Effects of simvastatin on systemic inflammatory responses after cardiopulmonary bypass.

AIM: Cardiopulmonary bypass is associated with a complex systemic inflammatory response and the extent of their increase has been correlated with the development of postoperative complications. Recent studies suggest that treatment with statins is associated with a significant and marked decrease in inflammation-associated variables such as cytokines. Therefore, we investigated the effects of preoperative simvastatin treatment on systemic inflammatory response and perioperative morbidity after cardiopulmonary bypass. METHODS: A prospective, randomized study, was designed. Forty-four subjects undergoing elective coronary artery bypass grafting who fulfilled the inclusion criteria were randomized to treatment with simvastatin (20 mg/day, group A, N. 22) or control (group B, N. 22) before surgery. Plasma levels of interleukins (IL-6, IL-8, TNF-alpha), and systemic inflammatory response score (SIRS) were measured during the surgical intervention and over the following 48 postoperative hours. Cytokine levels were measured by enzyme-linked assays from plasma samples obtained at specific time points pre- and post-operation. RESULTS: In both groups the serum levels of the proinflammatory cytokines (IL-6, IL-8, TNF-alpha), and leukocytes, and the SIRS score increased significantly over the baseline, though no significant differences were observed between the two groups. The preoperative and postoperative course did not differ between both groups. CONCLUSIONS: In patients undergoing coronary artery bypass grafting with cardiopulmonary bypass, the administration of simvastatin doses not produce any changes in the inflammatory response as measured by the levels of IL-6, IL-8, TNF-alpha and SIRS score, nor does it reduce the complications after cardiac surgery.

Presión venosa central, tiempo de recalentamiento y líquidos totalesson factores postoperatorios de morbi-mortalidad en cirugía cardiaca / Central venous pressure, rewarming time, and total fluid replacement volume are predictors of mortality and complications after cardiac surgery

OBJETIVOS: Analizar la influencia de factores del postoperatorioinmediato (primer día), como posibles marcadoresde la evolución postoperatoria en los enfermosoperados de cirugía cardiaca.PACIENTES Y MÉTODOS: Se diseñó un estudio transversalen el que se incluyeron consecutivamente pacientesintervenidos de cirugía cardiaca. Se analizó el efecto dela presión venosa central, el tiempo de recalentamientohasta alcanzar los 35,5ºC de temperatura central y loslíquidos totales administrados en 24 horas, sobre la mortalidady las complicaciones cardiacas, pulmonares yrenales.RESULTADOS: Se incluyeron 236 pacientes. Se observóque la presión venosa central mayor de 18 mmHg, eltiempo de recalentamiento mayor de 6 horas y la administraciónde líquidos mayores a 5 litros durante las primeras24 horas, se asoció a un incremento de la mortalidady a la aparición de complicaciones cardiovasculares,pulmonares y renales.CONCLUSIONES: La presión venosa central, el tiempode recalentamiento y los líquidos administrados duranteel primer día son determinantes de la evolución postoperatoria (AU)

OBJECTIVE: To analyze the influence of early (firstday) postoperative factors on postoperative course inpatients who have undergone heart surgery.PATIENTS AND METHODS: A cross-sectional study ofconsecutively enrolled heart surgery patients wasdesigned. We recorded central venous pressure, timerequired for rewarming to a core temperature of 35.5°C,and total fluids administered in 24 hours. We thenanalyzed their influence on mortality and cardiac,pulmonary, and renal complications.RESULTS: Two hundred thirty-six patients wereincluded. Central venous pressure over 18 mm Hg, timeto rewarming over 6 hours, and administration of morethan 5 L of fluids in the first 24 hours were factorsassociated with increased mortality and the developmentof cardiovascular, pulmonary, and renal complications.CONCLUSIONS: Central venous pressure, rewarmingtime, and fluid replacement volume required on the firstday are predictors of postoperative course (AU)

