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Zheng D, Yu GL, Zhou YP, Zhang QM, Wang CG, Zhang S. Association between lactic acidosis and multiple organ dysfunction syndrome after cardiopulmonary bypass. PeerJ 2024; 12:e16769. [PMID: 38313014 PMCID: PMC10838087 DOI: 10.7717/peerj.16769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/16/2023] [Indexed: 02/06/2024] Open
Abstract
Background The relationship between hyperlactatemia and prognosis after cardiopulmonary bypass (CPB) is controversial, and some studies ignore the presence of lactic acidosis in patients with severe hyperlactacemia. This study explored the association between lactic acidosis (LA) and the occurrence of multiple organ dysfunction syndrome (MODS) after cardiopulmonary bypass. Methods This study was a post hoc analysis of patients who underwent cardiac surgery between February 2017 and August 2018 and participated in a prospective study at Taizhou Hospital. The data were collected at: ICU admission (H0), and 4, 8, 12, 24, and 48 h after admission. Blood lactate levels gradually increased after CPB, peaking at H8 and then gradually decreasing. The patients were grouped as LA, hyperlactatemia (HL), and normal control (NC) based on blood test results 8 h after ICU admission. Basic preoperative, perioperative, and postoperative conditions were compared between the three groups, as well as postoperative perfusion and oxygen metabolism indexes. Results There were 22 (19%), 73 (64%), and 19 (17%) patients in the LA, HL, and NC groups, respectively. APACHE II (24h) and SOFA (24h) scores were the highest in the LA group (P < 0.05). ICU stay duration was the longest for the LA group (48.5 (42.5, 50) h), compared with the HL (27 (22, 48) h) and NC (27 (25, 46) h) groups (P = 0.012). The LA group had the highest incidence of MODS (36%), compared with the HL (14%) and NC (5%) groups (P = 0.015). In the LA group, the oxygen extraction ratio (O2ER) was lower (21.5 (17.05, 32.8)%) than in the HL (31.3 (24.8, 37.6)%) and the NC group (31.3 (29.0, 35.4) %) (P = 0.018). In the univariable analyses, patient age (OR = 1.054, 95% CI [1.003-1.109], P = 0.038), the LA group (vs. the NC group, (OR = 10.286, 95% CI [1.148-92.185], P = 0.037), and ΔPCO2 at H8 (OR = 1.197, 95% CI [1.022-1.401], P = 0.025) were risk factor of MODS after CPB. Conclusions We speculated that there was correlation between lactic acidosis and MODS after CPB. In addition, LA should be monitored intensively after CPB.
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Affiliation(s)
- Dan Zheng
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Guo-Liang Yu
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Yi-Ping Zhou
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Qiao-Min Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Chun-Guo Wang
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
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Abstract
BACKGROUND Although serum lactate levels are widely accepted markers of haemodynamic instability, an alternative method to evaluate haemodynamic stability/instability continuously and non-invasively may assist in improving the standard of patient care. We hypothesise that blood lactate in paediatric ICU patients can be predicted using machine learning applied to arterial waveforms and perioperative characteristics. METHODS Forty-eight post-operative children, median age 4 months (2.9-11.8 interquartile range), mean baseline heart rate of 131 beats per minute (range 33-197), mean lactate level at admission of 22.3 mg/dL (range 6.3-71.1), were included. Morphological arterial waveform characteristics were acquired and analysed. Predicting lactate levels was accomplished using regression-based supervised learning algorithms, evaluated with hold-out cross-validation, including, basing prediction on the currently acquired physiological measurements along with those acquired at admission, as well as adding the most recent lactate measurement and the time since that measurement as prediction parameters. Algorithms were assessed with mean absolute error, the average of the absolute differences between actual and predicted lactate concentrations. Low values represent superior model performance. RESULTS The best performing algorithm was the tuned random forest, which yielded a mean absolute error of 3.38 mg/dL when predicting blood lactate with updated ground truth from the most recent blood draw. CONCLUSIONS The random forest is capable of predicting serum lactate levels by analysing perioperative variables, including the arterial pressure waveform. Thus, machine learning can predict patient blood lactate levels, a proxy for haemodynamic instability, non-invasively, continuously and with accuracy that may demonstrate clinical utility.
