A pilot study to investigate the effects of an infusion of aminophylline on renal function following major abdominal surgery

Evaluation of the Effect of Aminophylline in Reducing the Incidence of Acute Kidney Injury After Cardiac Surgery

Objectives

Acute renal failure is a common complication of major cardiovascular surgeries (One-third of patients). Adenosine release as a vascular vasodilator increases after cardiac surgery, which reduces renal and glomerular blood flow and subsequently causes kidney ischemic damage. The present study aimed at evaluating the impact of aminophylline as an adenosine receptor antagonist on renal function after cardiac surgery hoping to find an appropriate method to reduce acute kidney injury.

Methods

The patients in the intervention group received 5 mg/kg aminophylline bolus after induction of anesthesia; then, 0.25 mg/kg/hr of the drug was administered intraoperatively and up to 48 hours after surgery in the ICU cardiac surgery. Similar volume of normal saline was injected to the patients of the second group. Serum BUN, Cr, and GFR were measured pre- and postoperatively and 3 days postsurgery. Patients’ 24- hour urine output and RIFLE were also calculated.

Results

Those patients who received medication were extubated earlier (P = 0.018) and received lower amount of inotropic drugs (P < 0001). According to the RIFLE criteria, most of the patients experienced no change or even improved GFR and Cr amounts compared to the control group (p < 0.05). GFR and Cr value of all the patients with Cleveland score, less and more than 6, showed a significant difference between the 2 groups (P = 0.001 and P = 0.01, respectively). According to the RIFLE criteria, most of the patients experienced no change or even improved GFR.

Conclusions

Aminophylline in cardiac surgery can reduce the frequency of acute kidney injury according to RIFLE criteria and could be used in the prevention of AKI as a safe and efficient modality in high-risk patients. Also, the use of this drug may reduce the need for inotropic medication at the time of surgery, intensive care unit stay length, and extubation time.

The clinical research enterprise in critical care: what's right, what's wrong, and what's ahead?

Intensivists have been remarkably successful in using randomized controlled trials to assess aspects of current practice. Unfortunately, this success has not been mirrored in trials of new pharmacotherapy, despite convincing pathophysiological rationales and encouraging preliminary studies. Misunderstandings of biological processes and flawed early clinical studies have led to the almost universal failure of fundamentally new treatments subjected to large phase III trials, despite their sound methodology. Compounding these problems is the tendency for new approaches to be either implemented widely on the basis of relatively poor studies or ignored despite strong supporting evidence. Having mastered the principles of evidence-based medicine in assessing existing therapy, intensivists have established a strong foundation. Critical care medicine must now embrace the challenge of translating a more solid understanding of basic disease mechanisms into widely implemented treatments.

Supplementation of pre-oxygenation in morbidly obese patients using nasopharyngeal oxygen insufflation

During apnoea following induction of anaesthesia, morbidly obese patients may suffer a rapid decrease in oxygen saturation. This study compares pre-oxygenation alone with pre-oxygenation followed by nasopharyngeal oxygen insufflation on the onset of desaturation occurring during the subsequent apnoea. A randomised controlled trial was performed in 34 morbidly obese patients undergoing gastric bypass or gastric band surgery. Seventeen patients received nasopharyngeal oxygen supplementation following pre-oxygenation (Study group, body mass index = 41.8 (6.9) kg.m(-2)), and the other 17 patients received pre-oxygenation alone (Control group, body mass index = 42.7 (5.4) kg.m(-2)). Time from the onset of apnoea until S(p)o(2) fell to 95% was compared between the two groups with a cut-off of 4 min. In the control group, the S(p)o(2) fell from 100% to 95% during the subsequent apnoea in 145 (27) s, with a significantly negative correlation (r(2) = 0.66, p < 0.05) between the time to desaturation to 95% and the body mass index. In the study group, the S(p)o(2) was maintained in 16 of 17 patients at 100% for 4 min when apnoea was terminated. In conclusion, nasopharyngeal oxygen insufflation following pre-oxygenation in morbidly obese patients delays the onset of oxyhaemoglobin desaturation during the subsequent apnoea.

