocardial protection during cardiac surgery has not kept the same pace. High potassium cardioplegic solutions were introduced in the 1950s, and in the early 1960s they were soon recognized as harmful. Since that time, surgeons have minimized many of the adverse effects by lowering the temperature of the heart, lowering K+ concentration, reducing contact K+ time, changing the vehicle from a crystalloid solution to whole-blood, adding many pharmacological protectants and modifying reperfusion conditions. Despite these attempts, high potassium remains a suboptimalway to arrest the heart. We briefly review the historical advances and failures of finding alternatives to high potassium, the drawbacks of a prolonged depolarized membrane, altered Ca2+ intracellular circuits and heterogeneity in atrial-ventricular K+ repolarization during reanimation. Many of these untoward effects may be alleviated by a polarized membrane, and we will discuss the basic science and clinical experience from a number of institutions trialling different alternatives, and our institution with a non-depolarizing adenosine, lidocaine and magnesium (ALM) cardioplegia. The future of polarized arrest is an exciting one and may play an important role in treating the next generation of patients who are older, and sicker with multiple comorbidities and require more complex operations with prolonged cross-clamping times.
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Affiliation(s)
- Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
- Correspondence: ; Tel.: +39-3356213738
| | - Filippo Tonelli
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Cecilia Rossetti
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Ilaria Tropea
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Geoffrey Phillip Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville 4811, Australia;
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
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Dobson GP, Biros E, Letson HL, Morris JL. Living in a Hostile World: Inflammation, New Drug Development, and Coronavirus. Front Immunol 2021; 11:610131. [PMID: 33552070 PMCID: PMC7862725 DOI: 10.3389/fimmu.2020.610131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
We present a brief history of the immune response and show that Metchnikoff's theory of inflammation and phagocytotic defense was largely ignored in the 20th century. For decades, the immune response was believed to be triggered centrally, until Lafferty and Cunningham proposed the initiating signal came from the tissues. This shift opened the way for Janeway's pattern recognition receptor theory, and Matzinger's danger model. All models failed to appreciate that without inflammation, there can be no immune response. The situation changed in the 1990s when cytokine biology was rapidly advancing, and the immune system's role expanded from host defense, to the maintenance of host health. An inflammatory environment, produced by immune cells themselves, was now recognized as mandatory for their attack, removal and repair functions after an infection or injury. We explore the cellular programs of the immune response, and the role played by cytokines and other mediators to tailor the right response, at the right time. Normally, the immune response is robust, self-limiting and restorative. However, when the antigen load or trauma exceeds the body's internal tolerances, as witnessed in some COVID-19 patients, excessive inflammation can lead to increased sympathetic outflows, cardiac dysfunction, coagulopathy, endothelial and metabolic dysfunction, multiple organ failure and death. Currently, there are few drug therapies to reduce excessive inflammation and immune dysfunction. We have been developing an intravenous (IV) fluid therapy comprising adenosine, lidocaine and Mg2+ (ALM) that confers a survival advantage by preventing excessive inflammation initiated by sepsis, endotoxemia and sterile trauma. The multi-pronged protection appears to be unique and may provide a tool to examine the intersection points in the immune response to infection or injury, and possible ways to prevent secondary tissue damage, such as that reported in patients with COVID-19.
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Affiliation(s)
- Geoffrey P. Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Onorati F, Francica A, Dobson GP, Faggian G. Myocardial protection: the forgotten 'polarized' modality. Eur J Cardiothorac Surg 2021; 59:284. [PMID: 32728693 DOI: 10.1093/ejcts/ezaa218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/23/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Francesco Onorati
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
| | - Geoffrey P Dobson
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
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Allen B. Reply to Onorati et al. Eur J Cardiothorac Surg 2021; 59:285. [PMID: 32728731 DOI: 10.1093/ejcts/ezaa219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 05/23/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bradley Allen
- Division of Acute Care Surgery, Department of Surgery, USC School of Medicine and Los Angeles County Medical Center, Los Angeles, CA, USA
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Letson HL, Granfeldt A, Jensen TH, Mattson TH, Dobson GP. Adenosine, Lidocaine, and Magnesium Support a High Flow, Hypotensive, Vasodilatory State With Improved Oxygen Delivery and Cerebral Protection in a Pig Model of Noncompressible Hemorrhage. J Surg Res 2020; 253:127-138. [PMID: 32353638 DOI: 10.1016/j.jss.2020.03.048] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/20/2020] [Accepted: 03/24/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Noncompressible hemorrhage is the leading cause of preventable death in military and civilian trauma. Our aim was to examine the effect of adenosine, lidocaine, and magnesium (Mg2+; ALM) on cardiovascular and cerebral function in a porcine hepatic hemorrhage model. MATERIALS AND METHODS Pigs (59.1 ± 0.34 kg) were anesthetized, instrumented, and randomly assigned into sham (n = 6), saline controls (n = 10) or ALM (n = 10) groups before laparoscopic liver resection. After 30 min, groups received 4 mL/kg 3% NaCl ± ALM bolus (Phase 1) followed 60 min later with 3 mL/kg/h 0.9% NaCl ± ALM drip (4 h; Phase 2), then transfusion. Hemodynamics, carotid artery flow, and intracranial pressure were measured continuously. Microdialysis samples were analyzed for metabolites. RESULTS Saline controls had 20% mortality (mean survival time: 307 ± 38 min) with no ALM deaths over 6 h. Bolus administration increased mean arterial pressure (MAP) in both groups, and drip led to further increases to 62 ± 10 mmHg in controls compared with a steady fall to 47 ± 8 mmHg in ALM group at 240 min. The lower MAP was associated with a dramatic fall in systemic vascular resistance and improved oxygen delivery. ALM drip significantly increased cardiac output and stroke volume with lower dP/dtMin, indicating a less stiff heart. ALM drip also significantly decreased cerebral perfusion pressure, reduced cerebral oxygen consumption (28%), and reduced brain glycerol (60%), lactate (47%), and relative expression of hypoxia-inducible factor (38%) compared with saline controls. CONCLUSIONS ALM therapy improved cardiac function and oxygen delivery by lowering systemic vascular resistance after noncompressible hemorrhage. ALM also appeared to protect the brain at hypotensive MAPs with significantly lower cerebral perfusion pressure, lower O2 consumption, and significantly lower cortical lactate and glycerol levels compared to saline controls.