Efecto del purgado de la bomba de circulación extracorpórea con coloides o cristaloides sobre la concentración de las proteínas de fase aguda despué de la cirugía cardíaca / Effects of colloid or crystalloid for pump priming of cardiopulmonary bypass on acute-phase protein levels after cardiac suergery

OBJETIVO. La respuesta inflamatoria que se produce después de las intervenciones de cirugía de bypass aorto-coronario serelaciona con la morbilidad y mortalidad. En este estudio planteamos la hipótesis que el purgado del circuito de circulaciónextracorpórea con colides produce un síndrome respuesta inflamatorio sistémico (SRIS) de menor intensidad y se acompañade concentraciones sanguíneas más bajas de proteínas de fase aguda. MATERIAL Y MÉTODO. Se diseñó un estudio prospectivoen el que se incluyeron pacientes sometidos a intervenciones de cirugía electiva de pontaje aorto-coronario. Se incluyeron enel estudio 44 pacientes que fueron divididos en dos grupos: 22 pacientes con cebado de Ringer Lactato (RL; B. Braum,Melsungen, Alemania) (grupo RL) y 22 pacientes con cebado conteniendo gelatina (Gelafundina; B. Braun, Suiza) (grupoGEL) en la circulación extracorpórea (CEC). Se midieron las concentraciones plasmáticas de interleukina-6, protein C reactiva(PCR) y complement-4 (C-4) y la escala del SRIS, durante la intervención y las primeras 48 horas del postoperatorio.IL-6 se determinó por ELISA, C4 y PCR se determinaron por nefelometría. RESULTADOS. No se observaron diferencias significativasentre ambos grupos en las variables perioperatorias, en la concentración de IL- 6, C-4 y PCR, ni en las complicacionesdespués de la derivación cardiopulmonar. En ambos grupos, las concentraciones máximas de IL-6 se observaron a las6 horas después de la cirugía (p < 0.0001) y las de PCR a las 48 horas (p < 0.0001). Las concentración de C4 descendieron(p < 0.0001) al inicio de la derivación cardiopulomnar volviendo a la normalidad a las 48 horas (p > 0.05).CONCLUSIONES. El purgado del bypass cardiopulmonary con gelatin versus ringer no produce diferencias significativas en laintensidad del SRIS y en las concentraciones sanguíneas de proteínas de fase aguda (AU)

OBJETIVE. Systemic inflammatory response frequently occurs after coronary artery bypass surgery and is strongly correlatedwith the risk of postoperative morbidity and mortality. This study tests the hypothesis that the priming of the extracorporealcircuit with colloid solutions results in less inflammation and reduces the protein plasma levels in the acute phase.METHODS. A prospective study was designed. Forty four patients undergoing elective coronary artery bypass grafting wereallocated to one of two groups: 22 patients primed with Ringer’s lactate solution and 22 patients primed with gelatin-containingsolution during coronary artery bypass surgery. Plasma levels of interleukin IL-6, C-reactive protein, complement 4,and SIRS score were measured during the surgical intervention and over the following 48 postoperative hours. Interleukine-6 levels were measured by enzyme-linked, total C4 and CRP were determined by nephelometry. RESULTS. No significant differenceswere noted between the two groups with respect to the perioperatory variables, the acute-phase protein levels, or thepost-cardiopulmonary bypass complications. In both groups, compared with the initial levels, IL-6 levels peaked at 6 hrs aftersurgery and CRP at 48 hrs. Complement 4 levels decreased from the start of the cardiopulmonary bypass and returned progressivelytoward the baseline value at 48 hrs after surgery. CONCLUSIONS. Priming with gelatin versus Ringer’s lactate producesno significant differences in the inflammatory response in patients undergoing coronary artery bypass grafting withcardiopulmonary bypass(AU)

[Central venous pressure, rewarming time, and total fluid replacement volume are predictors of mortality and complications after cardiac surgery]. / Presión venosa central, tiempo de recalentamiento y líquidos totales son factores postoperatorios de morbi-mortalidad en cirugía cardiaca.

