[Predictive value of body mass index for perioperative hyperglycemia occurrence in cardio-surgical patients without diabetes mellitus].

UNLABELLED: Purpose of the study was to assess a predictive value of body mass index for perioperative hyperglycemia occurrence in cardio-surgical patients without a diabetes mellitus. MATERIALS AND METHODS: Retrospective analysis of glycemic profile, frequency and level of perioperative hyperglycemia was performed 120 patients without a diabetes mellitus, undergoing elective cardiac surgeries with cardiopulmonary bypass were included in the study. All patients were divided into three groups. Group-1 included patients with normal body weight (body mass index (BMI) < 25), Group-2--patients with increased body weight (BMI 25-29.9), Group-3--patients with obesity (BMI > 30). RESULTS: Elective cardiac surgeries with artificial circulation accompanied with episodes of hyperglycemia. Hyperglycemia occurrence did not have relation with initial glycemic profile of the patients. Glycemia level increased during surgery and the highest levels of both glycemia increasing of hyperglycemia frequency were fixed during cardiopulmonary bypass and postperfusion period. Increased body weight and obesity are predisposing causes of perioperative hyperglycemia.

[Mesenteric circulation evaluation during myocardial revascularization with different temperature modes of extracorporeal circulation].

The Mesenteric blood circulation during myocardium revasculization was investigated 40 patients were divided in 2 groups: 1st group - normothermia CPB, 2nd group hypothermia CPB. It was found that reduced mesenteric perfusion occurred in both groups, but it was more pronounced in hypothermia CPB group and was caused by a significant deterioration of the microcirculation.

[Sevoflurane optimal dosage estimation for myocardium pharmacological postconditioning: an experimental study].

We estimated the optimal dosage of inhalation anesthetic sevoflurane, for the maximum cardioprotective effect with minimal angioparalytic action. 25 pigs were included in this study, they were divided into 5 groups, depending on the sevoflurane dosage used for pharmacological postconditioning (PPC): control group - PPC has't been conducted, a group of PPC 0.5 - sevoflurane PPC in a dose of 0.5 V%, a group of PPC 1.0 - sevoflurane PPC in a dose of 1.0 V%, a group of PPC 1.5 - sevoflurane PPC in a dose of 1.5 V%, a group of PPC 2.0 - sevoflurane PPC in a dose of 2.0 V%, a group of PPC 2.5 - sevoflurane PPC in a dose of 2.5 V%. Ischemia was simulated by left coronary artery crossclamping. Further PPC was held according to the following Protocol: 20 min before left coronary artery clamp off and first 20 min of reperfusion sevoflurane was given into CPB circuit. Myocardial ischemia period was 60 min in all groups. It was found and experimentally proved that the optimal sevoflurane dosage for PPC is 2 V%

[Optimization of anesthetic maintenance using two-channel laryngeal masks Proseal during endovascular correction of congenital defects in infants and young children].

The paper analyzes the efficiency of the authors' procedure for anesthetic maintenance based on a combination of inhalational (sevoflurane) and intravenous (1% propofol) anesthesia on spontaneous breathing through a ProSeal laryngeal mask airway in the X-ray endovascular correction of congenital heart diseases in infants and young children. The study included 118 children aged 2 to 7 years with secondary atrial septal defect, who had undergone endovascular defect correction, by applying an Amplazer septal occluder. The key points of the anesthetic maintenance proposed by the authors are: (1) substitution of routine pharmacological premedication for psychological (the presence of parents); (2) inhalational (sevoflurane) anesthesia in the induction of anesthesia; (3) replacement of an endotracheal tube by a ProSeal laryngeal mask; (4) refusal of myorelaxants and respiratory support without artificial ventilation. The authors' anesthesia protocol during these operations provides a safe perioperative period.

[Diagnostics of volemic disorders in cardiosurgical patients: modern state of the problem].

Volemic disorders are widely encountered in anesthesiology and intensive therapy. Lower cardiac output caused by inadequate preload leads to tissue hypoperfusion, increased frequency of perioperative complications and higher death rates. The objective diagnosis of the volemic status remains a challenge since before as all the indices characterizing the preload, which are currently used in clinical practice, enable the true preload to be estimated only to a certain extent. The paper considers the currently available diagnostic studies for volemic disorders in cardiosurgical patients, their merits, demerits, and possible limitations of their use.

[Role of entropy-based neuromonitoring during cardiac surgery].

