Amaç: Uzun süreli Kardiyo-Pulmoner Baypas (KPB)'ın böbrek fonksiyonları üzerine olumsuz etkilerini azaltmak için kullanılan dopamin ve mannitol'ün veriliş şekil ve zamanına göre etkilerini karşılaştırmayı amaçladık

Effects of Mannitol and Dopamine on Renal Function in Coronary Artery Bypass SurgeryObjective: To compare the effects of dopamine and mannitol which are used to reduce the negative effects of long-term cardio-pulmonary bypass (CPB) on kidney function in according to manner of administration and by the time. Material and Methods: Group 1 (n = 25 patients): Mannitol (M) 1 g kg was added to a priming solution of CPB. Group 2 (n = 25 patients): Dopamine infusion (D) (2 mg kg min IV) was used from induction of anesthesia until end of the operation. Group 3 (n = 25 patients): D (2 mg kg min IV) was used from induction of anesthesia until end of the operation and M 1 g kg in the priming solution of CPB. Group 4 (n = 25 patients) (Control Group): Furosemide was performed in case of a decrease of urine. The values of serum urea, creatinine, albumin, urine microalbumin, urine creatinine, serum cystatin-C were compared to preop and postop periods.Results: Postop Cystatin C levels in Group I, II, III were observed a significant rise. The levels of Microalbumin / creatinine ratio in urine in all the groups at postop were seen advanced statistical significant (p <0.01). Conclusion: To determine kidney damage we have observed that microalbumin / creatinine ratio in urine compared to the Cystatin C level is to be a more sensitive parameter. We think that the use of D (2 µg kgmin ) combined with M (1 g kg) added during CPB is more effective in terms of preventing adverse effects of CPB on renal function.

Objective: Propofol has been accused for increasing plasma lipid levels during continuous infusion due to its lipid content. We aimed to show the effect and the risk of propofol infusion on plasma lipid and glucose levels in patients with hyperlipidemia undergoing coronary artery bypass graft surgery (CABG), and to compare them with a midazolam used control group. Material and Methods: In this randomized controlled study, 15 patients in the propofol group had anesthesia induction with intravenous propofol 1%, 2 mg/kg, fentanyl 10-15 mcg/kg, pancuronium 0.1 mg/kg, and the anesthesia was maintained with 1% 2-5 mg/kg/h propofol infusion, fentanyl 5-10 mcg/kg/hr, and an hourly pancuronium dose of 0.03 mg/kg The anesthetia management of 15 patients in midazolam group included induction with midazolam 0.1 mg/kg, fentanyl 10-15 mcg/kg, pancuronium 0.1 mg/kg, and infusion of midazolam 0.05-0.07 mg/kg/hr, fentanyl 5-10 mcg/kg/hr, and an hourly pancuronium dose of 0.03 mg/kg Plasma lipid [total cholesterol (CHL), triglyceride (TRG), high density lipoprotein (HDL), low density lipoprotein (LDL), very low density lipoprotein (VLDL)] and glucose concentrations were measured in both groups perioperatively, at seven different time points until 72 hours after the operation. Results: The decreases of TRG and HDL levels were statistically significant in the midazolam group. There were no significant differences for the decreases in CHL, LDL and VLDL levels between the groups. In both groups, plasma glucose levels increased significantly, independent from the propofol and midazolam infusions. Conclusion: We observed that propofol and midazolam anesthesia used in patients with hyperlipidemia undergoing to CABG did not have any effect on plasma lipid or glucose levels.

