RESUMEN
This multicentre, non-comparative study investigated the range of target blood propofol concentrations required to sedate 122 adult intensive care patients when propofol was administered using Diprifusor target-controlled infusion systems together with opioid analgesia. Depth of sedation was assessed with a modified Ramsay score and the target blood propofol setting was adjusted to achieve the sedation desired for each patient. A desired level of sedation was achieved for 84% of the sedation period. In postcardiac surgery patients the median time-weighted average propofol target setting was 1.34 microg.ml(-1) (10th - 90th percentiles: 0.79-1.93 microg.ml(-1)). Values in brain injured and general ICU patients were 0.98 (10th - 90th percentiles: 0.60-2.55) microg.ml(-1) and 0.42 (10th - 90th percentiles: 0.16-1.19) microg.ml(-1), respectively. Measured propofol concentrations were generally close to values predicted by the Diprifusor system. Target settings in the range of 0.2-2.0 microg.ml(-1) are proposed for propofol sedation in this setting with titration as required in individual patients.
Asunto(s)
Sedación Consciente/métodos , Hipnóticos y Sedantes/administración & dosificación , Bombas de Infusión , Propofol/administración & dosificación , Adulto , Anciano , Cuidados Críticos/métodos , Femenino , Humanos , Hipnóticos y Sedantes/sangre , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios/métodos , Propofol/sangreRESUMEN
Cardiopulmonary bypass (CPB) significantly contributes to the plasma pro-inflammatory cytokine response at cardiac surgery. Complementary plasma and urinary anti-inflammatory cytokine responses have been described. The pro-inflammatory cytokines interleukin 8 (IL-8), tumour necrosis factor alpha (TNF-alpha) and interleukin 1beta (IL-1beta) have lower molecular weights than the anti-inflammatory cytokines interleukin 10 (IL-10), interleukin 1 receptor antagonist (IL-1ra) and TNF soluble receptor 2 (TNFsr2) and thus undergo glomerular filtration more readily. In vitro work suggests that proximal tubular cells are vulnerable to pro-inflammatory cytokine mediated injury. Accordingly, this study investigated the hypothesis that cardiac surgery without CPB would not have significant changes in plasma and urinary cytokines and proximal renal dysfunction. Eight patients undergoing coronary artery bypass grafting (CABG) without CPB were studied. Blood and urine samples were analysed for pro- and anti-inflammatory cytokines. Proximal tubular dysfunction was measured using urinary Nu-acetyl-beta-D-glucosaminidase (NAG)/creatinine and alpha(1)-microglobulin/creatinine ratios. Plasma IL-8, IL-10, IL-1ra and TNFsr2 were significantly elevated compared with baseline. Urinary IL-1ra and TNFsr2 were significantly elevated, as were urinary NAG/creatinine and alpha(1)-microglobulin/creatinine ratios. Two hours following revascularization, urinary IL-1ra correlated with urinary alpha(1)-microglobulin/creatinine ratios (P<0.05). As previously reported in CABG surgery with CPB, we now report that non-CPB cardiac surgery also has significant changes in plasma and urinary cytokine homeostasis and early proximal tubular injury. The correlation between urinary IL-1ra and alpha(1)-microglobulin/creatinine ratios is consistent with earlier suggestions of a mechanistic link between cytokine changes and proximal tubular dysfunction. The relative roles of CPB and non-CPB processes in producing inflammation still require definition.