The paper deals with a role of spectral entropy-based neuromonitoring at cardiac surgery. Eighty cardiosurgical patients were examined. The depth of entropy-based anesthesia was monitored in all the patients. The patients enrolled into the study were divided into 2 groups. Anesthesia was carried out in the study group (n=40), by taking into account entropic parameters, and in the control group (n=40) on clinical grounds. Information on entropic parameters in this group was accessible only to an investigator and inaccessible to an anesthesiologist who had made anesthesia. The results of the study indicated that entropy-based neuromonitoring permits more controllable and predictable anesthesia to be achieved, makes an individual adjustment of the doses of sedatives easier for each patient, at the induction of anesthesia particularly, enables hypo- and hyperhypnotic episodes to be timely revealed, thus reducing the frequency of hypo- and hyperdynamic reactions by 2.4 times.

[Target-oriented infusion therapy in patients during myocardial revascularization].

The paper analyzes goal-oriented infusion therapy used during myocardial revascularization on the working heart. Forty-seven patients with coronary heart disease were examined. Group 1 (control) (n = 20) received standard infusion therapy (a combination of colloids and crystalloids (1:1) at a rate of 6-7 ml/kg/h, by being oriented to indices, such as heart rate, blood pressure, central venous pressure, and diuresis rate. In group 2, an anesthetist was oriented to central hemodynamic parameters during infusion therapy. In addition, the patients of this group underwent the 45 degrees passive leg raising test. In this group, a volume load was done at the beginning of an operation until the maximum possible SV resulted from increased preload (global end-diastolic volume index). The goal of infusion therapy throughout the operation was to maintain these values of the latter index. Goal-oriented infusion therapy, the purpose of which was to determine and maintain the individual optimal values of preload, was found to minimize hemodynamic disorders at surgery and to reduce the frequency of use of cardiotonic agents and the duration of artificial ventilation.

[The efficacy and safety of tranexamic acid and epsilon-aminocapronic acid in cardiac surgery under extracorporeal circulation].

Sixty patients who had undergone cardiosurgical operations under extracorporeal circulation (EC) were enrolled in the study. All the patients were divided into 2 groups: (1) 40 patients were injected tranexamic acid (TA) (its loading dose was 15 mg/kg; maintenance infusion 1 mg/kg/h throughout the operation; 500 mg in the primary packing volume for an EC apparatus (EA); (2) 20 patients received epsilon-aminocapronic acid (ACA) (its loading dose was 5 g; 5 g in the primary packing volume for an EA and 10 g for infusion after EC). The effects of TA and ACA on the fibrinolytic system were evaluated from the time of XIIa-kallikrein-dependent fibrinolysis (sec) and the concentration of D-dimer (mg/ml). The hemocoagulation system (activated partial thromboplastin time, thrombin clotting time, prothrombin time with the determination of the international normalized ratio, fibrinogen) was studied. The thromboelastogram (the time R, K, and alpha-angle, MA) was analyzed. The indices were determined at the beginning and end of, and 12 hours after surgery. The analysis of the clinical efficacy and safety of the agents was based on the following perioperative data: the incidence of adverse reactions and complications associated with the administration of the agents, the frequency and amount of transfused donor blood components, the volume of blood loss, and the rate of resternotomies. The laboratory and clinical findings lead to the conclusion that TA (Tranexam, OOO "MIR-PHARM") has a 4-fold antifibrinolytic activity as compared with epsilon-ACA. The more pronounced TA-induced suppression of fibrinolysis affects the clinical course of a perioperative period in this group, which manifests itself as a reduced blood loss volume during and after surgery and a lower frequency of use of donor blood elements. By taking into account these data, TA may be recommended as one of the blood-preserving technology components during cardiosurgical operations under EC.

[Method of pharmacological myocardial preconditioning with halogen-containing anesthetics in cardiosurgical patients].

The purpose of the investigation was to study whether isoflurane and sevoflurane might be used for pharmacological myocardial preconditioning (PMP) in patients with coronary heart disease during myocardial revascularization on the working (Part I) and arrested (Part II) heart and to develop a possible procedure for PMP. Part I deals with the study of the effect of PMP with halogen-containing anesthetics during myocardial revascularization on the working heart. The study included 66 patients who were divided into 4 groups; 1) sevoflurane feeding was started just after anesthesia induction and it lasted until some coronary arteries were ligated; 2) sevoflurane was fed for 15 min; 3) isoflurane was used; 4) controls. The markers of myocardial lesion (troponin T, I) were measured and the incidence of perioperative myocardial ischemia and needs for inotropic support were also analyzed. Part II was dedicated to the study of the effect of PMP during myocardial revascularization under extracorporeal circulation (EC). The study covered 65 patients who were divided into 4 groups; 1) sevoflurane was administered throughout the anesthesia until the aorta was ligated; 2) it was used for 15 min before aortic ligation; 3) sevoflurane was employed only to induce anesthesia; 4) controls. The variables similar to those in Part I of the investigation were chosen to assess the results of this study. The use of sevoflurane and isoflurane reduces a risk for myocardial ischemic lesion during myocardial revascularization both under EC and on the working heart. Short-term (15-min) use of an agent before myocardial ischemia suffices for PMP to develop its effect. The effect of PMP has its duration that is 76 min, as shown by our findings.