Amaç: Toraks cerrahisinde pnömonektomi ve lobektomi gibi pulmoner rezeksiyon operasyonlarını takiben akut olarak artan sağ ventrikül art yükü, sağ kalp yetmezliğine neden olabilmektedir. Bu çalışmada pulmoner rezeksiyon sonrası hemodinamik değişiklikler ile diltiazemin bu değişiklikler üzerine olan etkilerinin araştırılması amaçlandı. Gereç ve Yöntemler: Elektif lobektomi operasyonu planlanan 16 hasta prospektif çalışmaya alındı. Hastaların preoperatif hemodinamik parametreleri; kalp hızı (KH), ortalama arter basıncı (OAB), ortalama pulmoner arter basıncı (OPAB), kardiyak debi (CO), sistemik vasküler rezistans (SVR), pulmoner vasküler rezistans (PVR), sol ventrikül (LVSWI) ve sağ ventrikül atım işi indeksleri (RVSWI) kaydedildi. Pulmoner rezeksiyon sonrası postoperatif verileri alınan hastalara diltiazem 0,3 mg/kg IV bolusu takiben 0,1-0,7mg/kg/sa'ten infüzyon başlandı. Hastaların diltiazem infüzyonunun 1, 3, 6 ve 12. saatlerinde ölçümleri ve kayıtları yinelendi. İstatistiksel analiz için Wilcoxon testi kullanıldı, p<0,05 değeri anlamlı kabul edildi. Bulgular: Çalışmamızda preoperatif (T0) ve postoperatif (T1) değerler karşılaştırıldığında, pulmoner rezeksiyon sonrasında OPAB (p<0,001), PVR (p<0,001) ve RVSWI'de (p<0,001) istatistiksel olarak anlamlı artış oldu. Postoperatif değerlerin (T1) diltiazem infüzyonu sırasındaki değerlerle karşılaştırılmasında ise (T3, T4 ve T5'te) sırası ile OAB (p=0,006, p=0,004, p=0,003), KH (p=0,006, p=0,006, p=0,025), OPAB (p<0,001, p<0,001, p<0,001), RVSWI (p<0,001, p<0,001, p<0,001) ve PVR (p<0,001, p<0,001, p<0,001) istatistiksel olarak anlamlı azaldı. Sonuç: Çalışmamızda pulmoner rezeksiyonla postoperatif dönemde sağ ventrikül art yükünün artışını gösteren parametrelerdeki yükselmeler, diltiazem infüzyonu ile azalmıştır. Özellikle hipertansif ve taşikardik hastalarda diltiazem, artan sağ ventrikül iş yükünü azaltması ve stabil bir postoperatif hemodinami sağlaması açısından güvenli bir farmakolojik ajan olarak kullanılabilir.

Background: This study aims to determine the risk factors for hyperlactatemia developing after coronary artery bypass grafting (CABG) surgery and to analyze its effect on mortality and the morbidity. Methods: Four-hundred and eighty-two consecutive patients who had undergone elective CABG were prospectively included in the study and divided into two groups: group 1 (n=260), patients who had high blood lactate levels in the first measurement (>3.5 mmol/l) in the intensive care unit (ICU); group 2 (n=222), patients who had normal blood lactate levels (<3.5 mmol/l). The duration of cardiopulmonary bypass (CPB) and cross-clamping (CC), hyperglycemia (blood glucose level >140 mg/dL), the presence of hemodynamic instability and requirement for vasopressors during CPB, inotropic agent administration for more than three hours and the temperature and lactate changes at five different time points during ICU stay were measured. Postoperative neurologic, infectious and renal complications and the durations of ICU stay and mechanical ventilation were recorded. Results: The blood lactate levels were found significantly higher in patients with longer CPB and CC durations and peroperative hemodynamic instability. Postoperatively, the patients who had high glucose levels and high inotropic agent needs also had higher lactate levels. The patients in group 1 had longer extubation times and ICU stays. There was a significant correlation between blood lactate levels and mortality and morbidity (p<0.01). Conclusion: Having an initial blood lactate concentration higher than 3.5 mmol/l after being transferred to ICU is a bad prognostic indicator. Serial lactate measurements may allow for detection of patients with high risk of developing mortality and morbidity and taking the necessary preventive measures.

IntroductionEarly extubation after congenital heart surgery has been described. However, prolonged postoperative mechanical ventilation in the intensive care unit (ICU) remains common practice in many centres. This study was undertaken to determine the feasibility of early extubation of children after surgical repair of congenital heart lesions.MethodWe performed a prospective study of 100 patients aged 0-16 years (median 5.5 yr) who underwent congenital heart surgery. All patients were managed as potential candidates for early extubation. 50 patients were extubated within 6 hr (Group I) and 50 patients were extubated between 7-24 hr after surgery (Group II). The criteria for extubation were adequate spontaneous ventilation, haemodynamic stability, normothermia and adequate haemostasis. The two groups were compared by patient age, weight, status on arrival in the paediatric ICU (including haemodynamics, pH, PaCO2, SaO2, base excess, haematocrit and lactate level at 0, 6th and 12th hr). Mann Whitney-U-test was used for statistical analysis (P<0.05).ResultsPatients extubated late were younger and smaller. There were no significant differences of haemodynamics between the two groups. In the early extubation group, cardiopulmonary bypass (CPB) time and aortic cross-clamp (XCL) time were shorter (P<0.05). Use of inotropic agents was lower in group I. PaCO2 after extubation was higher in the early extubation group and pH was lower (P<0.01) but this mild to moderate respiratory acidosis was transient and required no specific treatment. One patient required re-intubation in group I. The length of ICU stay (27.97 ± 10.40 vs. 48.38 ± 32.27 hr) and hospital stay (6.51 ± 1.08 vs. 9.14 ± 3.76 days) for the early extubation group were significantly shorter (P<0.01).DiscussionThis study supports that in selected paediatric cardiac patients, early extubation can be performed safely, with a low rate of failed extubation [1Meissner U. Scharf J. Dötsch J. et al.Very early extubation after open-heart surgery in children does not influence cardiac function.Pediatr Cardiol. 2008; 29: 317-320Crossref PubMed Scopus (21) Google Scholar]. This technique reduces ICU and hospital stay without increasing postoperative complications. The strongest independent risk factors for failure of this strategy included younger age, smaller weight, longer CPB and aortic XCL time. IntroductionEarly extubation after congenital heart surgery has been described. However, prolonged postoperative mechanical ventilation in the intensive care unit (ICU) remains common practice in many centres. This study was undertaken to determine the feasibility of early extubation of children after surgical repair of congenital heart lesions.