Asunto(s)
Puente Cardiopulmonar , Puente de Arteria Coronaria/efectos adversos , Citocinas/sangre , Citocinas/orina , Túbulos Renales Proximales/lesiones , Inhibidor de la Tripsina de Soja de Kunitz , Acetilglucosaminidasa/orina , Adulto , Anciano , Antígenos CD/sangre , Antígenos CD/orina , Creatinina/sangre , Creatinina/orina , Femenino , Homeostasis , Humanos , Proteína Antagonista del Receptor de Interleucina 1 , Interleucina-1/sangre , Interleucina-1/orina , Interleucina-10/sangre , Interleucina-10/orina , Interleucina-8/sangre , Interleucina-8/orina , Túbulos Renales Proximales/fisiopatología , Masculino , Glicoproteínas de Membrana/orina , Persona de Mediana Edad , Receptores del Factor de Necrosis Tumoral/sangre , Receptores Tipo II del Factor de Necrosis Tumoral , Sialoglicoproteínas/sangre , Sialoglicoproteínas/orina , Cirugía Torácica , Factor de Necrosis Tumoral alfa/orinaRESUMEN
BACKGROUND: Cardiac surgery induces changes in plasma cytokines. Proinflammatory cytokines have been associated with a number of renal diseases. The proinflammatory cytokines interleukin 8 (IL-8), tumor necrosis factor alpha (TNFalpha), and interleukin 1beta (IL-1beta) are smaller than the antiinflammatory cytokines interleukin 10 (IL-10), interleukin 1 receptor antagonist (IL-1ra), and TNF soluble receptor 2 (TNFsr2), and thus undergo glomerular filtration more readily. Accordingly, this study investigated the relation between plasma and urinary cytokines and proximal renal dysfunction during cardiac surgery. METHODS: Twenty patients undergoing coronary artery bypass grafting with cardiopulmonary bypass (CPB) were studied. Blood and urine samples were analyzed for proinflammatory and antiinflammatory cytokines. Proximal tubular dysfunction was measured using urinary N-acetyl-beta-d-glucosaminidase (NAG)/creatinine and alpha1-microglobulin/creatinine ratios. RESULTS: Plasma IL-8, IL-10, IL-1ra, and TNFsr2 values were significantly elevated compared with baseline. Urinary IL-1ra and TNFsr2 were significantly elevated. Urinary NAG/creatinine and alpha1-microglobulin/creatinine ratios were also elevated. Plasma TNFalpha at 2 h correlated with urinary NAG/creatinine ratio at 2 and 6 h (P < 0.05) and with urinary IL-1ra at 2 h (P < 0.05). Plasma IL-8 at 2 h correlated with NAG/creatinine at 6 h (P < 0.05). Urinary IL-1ra correlated with urinary NAG/creatinine ratio after cross-clamp release and 2 and 6 h after CPB (P < 0.05). CONCLUSIONS: Cardiac surgery using CPB leads to changes in plasma and urinary cytokine homeostasis that correlate with renal proximal tubular dysfunction. This dysfunction may be related to the renal filtration of proinflammatory mediators. Renal autoprotective mechanisms may involve the intrarenal generation of antiinflammatory cytokines.
Asunto(s)
Puente Cardiopulmonar/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Citocinas/metabolismo , Enfermedades Renales/etiología , Enfermedades Renales/metabolismo , Acetilglucosaminidasa/orina , alfa-Globulinas/orina , Biomarcadores/orina , Creatinina/orina , Citocinas/sangre , Citocinas/orina , Femenino , Homeostasis/fisiología , Humanos , Riñón/metabolismo , Enfermedades Renales/sangre , Enfermedades Renales/orina , Túbulos Renales Proximales/fisiopatología , Masculino , Persona de Mediana EdadAsunto(s)
Procedimientos Quirúrgicos Cardíacos , Moléculas de Adhesión Celular/análisis , Granulocitos/metabolismo , Oxígeno/sangre , Anestesia , Líquido del Lavado Bronquioalveolar/química , Antígenos CD18/análisis , Puente Cardiopulmonar , Quimiocina CCL2/análisis , Niño , Preescolar , Femenino , Humanos , Lactante , Mediadores de Inflamación/análisis , Interleucina-10/análisis , Interleucina-8/análisis , Selectina L/análisis , Linfocitos/metabolismo , Antígeno de Macrófago-1/análisis , Masculino , Monocitos/metabolismo , Oxígeno/fisiología , Presión Parcial , Periodo PosoperatorioRESUMEN
We have assessed the haemodynamic effects of rapacuronium (Org 9487) in adults undergoing cardiac surgery and compared these with vecuronium and placebo. We studied 56 adult patients undergoing coronary artery bypass grafting or valve replacement surgery using a fentanyl-based anaesthetic technique. A pulmonary artery flotation catheter was inserted before induction of anaesthesia. After induction, tracheal intubation and stabilization of haemodynamic measurements, subjects were allocated randomly to receive rapacuronium 1.5 mg kg-1 vecuronium 0.1 mg kg-1 or saline placebo. Haemodynamic measurements were made before drug administration and 1, 3, 5 and 10, and if possible, 15 min after administration. Rapacuronium was associated with statistically significant increases in heart rate (17%) and cardiac index (15%) and decreases in mean arterial pressure (11%) and systemic vascular resistance (18%), whereas vecuronium and placebo were associated with significant decreases in heart rate only (14-15%) (P < 0.05). No cutaneous signs of histamine release were observed. Clinically, the results were within acceptable limits. Our results suggest that administration of rapacuronium may be associated with significant changes in heart rate and arterial pressure in patients undergoing coronary artery bypass grafting.