[Use of loading test to predict intraoperative heart failure in cardiosurgical patients].

The paper deals with the development of a procedure for using loading tests to predict the development of intraoperative heart failure in cardiosurgical patients. A volumetric loading test (limb elevation) was carried out to assess the mechanisms of responsible for the regulation of performance of the heart and the efficiency of its work. Cardiac output, end diastolic volume index, and ejection fraction were recorded and a hemodynamic response was assessed from their changes. Loading tests enabled the authors to identify 3 types of a hemodynamic response to a volumetric load. The incidence of postperfusion heart failure may be predicted depending on the identified type of a hemodynamic response to the volumetric load given at the very beginning of surgery.

[Intraoperative evaluation of the microcirculatory system in cardiosurgical patients].

The investigation was undertaken to study the specific features of vessels of the microcirculatory bed in cardiosurgical patients during myocardial revascularization. The study covered 20 patients with NYHA Functional Classes III-IV coronary heart disease. Ten patients from Group 1 were operated on the working heart (aortocoronary bypass surgery (ACBS) without extracorporeal circulation (EC)). In 10 patients from Group 2, myocardial revascularization was performed under normothermal (tcenter = 36 degrees C) EC (ACBS + EC). Microcirculatory blood flow was analyzed by laser Doppler fluometry. Microcirculatory blood flow index, variation coefficient, neurogenic and myogenic microvascular tone indices, and bypass value were estimated. It has been concluded that 1) laser Doppler fluometry evaluates the microcirculatory bed during anesthesia in cardiosurgical patients; 2) a dynamic response of the microcirculatory bed to stresses is retained during general anesthesia; 3) under normothermal EC, there are more pronounced microcirculatory disorders than during myocardial revascularization on the working heart.

[Optimization of the volemic status of cardiosurgical patients before initial anesthesia].

Twenty-six patients with coronary heart disease who had undergone aortocoronary bypass surgery were examined. In all the patients, central hemodynamic parameters were monitored by transpulmonary thermodilution. The patients were divided into 2 groups. In Group 1 (n = 14), routine initial anesthesia was made without a preliminary volumetric loading test. In Group 2 (n = 12), a controlled volumetric loading test was carried out before induction; a decision on whether it might be made was taken on the basis of the results of a loading test for passive leg raise. The patients from both groups were hypovolemic at baseline, as suggested by the low values of central venous pressure (CVP) and global end-diastolic volume index (GEDVI). By the initiation of initial anesthesia, in Group 2 the mean blood pressure (BPmean), CVP, stroke index (SI), and GEDVI were significantly higher and total peripheral vascular resistance index (TPVRS) was significantly lower than in Group I (p < 0.05), as achieved via preliminary loading tests. After the maximum hypnotic effect being achieved in Group 1, there were reductions in BPmean, SI, GEDVI, dPmax, and TPVRS (p < 0.05). In Group 1, 50% of the patients were observed to have hypotension episodes requiring the patient to be placed in Trendelenburg's position and to be given colloids as jets, and 3 patients received bolus vasopressors. After achieving the maximum hypnotic effect, BPmean, SI, GEDVI, and dPmax also decreased in Group 2 patients (p < 0.05). However, due to preliminary loading tests, these variables remained to be in the normal ranges and were significantly higher than in Group 1 (p < 0.05). IOPSS objectively reflects the preload status at all stages of initial anesthesia and the leg raising test enables prediction of a cardiovascular response to a volumetric load. When infusion therapy is performed, it is advisable to take into account a relationship between altered preload (GEDVI) and cardiac performance (SI). This volumetric loading testing tactics before induction promotes GEDVI to be maintained in the normal ranges throughout the initial anesthesia and minimizes hemodynamic disorders at this stage.

[Anesthesiological provision of surgical correction of dilated cardiomyopathy in patients with chronic heart failure].