Background: This study determined the hemodynamic and metabolic effects of insulin cardioplegia, glucose-insulin-potassium (GIK) solution combined with insulin cardioplegia, and blood-only cardioplegia on postoperative recovery in coronary artery bypass grafting (CABG). Methods: One-hundred and twenty patients with normal ventricle function and no history of diabetes mellitus (DM) were randomly divided into three groups. During the operation, 10 IU/L of crystalized insulin-added blood cardioplegia was administered to the patients in group 1 (n=40) and group 2 (n=40), and standard blood cardioplegia was used in group-3 (n=40). In addition, GIK solution was started before the removal of cross-clamp (CC) period in group 2. The blood samples from arterial and coronary sinus were collected before CC application (T0), before CC removal (T1) and 0, 5(th), 10(th), and 15(th) minutes (T2-T3-T4-T5) after CC removal. Hemodynamic parameters were measured at the 30(th) minute after anesthesia induction and 1(st) and 24(th) hours following, surgery. During the pen- and postoperative course, the need for defibrillation, inotropic and intraaortic balloon pump support, the incidence of postoperative arrythmias, duration of intubation, intensive care unit stay and hospitalization were recorded. Results: The levels of arterial and coronary sinus lactate were significantly lower in group 2 compared to group 3 in the 5(th), 10(th), and 15(th) minutes. The blood glucose levels of arterial and coronary sinus were significantly higher in group 3. In group 2, the incidence of postoperative arrythmias and requirement for inotropic support was less than that of group 1 and group 3 (p<0.05). Conclusion: After CABG, in the reperfusion period, persistant release of lactate or higher lactate levels demonstarate that myocardial protection was unsatisfactory and the recovery of aerobic metabolism was diminished perioperatively. Glucose-insulin-potassium solution combined with insulin cardioplegia decreases the myocardial lactate level, incidence of arrythmias, and requirement for inotropic support and leads to better myocardial protection.

It is not clear how levels of serum lipids and glucose and plasma osmolality change during propofol infusion in the pre- and postoperative period of coronary artery bypass graft surgery (CABG). This prospective, randomized, controlled trial evaluated changes in these parameters during propofol or midazolam infusion during and in the early postoperative period following surgery. Twenty patients undergoing CABG were randomized preoperatively into two groups: 10 patients received propofol (induction 1.5 mg/kg, maintenance 1.5 mg kg(-1) h(-1)) and 10 patients received midazolam (induction 0.5 mg/kg, maintenance 0.1 mg kg(-1) h(-1)). Both groups also received fentanyl (induction 20 mug/kg, maintenance 10 microg kg(-1)). Serum lipids, glucose, and plasma osmolality were measured preinduction, precardiopulmonary bypass, at the end of cardiopulmonary bypass, at the end of surgery, and 4 and 24 h postoperatively. In the propofol group, we observed a significant increase in triglycerides and very low-density lipoprotein levels 4 h postoperatively. In the midazolam group, we observed a significant decrease in low-density lipoprotein, cholesterol at the end of cardiopulmonary bypass, end of surgery, and 4 and 24 h postoperatively and significant increase in osmolality at the end of cardiovascular bypass. Changes in glucose levels did not differ significantly different between the two groups. In patients with normal serum lipids, glucose, and plasma osmolality undergoing CABG, propofol infusion for maintenance anesthesia is not associated with dangerous changes in serum lipids, glucose, and plasma osmolality compared with midazolam. A propofol infusion technique for maintenance of anesthesia for cardiac surgery where serum lipids and glucose may be of concern could be recommended as an alternative to midazolam.