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Affiliation(s)
- Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine & Dentistry, James Cook University, Townsville, Queensland, Australia
| | | | | | | | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine & Dentistry, James Cook University, Townsville, Queensland, Australia.
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Spellman J. Pro: In Favor of More Generalized Use of del Nido Cardioplegia in Adult Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2019. [DOI: 10.1053/j.jvca.2018.01.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abdelwahab AA, Sabry M, Elshora HA, Arafat AA. Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery. Heart Lung Circ 2018; 28:1714-1719. [PMID: 30253969 DOI: 10.1016/j.hlc.2018.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 07/16/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery. METHODS Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7. RESULTS There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups. CONCLUSIONS Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.
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Affiliation(s)
| | - Mohab Sabry
- Cardiothoracic Surgery Department, Tanta University, Egypt
| | - Hatem A Elshora
- Anesthesia and Surgical ICU Department, Tanta University, Egypt
| | - Amr A Arafat
- Cardiothoracic Surgery Department, Tanta University, Egypt.
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Evaluation of adenosine, lidocaine, and magnesium for enhancement of platelet function during storage. J Trauma Acute Care Surg 2017; 83:S9-S15. [PMID: 28383470 DOI: 10.1097/ta.0000000000001479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The combination of adenosine, lidocaine, and magnesium (Mg2+) (ALM) has demonstrated cardioprotective and resuscitative properties in models of cardiac arrest and hemorrhagic shock that are linked to reduction of metabolic demand. Platelets play a key role in resuscitation strategies for ATC but suffer from loss of function following storage in part owing to mitochondrial exhaustion. This study evaluates whether ALM also demonstrates protective properties in stored platelet preparations. METHODS Platelets were tested at (baseline, Day 5, Day 10, and Day 15) at 22°C (room temperature) or 4°C in 100% plasma and platelet additive solution. Adenosine, lidocaine, and magnesium treatment or its individual components (A, L, M, or combinations) were added directly to the minibags at baseline for storage. Measurements consisted of blood gas and chemistry analyses, thromboelastography, impedance aggregometry, and flow cytometry. RESULTS Blood gas and cell analysis, as well as flow cytometry measures, demonstrated only differences between temperature groups starting at Day 5 (p < 0.05) and no differences between treatment groups. Aggregation response to collagen (A only, M only, and ALM high dose) and thrombin receptor activation peptide (A + M, and ALM high dose) was significantly greater at Day 5 compared to respective 4°C (100% plasma) controls (p < 0.05). Thromboelastography analysis revealed significant preservation of all measures (reaction time, maximum amplitude, and angle) at Day 15 for 4°C-stored samples in 100% plasma in both controls (no ALM) and ALM treatment compared to room temperature (p < 0.05); no differences were observed between the ALM and control groups. CONCLUSIONS The mechanism of ALM's protective effect remains unclear; key cellular functions may be required to provide protection. In this study, improvements in collagen and thrombin receptor activation peptide aggregation were seen when compared to 4°C-stored plasma samples although no improvements were seen when compared to 4°C-stored platelet additive solution platelets. LEVEL OF EVIDENCE Therapeutic/care management, level II.
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Small-Volume Adenosine, Lidocaine, and Mg2+ 4-Hour Infusion Leads to 88% Survival after 6 Days of Experimental Sepsis in the Rat without Antibiotics. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2016; 23:863-872. [PMID: 27581435 DOI: 10.1128/cvi.00390-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/25/2016] [Indexed: 12/29/2022]
Abstract
Innovative host-directed drug therapies are urgently required to treat sepsis. We tested the effect of a small-volume 0.9% NaCl adenosine, lidocaine, and Mg2+ (ALM) bolus and a 4-h intravenous infusion on survivability in the rat model of polymicrobial sepsis over 6 days. ALM treatment led to a significant increase in survivability (88%) compared to that of controls (25%). Four controls died on day 2 to 3, and two died on day 5. Early death was associated with elevated plasma and lung inflammatory markers (interleukin-6 [IL-6], IL-1β, C-reactive protein), reduced white blood cell (WBC) count, hypoxemia, hypercapnia, acidosis, hyperkalemia, and elevated lactate, whereas late death was associated with a massive cytokine storm, a neutrophil-dominated WBC rebound/overshoot, increased lung oxidant injury, edema, and persistent ischemia. On day 6, seven of eight ALM survivors had inflammatory and immunological profiles not significantly different from those of sham-treated animals. We conclude in the rat model of experimental sepsis that small-volume ALM treatment led to higher survivability at 6 days (88%) than that of controls (25%). Early death in controls (day 2 to 3) was associated with significantly elevated plasma levels of IL-1β, IL-6, and C-reactive protein, severe plasma lymphocyte deficiency, reduced neutrophils, and acute lung injury. Late death (day 5) was associated with a massive neutrophil inflammatory storm, increased lung injury, and persistent ischemia. Possible mechanisms of ALM protection are discussed.
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