Asunto(s)
Puente de Arteria Coronaria , Implantación de Prótesis de Válvulas Cardíacas , Hemodinámica/efectos de los fármacos , Fármacos Neuromusculares no Despolarizantes/farmacología , Bromuro de Vecuronio/análogos & derivados , Adulto , Anestesia Intravenosa , Fentanilo , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Estimulación Química , Bromuro de Vecuronio/farmacologíaRESUMEN
We examined the effect of aprotinin on the production of interleukin-8 and the expression of leukocyte adhesion molecules in an isolated cardiopulmonary bypass circuit. Five healthy volunteers each donated 500 ml blood which was divided into equal portions (A) and (B). Portion A was treated with aprotinin 250000 kallikrein inactivator units and added to a circuit primed with a further 250000 kallikrein inactivator units. Portion B was simultaneously treated with 25 ml normal saline and added to an aprotinin-free circuit. Samples of blood were taken at donation, after addition of a drug and at 30-min intervals throughout isolated cardiopulmonary bypass. The interleukin-8 increase was smaller in the aprotinin group but the difference between groups was not statistically significant (p > 0.05). In contrast, aprotinin inhibited the cardiopulmonary bypass-induced increase in monocyte (p < 0.05) and granulocyte (p < 0.01) CD18 and the increase in granulocyte, but not monocyte, CD11b (p < 0.05). Cardiopulmonary bypass had little effect on expression of L-selectin. These results confirm that aprotinin attenuates leukocyte activation during isolated cardiopulmonary bypass.
Asunto(s)
Aprotinina/farmacología , Puente Cardiopulmonar , Hemostáticos/farmacología , Interleucina-8/sangre , Inhibidores de Serina Proteinasa/farmacología , Antígenos CD18/sangre , Humanos , Selectina L/sangre , Leucocitos/efectos de los fármacos , Leucocitos/metabolismo , Antígeno de Macrófago-1/sangreAsunto(s)
Interleucina-8/metabolismo , Isquemia Miocárdica/cirugía , Síndrome de Dificultad Respiratoria/diagnóstico , Síndrome de Dificultad Respiratoria/etiología , Factor de Necrosis Tumoral alfa/metabolismo , Adulto , Biomarcadores , Líquido del Lavado Bronquioalveolar , Procedimientos Quirúrgicos Cardiovasculares/efectos adversos , Femenino , Humanos , Masculino , Isquemia Miocárdica/metabolismo , Síndrome de Dificultad Respiratoria/metabolismo , Sensibilidad y EspecificidadRESUMEN
The aim of this study was to assess the utility of a radioimmunoconjugate containing a lead radionuclide for therapy and scintigraphy applications. The radioimmunoconjugate evaluated consisted of a bifunctional DOTA ligand and monoclonal antibody (MAb) B72.3 using athymic mice bearing LS-174T tumors, human colon carcinoma xenografts. In the studies reported here, the lead-203-DOTA complex itself was first demonstrated to have in vivo stability. MAb B72.3 was then conjugated with the DOTA ligand and labeled with 203Pb, and the immunoreactivity of B72.3 was maintained. The localization of the radioimmunoconjugate to tumor tissue and other select organs paralleled that of DOTA-125I-B72.3, suggesting a similar metabolic pattern of the two radioimmunoconjugates. Thus, the DOTA-metal complex does not alter the behavior of the radioimmunoconjugate. Tumor localization of the 203Pb-DOTA-B72.3 conjugate was demonstrated with biodistribution studies as well as immunoscintigraphy studies. Such data highlight the stability of a lead radionuclide in the DOTA ligand. The suitability of this chelation chemistry for labeling radioimmunoconjugates with a lead radionuclide now makes its application in nuclear medicine a feasible proposition.