OBJECTIVE: To analyze the influence of early (first day) postoperative factors on postoperative course in patients who have undergone heart surgery. PATIENTS AND METHODS: A cross-sectional study of consecutively enrolled heart surgery patients was designed. We recorded central venous pressure, time required for rewarming to a core temperature of 35.5degrees C, and total fluids administered in 24 hours. We then analyzed their influence on mortality and cardiac, pulmonary, and renal complications. RESULTS: Two hundred thirty-six patients were included. Central venous pressure over 18 mm Hg, time to rewarming over 6 hours, and administration of more than 5 L of fluids in the first 24 hours were factors associated with increased mortality and the development of cardiovascular, pulmonary, and renal complications. CONCLUSIONS: Central venous pressure, rewarming time, and fluid replacement volume required on the first day are predictors of postoperative course.

[Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine]. / Analgesia postoperatoria en cirugía cardiaca: comparación de morfina intratecal versus morfina intravenosa.

OBJECTIVE: To compare the effects of spinal and intravenous administration of morphine to supplement anesthesia with remifentanil in terms of analgesia during early postoperative recovery and considering time until extubation. MATERIAL AND METHODS: This prospective, randomized, blinded trial enrolled 59 patients scheduled for cardiac surgery. The patients were assigned to receive either a spinal infusion of morphine (15 microg x Kg(-1)) or an intravenous infusion (0.3 mg x Kg(-1)). Anesthesia was maintained with 0.15 to 0.50 microg x Kg(-1) x min(-1) of remifentanil and 2 to 4 mg x Kg(-1) x h(-1) of propofol in perfusion. After the period of extracorporeal circulation, all patients were given an intravenous infusion of 30 mg of ketorolac. Later intravenous ketorolac was ministered at a dose of 30 mg per 8 hours; intravenous morphine (bolus dose of 3 mg) was also administered until pain was relieved. RESULTS: The same quality of postoperative analgesia and anesthetic recovery was achieved with both spinal and intravenous administration. The incidence of side effects was also similar. Likewise, the extubation times were similar in the 2 groups (spinal infusion group: 294.5 [SD, 150.5] minutes; intravenous group: 325.0 [139.9] minutes; P>0.05). Less postoperative intravenous morphine was administered in the first 24 hours to patients in the spinal morphine group (P<0.05) and fewer patients in that group required intravenous morphine boluses (P<0.05). CONCLUSIONS: Our study suggests that spinal morphine does not offer advantages over intravenous morphine with regard to postoperative analgesia, hemodynamic stability and respiratory parameters, time until extubation, or adverse effects.

[The effect of isoflurane on coronary autoregulation in hypothermia]. / Efecto del isoflurano sobre la autorregulación coronaria en hipotermia.

OBJECTIVES: To analyze the effect of isoflurane on myocardial metabolism and coronary hemodynamics during the reheating phase after heart surgery. PATIENTS AND METHODS: Sixteen patients (12 women and 4 men), with cardiac output greater than 0.5 undergoing aortic and/or mitral valve surgery, were studied prospectively. A retrograde thermodilution catheter was placed in the heart and a Swan-Ganz catheter was inserted in the pulmonary artery to determine coronary blood flow and pulmonary wedge pressure, respectively, as well as myocardial and systemic parameters. After surgery, and with hemodynamic variables stable and rectal temperature at 34 +/- 0.5 degrees C, 0.4% isoflurane was administered at the end of expiration. Variables were recorded before administering isoflurane and 20 minutes afterwards. RESULTS: Isoflurane administration decreased coronary perfusion pressure, coronary vascular resistance, regional myocardial oxygen consumption and myocardial oxygen output. Increases in coronary oxygen saturation and in large coronary vein saturation were also observed. No patient experienced significant changes in ST segment, enzymes or decreased clearance of lactic acid. CONCLUSIONS: Administering 0.4% isoflurane at the end of expiration effected coronary vasodilation without altering oxygenation or myocardial metabolism. Moreover, no electrocardiographic, enzymatic or metabolic signs of myocardial ischemia were observed.