The phosphodiesterase inhibitor milrinone is usually preferred in patients with pulmonary hypertension and myocardial dysfunction after cardiopulmonary bypass. We investigated the effects of low-dose milrinone on pulmonary hypertension in the immediate pre- and postoperative period. Forty-seven patients were randomized to the control and milrinone groups. All patients had mean pulmonary artery pressure greater than 30 mmHg and pulmonary capillary wedge pressure greater than 20 mmHg and were candidates for mitral valve replacement for rheumatic mitral stenosis. Twenty-four patients received a loading dose of milrinone 25 microg/kg(-1) during weaning from cardiopulmonary bypass, followed by a maintenance dose of 0.25 microg/kg(-1)/min(-1) to the end of the surgery. Cardiac output and other hemodynamic variables were noted at induction, weaning from bypass, and postoperative 1 h. Pulmonary artery pressure, capillary wedge pressure, and central venous pressure were significantly lower in the milrinone group during weaning after cardiopulmonary bypass, while other variables were roughly similar. However, patients in the control group required higher doses of vasodilators, inotropes, and antiarrhythmic agents. Mean arterial pressure in the milrinone group was significantly lower at 1 h postoperatively than in the control group; however, the patients did not need many more vasopressors. Fluid restriction and diuretic agent use were more significant in the control group. Systemic arterial hypotension and vasopressor requirements with milrinone use at inotropic doses were not observed at the doses used for the study. A total of 21.7% of the patients in the control group required vasopressors in the perioperative period. Both groups demonstrated similar hematologic variables except that the hemoglobin level in the control group was significantly lower during postoperative days 1 and 7. Low-dose milrinone for a short-term during weaning from cardiopulmonary bypass may be used in patients with mitral stenosis and pulmonary hypertension for its effects on pulmonary artery pressures, less inotropic and vasopressor requirements, and fluid balance.

BACKGROUND:Since the presence of pulmonary hypertension (PHT) affects the prognosis of the patients, it is important to manage and evaluate PHT. The aim of this study was to compare the hemodynamic effects of inhaled nitroglycerin and iloprost during early postoperative period, in patients with PHT undergoing mitral valve replacement surgery.MATERIALS AND METHODS:One hundred patients with PHT (mean pulmonary artery pressure (MPAP) >25 mmHg at rest), were randomized to receive either inhalation of nitroglycerin (group I; n=50) or iloprost (group II; n=50) in the postoperative period. In both groups, baseline hemodynamic parameters were recorded before the treatment (T(0)). Then, patients in group I received 20 microg.kg(-1) nitroglycerin and those in group II received 2.5 microg.kg(-1) iloprost. The same parameters were recorded immediately after the end of the treatment (T(1)).RESULTS:In both study groups MPAP and pulmonary vascular resistance (PVR) were found to be significantly lower at T(1) when compared to that of T(0) period (p<0.05). MPAP and PVR were significantly lower and mean arterial pressure (MAP) was significantly higher in group II when compared to group I at T(1) period (p<0.05). In addition to decreases in PVR and MPAP, iloprost also increased cardiac output (CO)(4.9+/-1.3 vs 5.1+/-0.9, p<0.05) and stroke volume (SV)(48+/-13 vs 56+/-13, p<0.05).CONCLUSION:Inhaled iloprost and nitroglycerin, both effectively reduce MPAP and PVR without affecting MAP, systemic vascular resistance (SVR) and CO. However, iloprost seems to be a more powerful pulmonary vasodilator, therefore we suggest iloprost inhalation in patients with severe PHT.

Critical care nurses and physicians are familiar with the principles of patient controlled analgesia and the opioid analgesics' regimens and observations necessary for pain control in the postoperative cardiac surgical patients. The objective of the study was to compare the effects of morphine, fentanyl, meperidine, remifentanil and tramadol which were administered by patient controlled analgesia and continuous intravenous infusion combination on the various parameters. This study was designed as prospective randomised trial. Fifty patients undergone open heart surgery with sternotomy were entered equally into five randomized groups. Visual analog scale was used by researcher nurse to assess the patient' pain status. Respiratory rate, heart rate and blood gases (pO2, pCO2, SaO2), radial arterial blood pressures were measured in the first 24 hrs postoperatively. Bolus requirements were determined by physicians and side effects of the analgesics were documented. Fentanyl group showed statistically higher levels of mean pO2 (p=0.002). Meperidine had the lowest number of bolus doses (p=0.001). There were no significant differences between the groups for pain management except higher visual analog scales on tramadol. Headache, stomachache and, palpitations were observed in our patients. Remifentanil, meperidine, fentanyl and morphine showed similar effect with each other for pain relief except tramadol.