Asunto(s)
Anticuerpos Monoclonales , Compuestos Heterocíclicos , Inmunoconjugados/uso terapéutico , Radioisótopos de Plomo/uso terapéutico , Radioinmunodetección , Radioinmunoterapia , Animales , Anticuerpos Monoclonales/uso terapéutico , Neoplasias del Colon/diagnóstico por imagen , Neoplasias del Colon/radioterapia , Compuestos Heterocíclicos/uso terapéutico , Humanos , Ratones , Ratones Desnudos , Trasplante de Neoplasias , Distribución Tisular , Trasplante HeterólogoRESUMEN
UNLABELLED: Outcome in some diseases is determined by the relationship between pro- and antiinflammatory cytokines. Surgery may also provoke a cytokine response, which has both pro- and antiinflammatory components. The aim of this study was to ascertain whether anesthetic technique can modify the balance of cytokines associated with abdominal surgery. Twenty patients scheduled to undergo elective abdominal hysterectomy were randomly allocated to receive maintenance of anesthesia with isoflurane (IH group) or propofol (IV group). Venous blood samples for measurement of tumor necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6), interleukin-10 (IL-10), and interleukin-1 receptor antagonist (IL-1ra) were taken before the induction of anesthesia and at set intervals until 24 h postoperatively. TNF-alpha levels remained low throughout the study; however, all patients showed a significant postoperative increase in IL-6, IL-10, and IL-1ra (P < 0.05). Levels of the proinflammatory cytokine IL-6 were similar in both groups, whereas the antiinflammatory cytokine IL-10 was higher in the IV group at 4 h postoperatively (P < 0.02). The difference between groups in terms of IL-1ra production just failed to reach significance (P < 0.06). We conclude that the cytokine response to abdominal surgery has both pro- and antiinflammatory components and that the choice of anesthetic may modify the balance of these cytokines. IMPLICATIONS: This study demonstrates that in addition to the widely reported proinflammatory cytokine response, elective abdominal surgery provokes an antiinflammatory response, which may be enhanced by total intravenous anesthesia. The ability of anesthetics to modify the cytokine response to surgery may have therapeutic potential.
Asunto(s)
Anestesia , Anestésicos por Inhalación/farmacología , Anestésicos Intravenosos/farmacología , Citocinas/sangre , Histerectomía , Isoflurano/farmacología , Propofol/farmacología , Adulto , Femenino , Humanos , Mediadores de Inflamación/sangre , Interleucina-10/sangre , Interleucina-6/sangre , Persona de Mediana Edad , Receptores de Interleucina-1/antagonistas & inhibidores , Factor de Necrosis Tumoral alfa/análisisRESUMEN
This study was carried out to evaluate the ease of use and reliability of cardiac output estimations performed by an oesophageal Doppler monitor and to compare its use with that of a continuous cardiac output pulmonary flotation catheter. Measurements were made during and after surgery in 16 patients scheduled to undergo coronary revascularisation. Both devices suffered significant intra-operative problems which led us to question their suitability as operating theatre monitors. After surgery the continuous cardiac output monitor provided stable results while the oesophageal Doppler monitor required the continuous presence of an experienced anaesthetist to ensure comparable cardiac output estimations.
Asunto(s)
Gasto Cardíaco , Ecocardiografía Transesofágica , Monitoreo Intraoperatorio/métodos , Revascularización Miocárdica , Anciano , Cateterismo Cardíaco , Humanos , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Cuidados Posoperatorios/métodos , TermodiluciónRESUMEN
During adult cardiac surgery the plasma pro-inflammatory cytokine response is balanced by a phased anti-inflammatory cytokine response. Whether a similar balanced plasma pro- and anti-inflammatory cytokine response occurred in paediatric cardiac surgery was investigated. Changes in intra-pulmonary cytokine balance by measuring bronchoalveolar lavage (BAL) cytokine content were also estimated. Plasma and BAL samples were obtained from 10 children (aged 15 months to 10 years) 10 min after induction of anaesthesia (sample 0), 5 min after the onset of cardiopulmonary bypass (CPB) (sample 1), 10 min after release of the aortic cross clamp (sample 2), and 2 and 24 h after the end of CPB (samples 3 and 4). BAL and plasma was assayed for interleukin 1 beta (IL-1 beta), tumour necrosis factor alpha (TNF-alpha), IL-8, IL-10, interleukin 1 receptor antagonist (IL-1ra) and the TNF soluble receptors (TNFsrs). There was a phased plasma anti-inflammatory response commencing with IL-10 (sample 2), and followed by significant increases in IL-1ra (samples 3, 4 and 5) and TNF soluble receptors (sample 5). Plasma TNF-alpha and IL-1 beta concentrations were not significantly elevated from baseline. Mean baseline plasma IL-8 was 30 (SEM 9) pg/ml. This was significantly elevated at sample 4 (112 (SEM 68) pg/ml). In BAL, only IL-8 and IL-10 were significantly elevated after CPB as compared with baseline. During paediatric cardiac surgery there is a significant increase in plasma and BAL IL-8. This is balanced within the plasma by a phased anti-inflammatory cytokine response, and within the lung by IL-10.