When dilated cardiomyopathy (DCM) is surgically corrected, intraoperative intracardiac hemodynamic changes and additional ischemia of the disabling myocardium make special demands for anesthesia, prevention of cardiovascular insufficiency, and maintenance of circulatory oxygen-transporting function (COTF). For the development and evaluation of an anesthetic support protocol for patients with DCM, clinical parameters, hemodynamics and oxygen transport was comprehensively analyzed in 50 DCM patients aged 16-68 years in the intraoperative period of surgical correction of myocardial pathology. All the patients underwent implantation of an extracardiac mesh framework in combination, if required, with correction of mitral insufficiency under extracorporeal circulation (EC), drug-induced cold cardioplegia. Analysis of comprehensive clinical studies made it possible to provide scientific evidence and to successfully use the anesthetic support protocol for correcting operations of chronic heart failure in patients with DCM, the basic principles of the support being an effective preoperative preparation of a patient to attenuate the signs of congestive heart failure; preventive intraaortic balloon contrapulsation before surgery; overall monitoring of hemodynamics and oxygen transport; balanced use of anesthetic agents in the doses that exert no cardiosuppressive effect; preload optimization and postload reduction; the minimum use of catecholamines; prevention of arrhythmias; and a reduction in the duration of myocardial ischemia.

[Current approaches to intraoperative diagnosis and treatment of low cardiac output during cardiosurgical operations].

The paper deals with the development of a diagnostic and therapeutic algorithm of intraoperative heart failure during cardiosurgical operations on the basis of evaluation of systolic and diastolic functions of the left and right ventricles. The study included 101 patients with low cardiac output in the postperfusion period. All the patients suffered from coronary heart disease and they underwent myocardial revascularizing operations under extracorporeal circulation. In all the patients, in addition to traditional hemodynamic parameters (heart rate, blood pressure, central venous pressure), the functional status of the left and right ventricles was evaluated by transesophageal Doppler echocardiography (TED echoCG) and the thermodilution technique using a Swan-Ganz catheter having a prompt thermistor. Evaluating the diastolic and diastolic functions of the right and left ventricles makes it possible to identify 2 types of left and right ventricular failure: 1) that due to systolic dysfunction and 2) that due to concomitance of systolic and diastolic dysfunctions. Dobutrex (5-7.5 microg/kg/min) should be used in right ventricular systolic dysfunction. Amrinone (5-10 microg/kg/min) should be given to patients with concomitance of systolic and diastolic dysfunction; in this situation, a combination of dobutrex and nitroglycerin (100-150 ng/kg/min) may be used. The drugs of choice in impaired left ventricular systolic function are epinephrine (30-100 ng/kg/min), dopamine (5-10 microg/kg/min), or dobutrex (5-7.5 microg/kg/min). Their combination with sodium nitroprusside can enhance the efficiency of therapy. In patients with left ventricular failure caused by systolic and diastolic dysfunction, epinephrine, dopamine, or dobutrex may be combined with amrinone (5-10 microg/kg/min) or nitroglycerin (100-150 ng/kg/min).

[Preventive intraaortic balloon counterpulsation during surgical myocardial revascularization].

Fifty patients with low myocardial functional reserves (left ventricular ejection fraction less than 40%, disseminated cardiosclerosis, multiple affection of coronary arteries, NYHA class III-IV) after coronary artery bypass surgery (CABS) were examined. All the patients were divided into 2 groups. Preventive intraaortic balloon counterpulsation (IABC) was used in 24 patients (group 1). Group 2 consisted of 26 patients with similar physical state where IABC has not been used. It was revealed that preventive IABC leads to stabilization of the left ventricle function and cardiac output, a decrease in the doses and period of catecholamines administration. The rate of cardiac rhythm disorders in group 1 was 7 times, myocardial infarction -- 2.5 times, respiratory failure -- 5 times, stay at the intensive care unit -- 2 times less compared with those of group 2. Lethality was 12.5% in group 1 and 26.9% in group 2.

[The state of hemostasis in patients after mini-invasive aorta and coronary artery bypass surgery]. / Sostoianie gemostaza u bol'nykh posle operatsii mini-invazivnogo aortokoronarnogo shuntirovaniia.

The paper represents data on the condition of the hemostasis of plasma and platelet chains as well as of the system of natural anticoagulants and fibrinolysis as observed in cardiosurgical patients after mini-invasion coronary artery bypass surgery. An intensified generation of platelets, postoperative hyperaggregation of platelets and a lower level of natural anticoagulants in blood were shown as to be compensated for by an activated system of fibrinolysis.