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Does severe hyperlactatemia during cardiopulmonary bypass predict a worse outcome? Ann Med Surg (Lond) 2022; 73:103198. [PMID: 35070281 PMCID: PMC8767239 DOI: 10.1016/j.amsu.2021.103198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/14/2021] [Accepted: 12/19/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The aim of the current study was to evaluate the impact of increased blood lactate levels during cardiopulmonary bypass (CPB) on immediate results in patients who underwent open heart surgery. MATERIALS AND METHODS We performed a retrospective single-center study on 1290 patients. Adult cardiac surgical patients who underwent valve surgery, coronary artery bypass graft, combined procedure, adult congenital anomalies and aortic surgery were enrolled. Patients with associated comorbidities such as liver dysfunction, hemodynamic instability before surgery were excluded. Arterial blood lactate concentration was measured immediately after weaning from CPB and evaluated together with clinical data and outcomes including in hospital mortality. Patients were classified into 3 groups according to their peak arterial lactate level: group I [normal lactatemia, lactate ˂ 2 mmol/l (n = 749)], group II [mild hyperlactatemia, lactate 2-5 mmol/l (n = 489)], group III [severe hyperlactatemia, lactate ˃ 5 mmol/l (n = 52)]. RESULTS When comparing outcomes across the 3 groups, severe hyperlactatemia was correlated with worse outcomes including higher in-hospital mortality, low output cardiac syndrome, postoperative renal insufficiency, myocardial infarction, red blood cell transfusion (RBC) transfusion, prolonged mechanical ventilation and longer intensive care unit (ICU) stay hours. CONCLUSION Blood lactate level above 5 mmol/l and more during CPB is associated with higher in-hospital mortality rate and postoperative complications. More attention must be given to correct the common abnormalities conditions inherent of CPB in order to conduct adequate tissue perfusion and reduce the risk of hyperlactatemia.
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Roy PM, Bharti K, Sinha S, Khanna S, Mehta Y. Acute perioperative hyperlactatemia in oncoplastic reconstructive surgeries: What is the significance? J Anaesthesiol Clin Pharmacol 2021; 37:416-418. [PMID: 34759554 PMCID: PMC8562435 DOI: 10.4103/joacp.joacp_297_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 05/20/2020] [Accepted: 06/14/2020] [Indexed: 11/22/2022] Open
Abstract
Background and Aims: We aim to study the significance of intraoperative hyperlactatemia in reconstructive oncoplastic surgery. Material and Methods: A retrospective observational study was conducted on a cohort of patients who underwent reconstructive oncoplastic surgery with free flap for oral cancer over a 6-month period. The study population was divided into two groups based on peak lactate levels. Group N with peak lactate level less than 2 mmol/L and Group H peak lactate level more than 2 mmol/L. The various parameter studied were patient's comorbidities; intraoperative events (vasopressor requirement, blood transfusion, and duration of surgery); postoperative parameters including the need for re- exploration and duration of stay in hospital and intensive care unit. Results: The study demonstrates that intraoperative rise of lactate was not influenced by comorbidities. None of the intraoperative parameters studied influenced the lactate levels. Baseline lactate level was found to correlate with peak lactate level intraoperatively. But it was observed that there was normalization of lactate level within 24 hours postoperatively in both the groups. There was no difference in outcome parameters in the two groups. Conclusion: Intraoperative hyperlactatemia is not a significant prognostic factor for outcome in oncoplastic reconstructive surgery.
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Affiliation(s)
- Preety M Roy
- Department of Anaesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
| | - Kamal Bharti
- Department of Anaesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
| | - Sudha Sinha
- Department of Anaesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
| | - Sangeeta Khanna
- Department of Anaesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Anaesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
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Connolly C, Stättner S, Niederwieser T, Primavesi F. Systematic review on peri-operative lactate measurements to predict outcomes in patients undergoing liver resection. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:359-370. [PMID: 32065510 PMCID: PMC7496457 DOI: 10.1002/jhbp.727] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/04/2020] [Accepted: 02/09/2020] [Indexed: 12/26/2022]
Abstract
Lactate measurements have proven utility as a triage tool, therapeutic guide, and prognostic indicator, with broad use in Acute Care and transplantation. Its value in guiding therapy and predicting outcomes following liver resection is less well‐defined. This systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines assessed the relationship between peri‐operative lactate levels and morbidity and mortality after liver resection. Seven relevant studies comprising 2573 patients in total were identified. Six studies assessed intra‐operative or early postoperative lactate levels, one publication examined pre‐operative levels. All studies demonstrated a significant association between peri‐operative lactate levels and adverse outcomes. The influence of pre‐operative diabetes and cirrhosis on postoperative lactate levels was shown in one study each, no study assessed the association of lactate with post‐hepatectomy liver failure according to defined criteria. The heterogeneity of study measurements and end‐points precluded a meta‐analysis from being performed. Early postoperative lactate >3‐3.7 mmol/L is associated with mortality but validation of clear cut‐off levels for outcome prediction is pending. Literature suggests lactate is a useful predictive marker for outcomes post liver surgery, especially when measured in the early postoperative phase. Further research is required to standardize the use of lactate measurements in a meaningful therapeutic manner.
