Inhibition of phosphodiesterase type III before aortic cross-clamping preserves intramyocardial cyclic adenosine monophosphate during cardiopulmonary bypass.

UNLABELLED: Inotropes are often used to treat myocardial dysfunction shortly after cardiopulmonary bypass (CPB). beta-Adrenergic agonists improve contractility, in part by increasing cyclic adenosine monophosphate (cAMP) production, whereas phosphodiesterase type III inhibitors prevent its breakdown. CPB is associated with abnormalities at the beta-receptor level and diminished adenyl cyclase activity, both of which tend to decrease cAMP. These effects may be increased in the presence of preexisting myocardial dysfunction. We tested the hypothesis that inhibition of phosphodiesterase type III before global myocardial ischemia and pharmacologic arrest results in the preservation of intramyocardial cAMP concentration during CPB. Twenty adult patients undergoing coronary artery bypass grafting with CPB were studied. After CPB was instituted, a myocardial biopsy was obtained from the apex of the left ventricle. Patients were randomized to receive either placebo or milrinone (50 micro/kg) through the bypass pump 10 min before aortic cross-clamping. Another myocardial biopsy was performed adjacent to the left ventricular apex just before weaning from CPB. Myocardial cAMP concentration was determined by radioimmunoassay. Myocyte protein content was determined by the Bradford method by using a commercial kit. There were no significant demographic differences between the groups; however, patients in the Milrinone group had a lower left ventricular ejection fraction than placebo (41% +/- 13% vs 53% +/- 7%; P < 0.05). Patients who received milrinone had larger cAMP concentrations at the end of CPB compared with placebo (21 +/- 12.5 pmol/mg protein versus 12.8 +/- 2.2 pmol/mg protein; P < 0.05). The administration of milrinone before aortic cross-clamping is associated with increased intramyocardial cAMP concentration at the end of CPB. IMPLICATIONS: The administration of a single dose of milrinone before aortic cross-clamping resulted in significantly larger intramyocardial cyclic adenosine monophosphate concentration in myocardial biopsy specimens compared with controls.

A randomized study of left versus right internal jugular vein cannulation in adults.

STUDY OBJECTIVE: To compare the success rate and incidence of complications of right internal jugular vein (RIJV) versus left internal jugular vein (LIJV) cannulation using external landmarks or surface ultrasound guidance. DESIGN: Prospective randomized study. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 120 adult patients scheduled for elective abdominal, vascular, or cardiothoracic procedures with general anesthesia and mechanical ventilation in whom central venous cannulation was clinically indicated. INTERVENTIONS: Patients were randomized to four groups for RIJV cannulation using the landmark approach (Group 1) or surface ultrasound (Group 2) versus LIJV cannulation with the landmark approach (Group 3) or ultrasound (Group 4). MEASUREMENTS AND MAIN RESULTS: The data collected included time from first puncture to guidewire insertion, number of attempts, and associated complications. If conversion to the ultrasound technique was required, the number of crossover patients and reasons for failure were recorded. Cannulation of the LIJV was more time consuming; it required more attempts; and it was associated with a greater number of complications when compared to the right side (p < 0.05). CONCLUSIONS: Left IJV cannulation is more time consuming than RIJV cannulation and is associated with a higher incidence of complications. The use of ultrasound improves success rate and decreases the number of complications during IJV cannulation.