Purpose Despite the well-documented impairment of pulmonary function after cardiopulmonary bypass, effective precautions and ideal management strategies for this problem are still under debate. This study aimed to evaluate the effects of continuous positive airway pressure (CPAP) applied during cardiopulmonary bypass on respiratory and hemodynamic variables. Methods In this randomized, prospective, controlled trial, 120 male patients, aged 45 to 70 yr undergoing first-time elective bypass surgery, were randomly assigned to receive either 10 cm H 2 O of CPAP (Group I; n = 60) during cardiopulmonary bypass, or serve as control (Group II; n = 60), where the patient’s lungs were vented to atmosphere during the bypass period. Results Alveolar-arterial oxygen partial pressure difference and shunt fraction were significantly higher in the control group compared with the CPAP group after cardiopulmonary bypass (T 2 ) and after closure of sternum (T 3 ), ( P < 0.05). No differences between groups with respect to hemodynamic variables were observed at any time. Postoperative pulmonary function variables were lower in both groups compared to baseline values. Conclusions Continuous positive airway pressure administered during cardiopulmonary bypass decreased shunt fraction and alveolar-arterial oxygen partial pressure difference during surgery, but had no sustained effect on either variable postoperatively. We conclude that, in patients with normal preoperative pulmonary function, application of 10 cm H 2 O CPAP does not improve lung function after cardiac surgery.

OBJECTIVE:The aim of this study is to evaluate the effects of single dose insulin, given prior to reperfusion, in patients undergoing coronary artery bypass surgery (CABG).METHODS:One hundred and twenty patients were prospectively randomized to be given either insulin (Group 1;n=60), or saline (Group 2;n= 60). Blood samples were taken 15 minutes before the reperfusion and insulin was given (0.3 IU/kg) to the patients in Group 1. Arterial and coronary sinus blood samples were taken, after the release of aortic cross-clamp (0. min), and 5th -10th -15th minutes of reperfusion. Arterial and coronary sinus lactate and glucose levels, postoperative insulin, inotropic and intraaortic balloon pump requirements; need for defibrillation and postoperative dysrhythmia, creatine kinase- MB (CPK-MB) levels, and length of stay in intensive care unit (ICU) and hospital were compared.RESULTS:In Group 1, arterial lactate levels were found to be lower at 0.min, coronary sinus lactate levels were found to be lower at 0-5-10th minutes of reperfusion compared to Group 2. Similarly, defibrillation, glucose, postoperative insulin and inotrop requirements, postoperative arrhythmia and length of ICU stay were lower in Group 1. The CPK-MB levels and length of hospital stay were similar in all patients.CONCLUSIONS:We conclude that single dose insulin given before the reperfusion period, has positive perioperative effects. Therefore it can be used in patients undergoing CABG surgery to decrease ischemia-reperfusion injury.

OBJECTIVE:The aim of this study was to compare the effects of two different cardioplegic solutions on nitric oxide (NO) release from coronary vasculature in patients with type II diabetes mellitus undergoing coronary artery bypass grafting (CABG) surgery.METHODS:Forty patients undergoing elective CABG surgery were randomized to be given crystalloid (Group 1) or blood (Group 2) cardioplegia. Aortic and coronary sinus blood samples were taken at three different time periods and the release of NO from the coronary vasculature was determined by measuring its stable end-products, nitrite and nitrate. The difference between the aortic and coronary sinus concentrations of nitrite and nitrate represents the amount of NO released by coronary vascular bed.RESULTS:Before application of aortic cross-clamp, at T1 period, the levels of nitrite/nitrate from the coronary vasculature were similar in both groups (6.53+/-1.21 microM vs 6.07+/-1.24 microM , p>0.05). However after the removal of cross-clamp, a significant decrease in NO was observed in Group 1 as compared with Group 2 (4.21+/-0.73 microM vs 4.92+/-1.02 microM, p<0.01) . This decrease persisted at T3 period, after 30 minutes of reperfusion in group 1 being significantly different from group 2 (3.86+/-0.49 vs 4.37+/-0.72 microM, p<0.05).CONCLUSION:This study has shown that in patients with type II diabetes mellitus crystalloid cardioplegia causes a decrease in the release of NO from coronary vascular bed during aortic cross-clamp and reperfusion period whereas more physiologic blood cardioplegia did not. Our findings indicate that blood cardioplegia protects endothelial function better than crystalloid cardioplegia in diabetic patients.