Aminophylline: exploring cardiovascular benefits versus medical malcontent

Although aminophylline/theophylline has been relegated to third- and fourth-line status in the cardiopulmonary armamentarium, its use in specific pathophysiologic states, especially those of cardiac etiology, can be of significant benefit. The consulting clinician should maintain an awareness of its potential as adjunctive therapy in cases of atrioventricular block, cardiac arrest, heart failure, and bradyarrhythmias in particular. It should not yet be shelved as an archaic agent.

The role of K+ channels in vasorelaxation induced by hypoxia and the modulator effects of lidocaine in the rat carotid artery

Hypoxia induces vasodilation, partly via the activation of K(+) channels. Lidocaine impairs vasorelaxation mediated by a K(+) channel opener, suggesting that this antiarrhythmic drug may inhibit hypoxia-induced vasodilation mediated by K(+) channels. We designed the current study to determine whether, in the carotid artery, K(+) channels contribute to vasorelaxation in response to hypoxia and whether lidocaine modulates vasorelaxation induced by K(+) channels via pathophysiological and pharmacological stimuli. Rings of rat common carotid artery without endothelium were suspended for isometric force recording. During contraction to phenylephrine, hypoxia-induced vasorelaxation or concentration-response to an adenosine triphosphate-sensitive K(+) channel opener was obtained changing control gas to hypoxic gas and the cumulative addition of levcromakalim, respectively. Hypoxia-induced vasorelaxation was significantly reduced by glibenclamide (5 micro M) but not by iberiotoxin (0.1 micro M), apamin (0.1 micro M), BaCl(2) (10 micro M), or 4-aminopyridine (1 mM). Levcromakalim-induced vasorelaxation was completely abolished by glibenclamide. Lidocaine (10-100 micro M) concentration-dependently inhibited this vasodilation, whereas it did not affect hypoxia-induced vasodilation. These results suggest that adenosine triphosphate-sensitive K(+) channels play a role in hypoxia-induced vasodilation in the rat carotid artery and that lidocaine differentially modulates vasodilation via these channels activated by pathophysiological and pharmacological stimuli.

IMPLICATIONS

In rat carotid artery, levcromakalim produced vasorelaxation mediated by adenosine triphosphate (ATP)-sensitive K(+) channels, whereas hypoxia induced it partly via these channels. Lidocaine inhibited vasorelaxation induced by an ATP-sensitive K(+) channel opener but not by hypoxia, indicating the differential mechanisms of modulatory effects of this antiarrhythmic drug on vasodilation via ATP-sensitive K(+) channels activated by pathophysiological and pharmacological stimuli.

Acute renal failure in hospitalized patients: part II

BACKGROUND

Acute renal failure (ARF) is a common condition in hospitalized patients. Research has been unable to identify the optimal target for therapeutic intervention; hence, effective prevention of and/or treatment for ARF remain elusive.

OBJECTIVE

To examine the usefulness of current and potential pharmacologic treatments in seriously ill, hospitalized patients.

DATA SOURCES

A MEDLINE search (1996-June 2002) was conducted using the search terms kidney (drug effects) and acute kidney failure (drug therapy). Bibliographies of selected articles were also examined to include all relevant investigations.

STUDY SELECTION AND DATA EXTRACTION

Review articles, meta-analyses, and clinical trials describing prevention of and treatment for hospital-acquired ARF were identified. Results from prospective, controlled trials were given priority when available.

CONCLUSIONS

Appropriate management of ARF includes prospective identification of at-risk patients, fluid administration, and optimal hemodynamic support. Drug treatments, including low-dose dopamine and diuretics, have demonstrated extremely limited benefits and have not been shown to improve patient outcome. Experimental agents influence cellular processes of renal dysfunction and recovery; unfortunately, relatively few drugs show promise for the future.