Asunto(s)
Líquido del Lavado Bronquioalveolar/química , Citocinas/metabolismo , Cardiopatías Congénitas/cirugía , Mediadores de Inflamación/metabolismo , Niño , Preescolar , Citocinas/sangre , Cardiopatías Congénitas/sangre , Humanos , Lactante , Mediadores de Inflamación/sangre , Interleucinas/sangre , Interleucinas/metabolismo , Receptores del Factor de Necrosis Tumoral/metabolismo , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
We report a study conducted to determine if drugs given peri-operatively during cardiac surgery could themselves modulate the balance of pro- and anti-inflammatory cytokines. We determined the cytokine response of 10 separate in vitro monocyte cultures to the administration of drugs at concentrations used during cardiac 'surgery:fentanyl (25 ng.ml-1), heparin 2.5 i.u.ml-1, heparin with an equal concentration of protamine, and enoxaparin 2.5 i.u.ml-1. Fentanyl, heparin and low molecular weight heparin (enoxaparin) led to increased tumour necrosis factor alpha but this did not reach statistical significance. Tumour necrosis factor soluble receptor 1 and 2 was not elevated. Interleukin-1 beta was increased by heparin (p < 0.05), whereas interleukin-1 receptor antagonist was increased by fentanyl (p < 0.05). Protamine blocked the heparin-induced increase in tumour necrosis factor alpha and interleukin-1 beta. These data raise the possibility that endogenous and exogenously administered opioids may be partly contributing to the interleukin-1 receptor antagonist response seen during major surgery.
Asunto(s)
Analgésicos Opioides/farmacología , Anticoagulantes/farmacología , Citocinas/efectos de los fármacos , Fentanilo/farmacología , Heparina/farmacología , Procedimientos Quirúrgicos Cardíacos , Técnicas de Cultivo de Célula , Antagonistas de Heparina/farmacología , Heparina de Bajo-Peso-Molecular/farmacología , Humanos , Interleucina-1/sangre , Monocitos/efectos de los fármacos , Monocitos/inmunología , Protaminas/farmacología , Receptores de Interleucina-1/efectos de los fármacos , Receptores de Interleucina-1/metabolismo , Factor de Necrosis Tumoral alfa/efectos de los fármacos , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
In vitro work suggests that IL-10 plays a pivotal role in controlling the balance of pro- and anti-inflammatory cytokines and monocyte HLA-DR expression. In 20 patients undergoing cardiac surgery, we investigated elaboration of interleukin 10 (IL-10) and its relationship to pro- and anti-inflammatory cytokines and leucocyte expression of HLA-DR and adhesion molecules. There were small increases in pro-inflammatory cytokines (IL-1, IL-8 and tumour necrosis factor (TNF) after induction, returning to baseline on induction of cardiopulmonary bypass (CPB). After CPB another transient increase in IL-8 occurred (P < 0.05). The anti-inflammatory response began with elevated IL-10 during CPB (P < 0.001), which peaked early in recovery (P < 0.001), by which time IL-1 receptor antagonist (IL-1ra) and the TNF soluble receptors (TNFsr) had also increased (P < 0.01). The next day IL-10 and IL-1ra were decreasing but TNFsr continued to increase. Induction of anaesthesia caused HLA-DR downregulation. The IL-10 peak was associated with further monocyte HLA-DR downregulation (P < 0.001) and return towards baseline of granulocyte adhesion molecule expression which transiently increased during CPB (P < 0.001). To determine which aspects of the immune response arose from the interaction of blood with the CPB apparatus, the above variables were studied within an isolated CPB circuit and the influence of fentanyl on the magnitude of any such changes determined. Five healthy volunteers donated two, 250-ml samples of blood to which was added either fentanyl 175 micrograms with heparin 1050 u. or heparin alone 1050 u. These were used to prime two identical isolated CPB circuits and circulation was conducted under identical conditions for 90 min. Of the pro-inflammatory cytokines, only IL-8 was elevated at 90 min CPB (P < 0.05). There was no increase in anti-inflammatory cytokines and TNFsr decreased (P < 0.001). Granulocyte adhesion molecules were increased during CPB. In the fentanyl group, the CD11b increase was greater and preceded CPB. The reduction in lymphocyte HLA-DR expression, observed throughout the study period (P < 0.01), was greater with fentanyl (P < 0.05). Monocyte HLA-DR expression increased (P < 0.05), but to a lesser extent with fentanyl (P > 0.05). In contrast with the in vivo response where there was a phased anti-inflammatory response beginning with IL-10, in the isolated CPB model no anti-inflammatory cytokine response occurred.
