RESUMEN
BACKGROUND: Recent evidence suggests that hexokinase mitochondria association attenuates cell death, and that plasma glucose and insulin concentrations can influence clinical outcome. In the present study, we examined how different anesthetics per se affect these variables of glucose metabolism, i.e., under similar hemodynamic conditions and in the absence of major surgical stress. METHODS: In fed rats, the effects of pentobarbital (PENTO), isoflurane (ISO), sevoflurane (SEVO), ketamine-medetomidine-atropine (KMA), and sufentanil-propofol-morphine (SPM) on the cardiac cellular localization of hexokinase (HK) and levels of plasma glucose and insulin were determined and compared with values obtained in nonanesthetized animals (control). The role of mitochondrial and sarcolemmal K(ATP)-channels and alpha2-adrenergic receptor in ISO-induced hyperglycemia was also evaluated. RESULTS: Mean arterial blood pressure was similar among the different anesthetic strategies. PENTO (5.3 +/- 0.2 mM) and SPM (5.1 +/- 0.2 mM) had no significant effect on plasma glucose when compared with control (5.6 +/- 0.1 mM). All other anesthetics induced hyperglycemia: 7.4 +/- 0.2 mM (SEVO), 9.9 +/- 0.3 mM (ISO), and 14.8 +/- 1.0 mM (KMA). Insulin concentrations were increased with PENTO (2.13 +/- 0.13 ng/mL) when compared with control (0.59 +/- 0.22 ng/mL), but were unaffected by the other anesthetics. Inhibition of the mitochondrial K(ATP) channel (5-hydroxydecanoate acid) or the alpha(2)-adrenergic receptor (yohimbine) did not prevent ISO-induced hyperglycemia. Only the nonspecific K(ATP) channel inhibitor glibenclamide was able to prevent hyperglycemia by ISO. Cytoslic HK relative to total HK increased in the following sequence: control (35.5% +/- 2.1%), SEVO (35.5% +/- 2.7%), ISO (36.6% +/- 1.7%), PENTO (41.2% +/- 2.0%; P = 0.082 versus control), SPM (43.0% +/- 1.8%; P = 0.039 versus control), and KMA (46.6 +/- 2.3%; P = 0.002 versus control). CONCLUSIONS: Volatile anesthetics and KMA induce hyperglycemia, which can be explained, at least partly, by impaired glucose-induced insulin release. The data indicate that the inhibition of insulin release by ISO is mediated by sarcolemmal K(ATP) channel activation. The use of PENTO and SPM is not associated with hyperglycemia. SPM and KMA reduce the antiapoptotic association of HK with mitochondria.
Asunto(s)
Anestésicos/efectos adversos , Glucemia/efectos de los fármacos , Hexoquinasa/metabolismo , Hiperglucemia/inducido químicamente , Insulina/sangre , Mitocondrias Cardíacas/efectos de los fármacos , Miocardio/enzimología , Antagonistas Adrenérgicos alfa/farmacología , Animales , Peso Corporal/efectos de los fármacos , Citosol/enzimología , Ácidos Decanoicos/farmacología , Gliburida/farmacología , Hemodinámica/efectos de los fármacos , Hidroxiácidos/farmacología , Hiperglucemia/sangre , Hiperglucemia/enzimología , Masculino , Mitocondrias Cardíacas/enzimología , Periodo Posprandial , Bloqueadores de los Canales de Potasio/farmacología , Canales de Potasio/efectos de los fármacos , Canales de Potasio/metabolismo , Ratas , Ratas Wistar , Receptores Adrenérgicos alfa 2/efectos de los fármacos , Receptores Adrenérgicos alfa 2/metabolismo , Sarcolema/efectos de los fármacos , Sarcolema/metabolismo , Yohimbina/farmacologíaRESUMEN
OBJECTIVES: After cardiopulmonary bypass, patients often show redistribution hypothermia, also called afterdrop. Forced-air blankets help to reduce afterdrop. This study explores the effect of forced-air blankets on temperature distribution and peripheral perfusion. The blood perfusion data is used to explain the observed temperature effects and the reduction of the afterdrop. METHODS: Fifteen patients were enrolled in a randomised study. In the test group (n=8), forced-air warmers were used. In the control group (n=7), only passive insulation was used. Core and skin temperatures and thigh temperatures at 0, 8, 18 and 38 mm depth were measured. Laser Doppler flowmetry (LDF) was used to record skin perfusion from the big toe. Blood flow through the femoral artery was determined with ultrasound. RESULTS: Afterdrop in the test group was smaller than in the control group (1.2+/-0.2 degrees C vs 1.8+/-0.7 degrees C: P=0.04) whilst no significant difference in mean tissue thigh temperature was found between the groups. Local skin temperature was 2.5-3.0 degrees C higher when using forced-air heaters. However, skin perfusion was unaffected. Ultrasound measurements revealed that leg blood flow during the first hours after surgery was reduced to approximately 70% of pre- and peri-operative values. CONCLUSIONS: Forced-air blankets reduce afterdrop. However, they do not lead to clinical relevant changes in deep thigh temperature. LDF measurements show that forced-air heating does not improve toe perfusion. The extra heat especially favours core temperature. This is underlined by the decrease in postoperative leg blood flow, suggesting that the majority of the warmed blood leaving the heart flows to core organs and not to the periphery.