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Affiliation(s)
- Catherine Connolly
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Niederwieser
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Mohamed H, Hosny H, Tawadros Md P, Elayashy Md Desa Fcai M, El-Ashmawi Md H. Effect of Dexmedetomidine Infusion on Sublingual Microcirculation in Patients Undergoing On-Pump Coronary Artery Bypass Graft Surgery: A Prospective Randomized Trial. J Cardiothorac Vasc Anesth 2018; 33:334-340. [PMID: 30075898 DOI: 10.1053/j.jvca.2018.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Cardiac surgery is characterized by attenuation of microcirculatory perfusion. Dexmedetomidine has been proved to attenuate the microcirculatory derangements evoked by experimental sepsis. The authors investigated the effects of dexmedetomidine infusion on sublingual microcirculation in patients undergoing on-pump coronary artery bypass graft (CABG) surgery. DESIGN Prospective, randomized blinded study. SETTINGS Tertiary university hospital. PARTICIPANTS A total of 70 adults undergoing elective on-pump CABG surgery. INTERVENTION After a standard general anesthesia, participants were allocated randomly to receive either propofol continuous intravenous infusion, 50 to 70 µg/kg/min, or propofol infusion, 50 to 70 µg/kg/min plus dexmedetomidine infusion, 0.5 µg/kg/h, during cardiopulmonary bypass. Microcirculation was studied with side-stream dark field imaging at 3 times: immediately before starting bypass (T0), 30 minutes after initiation of bypass (T1), and 30 minutes after weaning from bypass (T2). MEASUREMENTS AND MAIN RESULTS Microvascular flow index was significantly higher in the dexmedetomidine group at T2 compared to the control group (2.20 ± 0.29 and 1.47 ± 0.30, respectively; p = 0.001). The perfused vessel density was significantly higher in the dexmedetomidine group at T2 compared to the control group (6.1 [3-8.9] mm/mm² and 3.3 [2.2-4.3] mm/mm², respectively; p = 0.01). The total vascular density was significantly higher in the dexmedetomidine group compared to the control group at T1 and T2 (9.9 [7.8-12.6] mm/mm² v 7.4 [6.1-9] mm/mm², p = 0.005; and 9.27 ± 2.27 mm/mm² v 7.24 ± 1.66 mm/mm², p = 0.003, respectively). CONCLUSION This trial demonstrated that dexmedetomidine infusion improved sublingual microcirculation indices in patients undergoing on-pump CABG surgery.
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Affiliation(s)
- Hassan Mohamed
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hisham Hosny
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt.; Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton and Harefield Foundation Trust, London, United Kingdom.
| | - Pierre Tawadros Md
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Hossam El-Ashmawi Md
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Ramani J, Malhotra A, Wadhwa V, Sharma P, Garg P, Tarsaria M, Pandya H. Single-Dose Lignocaine-Based Blood Cardioplegia in Single Valve Replacement Patients. Braz J Cardiovasc Surg 2017; 32:90-95. [PMID: 28492789 PMCID: PMC5409253 DOI: 10.21470/1678-9741-2016-0025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/24/2016] [Indexed: 11/21/2022] Open
Abstract
Objective Myocardial protection is the most important in cardiac surgery. We compared
our modified single-dose long-acting lignocaine-based blood cardioplegia
with short-acting St Thomas 1 blood cardioplegia in patients undergoing
single valve replacement. Methods A total of 110 patients who underwent single (aortic or mitral) valve
replacement surgery were enrolled. Patients were divided in two groups based
on the cardioplegia solution used. In group 1 (56 patients), long-acting
lignocaine based-blood cardioplegia solution was administered as a single
dose while in group 2 (54 patients), standard St Thomas IB (short-acting
blood-based cardioplegia solution) was administered and repeated every 20
minutes. All the patients were compared for preoperative baseline
parameters, intraoperative and all the postoperative parameters. Results We did not find any statistically significant difference in preoperative
baseline parameters. Cardiopulmonary bypass time were 73.8±16.5 and
76.4±16.9 minutes (P=0.43) and cross clamp time were
58.9±10.3 and 66.3±11.2 minutes (P=0.23) in
group 1 and group 2, respectively. Mean of maximum inotrope score was
6.3±2.52 and 6.1±2.13 (P=0.65) in group 1 and
group 2, respectively. We also did not find any statistically significant
difference in creatine-phosphokinase-MB (CPK-MB), Troponin-I levels, lactate
level and cardiac functions postoperatively. Conclusion This study proves the safety and efficacy of long-acting lignocaine-based
single-dose blood cardioplegia compared to the standard short-acting
multi-dose blood cardioplegia in patients requiring the single valve
replacement. Further studies need to be undertaken to establish this
non-inferiority in situations of complex cardiac procedures especially in
compromised patients.