Asunto(s)
Puente de Arteria Coronaria , Vasos Coronarios/cirugía , Citocinas/sangre , Tolerancia Inmunológica , Adulto , Anciano , Anestésicos Intravenosos/farmacología , Moléculas de Adhesión Celular/sangre , Femenino , Fentanilo/farmacología , Antígenos HLA-DR/sangre , Humanos , Tolerancia Inmunológica/efectos de los fármacos , Interleucinas/sangre , Periodo Intraoperatorio , Leucocitos/inmunología , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
We have measured the haemodynamic effects of mivacurium 0.15 and 0.2 mg kg-1, and atracurium 0.5 mg kg-1 administered over 10-15 s in patients undergoing coronary artery bypass surgery under fentanyl anaesthesia. There were no significant haemodynamic changes in the atracurium group, other than a transient decrease in pulmonary arterial wedge pressure. Changes in heart rate were small in all three groups. Mivacurium 0.15 mg kg-1 produced changes of only small magnitude (12% decrease in mean arterial pressure and 16% decrease in systemic vascular resistance index) however, mivacurium 0.2 mg kg-1 produced a 25% reduction in mean arterial pressure, a 14% increase in cardiac index and a 35% decrease in systemic vascular resistance index. Erythema developed in two, three and seven patients after atracurium, mivacurium 0.15 mg kg-1 and mivacurium 0.2 mg kg-1, respectively. One patient exhibited a 54% decrease in mean arterial pressure, generalized erythema and bronchospasm after mivacurium 0.2 mg kg-1. The haemodynamic changes with mivacurium suggested histamine release.
Asunto(s)
Atracurio/farmacología , Fentanilo , Hemodinámica/efectos de los fármacos , Isoquinolinas/farmacología , Fármacos Neuromusculares Despolarizantes/farmacología , Presión Sanguínea/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Puente de Arteria Coronaria , Esquema de Medicación , Eritema/inducido químicamente , Humanos , Mivacurio , Resistencia Vascular/efectos de los fármacosRESUMEN
The hemodynamic effects of propofol-fentanyl and isoflurane-fentanyl anesthesia during the prebypass period were compared in 42 patients undergoing coronary artery bypass grafting (CABG) and 22 patients undergoing valve replacement (VR) for stenotic lesions. Anesthesia was induced with fentanyl, 25 micrograms/kg, and pancuronium, 0.1 mg/kg, and was maintained with a propofol infusion commenced at 4 mg/kg/h (range 1 to 10 mg/kg/h) or with isoflurane commenced at 1% (range 0 to 2%). Additional fentanyl, 7.5 micrograms/kg, was given before sternotomy. Hemodynamic measurements were made before induction of anesthesia and at various times in the prebypass period. In the VR group, there were no significant differences between the two anesthetics in any hemodynamic variables during the study. Significant decreases (P < 0.05) in mean arterial pressure (MAP 14%), left ventricular stroke work index (LVSWI 29%), and stroke volume index (SVI 24%) occurred after 15 minutes of propofol anesthesia in the CABG group. With isoflurane MAP was well maintained with reductions in LVSWI and SVI of 22% and 20%, respectively. Isoflurane was, however, associated with a significant increase in heart rate (HR) in the CABG group (P < 0.05), whereas no significant change in HR occurred in CABG or VR patients receiving propofol. With both techniques there were no significant changes in right-sided or left-sided filling pressures or in systemic vascular resistance index in the CABG or VR groups, except for a decrease in pulmonary artery occlusion pressure in the propofol VR group and isoflurane CABG group at the time of aortic cannulation. Propofol produced similar hemodynamic changes in the CABG and VR groups. Both anesthetic techniques caused myocardial depression and effectively controlled the autonomic responses to sternotomy in both groups. The study suggests that propofol-fentanyl anesthesia is an acceptable technique for CABG surgery and for VR in patients with stenotic valvular heart disease.