Asunto(s)
Válvula Aórtica/cirugía , Temperatura Corporal , Implantación de Prótesis de Válvulas Cardíacas , Calefacción/métodos , Hipotermia/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Flujometría por Láser-Doppler , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Atención Perioperativa/métodos , Complicaciones Posoperatorias/prevención & control , Flujo Sanguíneo Regional , Piel/irrigación sanguínea , Temperatura CutáneaRESUMEN
Since the days of the first cardiac surgical operations in the previous century, myocardial preservation has been an essential component of the successful outcome of these procedures. Although many different techniques to achieve myocardial preservation and modulation have been described in the past 50 years, this review focuses on the use of glucose, insulin, and potassium (GIK) and its effect on ischemic and postischemic myocardium.
Asunto(s)
Cirugía Torácica , Ensayos Clínicos como Asunto , Glucosa/historia , Glucosa/uso terapéutico , Corazón/efectos de los fármacos , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Insulina/historia , Insulina/uso terapéutico , Infarto del Miocardio/tratamiento farmacológico , Potasio/historia , Potasio/uso terapéutico , Cirugía Torácica/historiaAsunto(s)
Artefactos , Ácidos Grasos no Esterificados/sangre , Glucosa/farmacología , Heparina/farmacología , Insulina/farmacología , Lipólisis/efectos de los fármacos , Potasio/farmacología , Reacciones Falso Positivas , Glucosa/administración & dosificación , Humanos , Técnicas In Vitro , Insulina/administración & dosificación , Lactonas/farmacología , Lipoproteína Lipasa/sangre , Orlistat , Paraoxon/farmacología , Potasio/administración & dosificación , Triglicéridos/sangreRESUMEN
The effect of calcium channel blockers may affect the feedback mechanism between myocardial metabolic activity and coronary blood flow. To test this hypothesis the effect of calcium channel blockade on metabolic coronary flow regulation was studied. In 10 patients with stable coronary artery disease, coronary sinus blood flow and myocardial oxygen supply and consumption (MVO2) were measured both at sinus rhythm and during atrial pacing (30 beats/min above sinus rate), at control and during infusion of felodipine, a vasoselective dihydropyridine. The myocardial oxygen supply-consumption ratio at control (i.e., the slope of the regression line characterizing normal metabolic flow regulation) was 1.58 (95% CI, 1.38-1.80). Following infusion of felodipine, systemic and coronary vascular resistance during sinus rhythm decreased by 20 +/- 11% and 23 +/- 15%, respectively, and coronary venous oxygen saturation increased from 36 +/- 6% at control to 42 +/- 7% (p = 0.047) during infusion of felodipine. The myocardial oxygen supply-consumption ratio, characterizing metabolic flow regulation during felodipine, was 1.52 (95% CI, 1.26-1.78) and thus not different from control. Metabolic coronary flow regulation was not affected by administration of felodipine, although the setpoint of this regulation mechanism might have been offset by the initial drug-induced coronary vasodilation, which persisted during pacing.