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Affiliation(s)
- Jaydip Ramani
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Amber Malhotra
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Vivek Wadhwa
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Pranav Sharma
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Pankaj Garg
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Malkesh Tarsaria
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Himani Pandya
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
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Lenkin PI, Smetkin AA, Hussain A, Lenkin AI, Paromov KV, Ushakov AA, Krygina MM, Kuzkov VV, Kirov MY. Continuous Monitoring of Lactate Using Intravascular Microdialysis in High-Risk Cardiac Surgery: A Prospective Observational Study. J Cardiothorac Vasc Anesth 2017; 31:37-44. [DOI: 10.1053/j.jvca.2016.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Indexed: 02/08/2023]
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Haanschoten MC, Kreeftenberg HG, Arthur Bouwman R, van Straten AH, Buhre WF, Soliman Hamad MA. Use of Postoperative Peak Arterial Lactate Level to Predict Outcome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:45-53. [DOI: 10.1053/j.jvca.2016.04.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 12/28/2022]
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Hosseinzadeh Maleki M, Derakhshan P, Rahmanian Sharifabad A, Amouzeshi A. Comparing the Effects of 5% Albumin and 6% Hydroxyethyl Starch 130/0.4 (Voluven) on Renal Function as Priming Solutions for Cardiopulmonary Bypass: A Randomized Double Blind Clinical Trial. Anesth Pain Med 2016; 6:e30326. [PMID: 27110527 PMCID: PMC4834664 DOI: 10.5812/aapm.30326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/26/2015] [Accepted: 08/17/2015] [Indexed: 11/25/2022] Open
Abstract
Background: The ideal strategy to prime the cardiopulmonary bypass (CPB) circuit in adult cardiac surgery is still a matter of debate. Objectives: In this retrospective study, we examined Albumin solution and hydroxyethyl starch (HES) for priming the CPB circuit and evaluated the differences in kidney function and bleeding and coagulation status in the two groups of patients. Patients and Methods: Sixty consecutive patients undergoing elective coronary artery bypass grafting were studied. Patients were excluded due to emergency surgery, history of cardiac surgery, history of receiving medication with antiplatelet agents except ASA 80 (mg/day) within the previous five days, preoperative coagulation disorder, left ventricular ejection fraction less than 50%, preoperative renal dysfunction (serum creatinine > 1.4 mg/dL), preoperative hepatic dysfunction (serum aspartate/alanine amino transferase > 60 U/l), preoperative electrolyte imbalance, known hypersensitivity to HES and chronic diuretic therapy. The patients were divided randomly into two groups of HES (n = 30) and Albumin (n = 30). Hemodynamic parameters, serum creatinine concentrations and glomerular filtration rate, PT, PTT and INR were measured. Early bleeding was measured according to the first 24-hour drainage from the tube. Hemodynamics and all laboratory measurements were performed after induction of anesthesia and at the morning of the first, second and third postoperative days in the ICU. Results: GFR differences were statistically lower in Albumin group in comparison with Group B at 24, 48 and 72 hours postoperation. Platelet count difference and postoperative bleeding were significantly lower in Albumin group. Conclusions: Administration of Albumin compared to HES in patients with a normal renal function results in a lower drop of GFR and platelet count, less bleeding and lower rise of serum creatinine.
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Affiliation(s)
| | - Pooya Derakhshan
- Department of Anesthesiology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
- Corresponding author: Pooya Derakhshan, Department of Anesthesiology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-9123884643, Fax: +98-2164352326, E-mail:
| | - Amir Rahmanian Sharifabad
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Ahmad Amouzeshi
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences, Birjand, Iran
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