Asunto(s)
Anestesia por Inhalación , Anestesia Intravenosa , Puente de Arteria Coronaria , Fentanilo , Válvulas Cardíacas/cirugía , Isoflurano , Propofol , Adolescente , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Constricción Patológica/cirugía , Combinación de Medicamentos , Fentanilo/administración & dosificación , Frecuencia Cardíaca/efectos de los fármacos , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Isoflurano/administración & dosificación , Persona de Mediana Edad , Propofol/administración & dosificación , Volumen Sistólico/efectos de los fármacos , Función Ventricular Izquierda/efectos de los fármacosRESUMEN
An 11-year-old boy who underwent a modified Fontan procedure required surgical re-exploration the next day. Profound cardiogenic shock developed and he required high frequency jet ventilation and milrinone therapy for 15 days. After 11 days of high frequency jet ventilation he developed a tracheal mucous plug leading to a hypoxic cardiac arrest from which he was successfully resuscitated.
Asunto(s)
Cardiotónicos/uso terapéutico , Cardiopatías Congénitas/cirugía , Ventilación con Chorro de Alta Frecuencia , Piridonas/uso terapéutico , Choque Cardiogénico/terapia , Niño , Atrios Cardíacos/cirugía , Humanos , Masculino , Milrinona , Complicaciones Posoperatorias/terapia , Arteria Pulmonar/cirugía , Reoperación , Factores de TiempoRESUMEN
The haemodynamic effects of propofol-fentanyl anaesthesia for elective cardiac surgery were compared in 24 patients with good left ventricular function (ejection fraction > 45%, left ventricular end-diastolic pressure < 16 mmHg) and nine patients with impaired function. Anaesthesia was induced with fentanyl 25 micrograms.kg-1 and pancuronium 0.1 mg.kg-1 and was maintained with a variable rate propofol infusion, mean rate 2.61 mg.kg-1 x h-1 in the good ventricular function group and 2.71 mg.kg-1 x h-1 in the impaired function group. Additional fentanyl 7.5 micrograms.kg-1 was given before sternotomy. Ventilation to normocarbia was with air and oxygen (FIO2 0.6). Haemodynamic measurements were made before induction, after tracheal intubation, before and after sternotomy and before aortic cannulation. There were no significant differences between the groups in any haemodynamic variables during the study. Twenty minutes after intubation both groups showed a decrease from pre-induction values in mean arterial pressure (p < 0.05) and left ventricular stroke work index (p < 0.05), the reduction in left ventricular stroke work index remaining significant during the prebypass period in both groups. There were no significant changes in right or left sided filling pressures, systemic vascular resistance or heart rate. The technique decreased cardiac work and effectively controlled the autonomic responses to sternotomy in both groups. This study suggests that propofol may be a suitable adjunct to opioid anaesthesia in patients with impaired ventricular function having cardiac surgery.
Asunto(s)
Anestesia General , Puente de Arteria Coronaria , Fentanilo , Prótesis Valvulares Cardíacas , Propofol , Función Ventricular Izquierda/efectos de los fármacos , Adolescente , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Persona de Mediana Edad , Factores de Tiempo , Función Ventricular Izquierda/fisiologíaRESUMEN
Haemodynamic variables were measured following administration of pipecuronium 70 micrograms.kg-1 and pancuronium 90 micrograms.kg-1 (approximately equivalent to 1.5 x ED95) in patients anaesthetised with fentanyl 50 micrograms.kg-1 and scheduled to undergo coronary artery bypass grafting. There were significant increases in heart rate (22%), mean arterial pressure (10%), cardiac index (16%), and the rate pressure product (35%) following administration of pancuronium. The absolute values of these parameters were, however, within acceptable clinical limits. Administration of pipecuronium produced minimal and insignificant changes in these parameters. Other measured or derived indices showed only small changes with both agents and these were generally insignificant. There were no incidences of significant bradycardia following pipecuronium administration. The results from the present study suggest that pipecuronium would have advantages for use in patients with significant cardiovascular disease.