[Continuous epidural infusion of ropivacaine hydrochloride (naropin) during postoperative analgesia in cardiosurgical patients]. / Postoiannaia épidural'naia infuziia ropivakaina gidrokhlorida (naropin) pri posleoperatsionnom obezbolivanii kardiokhirurgicheskikh bol'nykh.

An efficiency and safety of continuous infusion of naropin in the epidural analgesia of 38 patients after coronary artery bypass grafting were demonstrated. A variation of combined anesthesia, which was elaborated at the Russian Research Center of Surgery of the Russian Academy of Medical Sciences and which comprises (as a basic component of anesthetic management) a high thoracal epidural block (T2-T4) by continuous infusion of a 2% solution of naropin at a velocity of 5 +/- 2 ml/h. Anesthesia was supported by isoflurane (0.5 +/- 0.9%). The patients were extubated in the operated theater and taken to the resuscitation unit with continuous infusion of 0.2% naropin solution. All studied parameters were registered after discharge from the operating theater and 1, 3, 6, and 16-18 hours after surgery. The pain-syndrome intensity was measured at the verbal scale with 0 to 3 points. The mean duration of continuous naropin infusion was 16.7 +/- 0.5 h, mean dose--2.2 +/- 0.2 ml/h. Naropin was administered at a dose of 1-3 ml/h in 89.7% of cases and at a dose of 6 ml/h only in 2.9% of cases. The drug, when used in small doses, ensured a high anesthetic efficiency. A total lack of pain or a mild pain of 0.1 points was observed in 86.5% of patients at stage 5 of examinations and in 100% of patients at stage 3. Naropin infusion did not entail any impairment in ventilation or gaseous metabolism. A reliable decrease of arterial pressure (AP) and of central venous pressure (CVP), (p < 0.05) were registered beginning from stage 2. CVP decrease versus stage 1 was ensured in 38.% of patients by stage 4 and the number of patients with a decreased CVP (less than 60 mm H) went up, versus stage 1, by 3 times. APsyst of less than 90-80 mm Hg was registered in 15 (39.8%) of patients at different examination stages, which necessitated the use of noradrenalin at mean dose of 174 +/- 21 ng/kg.min. The infusion of naropin at dose of 1-6 ml/h did not entail any impairment in the central nervous system (hallucinations, convulsions, and headache).

[Currently available blood saving methods in a patient at cardiac surgery under extracorporeal circulation]. / Sovremennye metody sokhraneniia krovi bol'nogo pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

Different blood saving methods are analyzed in 2000 cardiac surgical patients undergoing coronary and vascular bypass surgery in 1993 to 2000. The basic blood saving methods are as follows: intraoperative autoreinfusion (normovolemic thermodilution), reinfusion of the patient's blood, preoperative autologous plasma donation in combination with aprotinine, aminocapronic acid, etc. An analysis revealed a decrease in homologous blood components intraoperatively. Red blood cell transfusion decreased from 100% in 1993 to 44% in 2000, fresh frozen plasma and platelet transfusions did from 98 to 39% and from 96 to 1%, respectively. Intraoperative homologous blood transfusion could be avoided in 70% of those undergone coronary bypass surgery.

[Use of H2-receptor blocker famotidine (quamatel) in anesthesiology for cardiopulmonary bypass surgery]. / Primenenie blokatora H2-retseptorov gistamina famotidina (kvamatela) v skheme anesteziologicheskogo obespecehniia kardiokhirurgicheskikh vmeshatel'stv s iskusstvennym krovoobrashcheniem.

The efficiency of perioperative therapy with quamatel (histamine H2-receptor blocker) for preventing gastrointestinal complications in cardiosurgical patients was evaluated. Quamatel was used in 68 cardiosurgical patients subjected to aortocoronary bypass surgery for coronary disease. Perioperative pH profile of the gastric contents was evaluated by a Gastroscan-5 acidogastrometer (Russia). The volume of gastric juice secretion was evaluated after induction anaesthesia, at the end of operation, and 6-8 h after the intervention. Quamatel was highly effective and well tolerated by cardiosurgical patients with concomitant gastrointestinal diseases during preparation to surgery. Use of quamatel for premedication, particularly in patients with gastrointestinal diseases, stabilized pH and decreased the gastric juice hypersecretion during the entire intraoperative and early postoperative period, thus preventing gastrointestinal complications. High therapeutic efficiency of quamatel and its good tolerance recommend it for cardiosurgical patients and to surgical patients of other profiles for prevention of gastrointestinal complications.