Pipecuronium Research Articles

Features of hemodynamics in elderly patients with coronary heart disease using a combination of propofol, ketamine and fentanyl for induction anesthesia

The aim – to analyze hemodynamic changes in elderly patients with coronary heart disease during coronary artery bypass grafting surgery without cardiopulmonary bypass at the stage of induction into anesthesia using propofol, ketamine and fentanyl.Materials and methods. The results of the examination of 20 patients with coronary artery disease over 60 years of age who underwent coronary artery bypass grafting without the use of artificial circulation are presented. The effect of anesthesia on hemodynamics was assessed by mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), and systemic vascular resistance index (SVRI). The following drugs were used for induction: Propofol 1.5 mg/kg, Ketamine 0.5 mg/kg, Fentanyl 2.0 μg/kg, Pipecuronium bromide 0.1 mg/kg. Anesthesia maintenance: Propofol 4 mg/kg/hour, Fentanyl 2.0 μg/kg/hour.Results and discussion. At the time of admission to the surgery room, hemodynamic parameters reflected that the general condition of patients was stable. After the administration of the combination of drugs for induction propofol + fentanyl + ketamine in the dosage according to the study design, it was found that MAP decreased by 18.71 % (p<0,0001), heart rate decreased by 4.72 % (p = 0,2199), CI decreased by 14.37 % (p = 0,0035), and SVRI decreased by 3.93 % (p = 0,41). After insertion of the intubation tube, it was determined that MAP was 92.34±7.26 % of the baseline values (p = 0,0001), heart rate was 100.81±9.77 % of the baseline data (p = 0,848), CI was determined at 110.38±12.37 % of baseline value (p = 0,0769), and SVRI was 83.57±10.7 % of the baseline, respectively. In 25 minutes after successful tracheal intubation, the parameters were re-registered again: MAP = 86.47±6.07 % of the baseline (p < 0,0001); heart rate = 100.08±5.03 % of the baseline value (p = 0,9711); CI = 108.29±9.95 % of baseline data (p = 0,1248); SVRI = 77.86±9.83 % of the baseline (p = 0,0001).Conclusions. Since hypotension is a frequent side effect of traditional drugs for induction of anesthesia, such as propofol and fentanyl, the addition of ketamine to this combination helps to stabilize hemodynamic parameters and prevents undesirable hemodynamic fluctuations.

Effects of sevoflurane and propofol on hemodynamics during cardiac surgery: A randomized controlled clinical trial

The anaesthetic support for various types of cardiac surgery such as coronary artery bypass grafting, heart valve repair or replacement is essential for success of a surgery. The planning of anaesthesia depends on the intended surgical procedure. The traditional approach is total intravenous anesthesia with propofol and inhalation with sevoflurane.<br /> <b>Objectives: </b>To identify the advantages and disadvantages of propofol and sevoflurane when cardiac surgery in adults.  <br /> <b>Material and methods: </b>A total of<b> </b>40 patients were assigned randomly into two groups to receive: in Group 1 - propofol and in Group 2 - sevoflurane. The induction to general anesthesia started with intravenous fractional administration of 1-1.5 mg/kg propofol, 5-7 µg/kg fentanyl and 1.5-2 mg/kg ketamine. Pipecuronium bromide 0.07-0.1 mg/kg was used as a myorelaxant in all patients in both groups. The anaesthesia in group P was supported with propofol 4-6 mg/kg/min intravenously by means of a perfusor as anaesthetic. In group 2, sevoflurane at a dose of 1.7-1.9 MAC was used as an anaesthetic. To maintain anaesthesia in both groups, there was a fractional administration of fentanyl at a dose of 100 µg intravenously when the heart rate and blood pressure increase, piperonium bromide in a dose of 2 mg intravenously was used for muscle relaxation.<br /> <b>Results: </b>The mean arterial pressure, oxygen demand, energy expenditure, cardiac index, total peripheral resistance showed statistically significant differences between propofol and sevoflurane groups. Through the correlation analysis, the relationship between cardiac index and oxygen consumption was moderately relevant, as R was 0.4 and P>0.05.<br /> <b>Conclusion</b>: When the use of sevoflurane for anesthesia, the hemodynamic parameters were stable. The oxygen consumption, energy expenditure in patients were significantly lower compared to propofol using the sevoflurane anesthesia.

ВЛИЯНИЕ ПЕРИОПЕРАЦИОННЫХ ФАКТОРОВ НА СОДЕРЖАНИЕ КОРТИЗОЛА ПРИ АНЕСТЕЗИОЛОГИЧЕСКОМ ОБЕСПЕЧЕНИИ КАРДИОХИРУРГИЧЕСКИХ ВМЕШАТЕЛЬСТВ

Background. In this study the dependence of the level of cortisol on the age of the patient, the presence of disorders of fat metabolism, the dose of muscle relaxant and anesthetic propofol was revealed. Determining the level of cortisol as a component of anesthetic monitoring enables not only to assess the level of perioperative stress, but also to predict the height of the expected stress response. The aim of our study was to determine the influence of perioperative factors on cortisol levels during cardiac surgery. Material and methods. A prospective non-randomized observational study was conducted. The study involved 30 cardiac surgery patients. The age of the patients ranged from 49 to 67 (64 (59; 70)) years, the body mass index was 29.05 (25.56; 33.25) kg/m2. All the patients underwent cardiac surgery under cardiopulmonary bypass. All the patients underwent venous blood sampling to determine the level of cortisol at the following stages: stage 1 - the patient on the operating table, peripheral vein catheterization; Stage 2 - during anesthesia, before connecting to a heart-lung machine; Stage 3 - the end of the operation, suturing the skin; Stage 4 - 1-3 hours after the operation; Stage 5 - 17-20 hours after surgery. Quantitative determination of cortisol in blood serum was carried out by the immunochemical method using the Architect plus i10000sr apparatus (Abbott, USA). Results. The analysis of the obtained data showed that the level of cortisol in the early postoperative period was significantly higher in patients older than 65 (18.8 (10.3; 26.0) µg/dL). The level of cortisol at the second stage of the study was higher in patients with impaired fat metabolism (11.1 (7.1; 15.6) µg/dL). Cortisol levels were significantly lower with higher doses of pipecuronium bromide during anesthesia (5.8 (3.6; 10.5) µg/dL). A significant correlation was found between the dose of propofol at the induction stage and the level of cortisol at stage 4 (R=-0.6; р=0.007). A moderate inverse correlation was established between the level of cortisol and the total dose of fentanyl at the second stage (R=-0.43; p=0.017). Conclusion. Determining the level of cortisol should be a component of anesthetic monitoring when performing cardiac surgery under conditions of cardiopulmonary bypass.

The use of multimodal low-opioid anesthesia for coronary artery bypass grafting surgery in conditions of artificial blood circulation.

IntroductionCardiovascular diseases (CVD) are the main cause of death worldwide, and according to experts, they will continue to dominate the structure of global mortality.AimThe effectiveness of the multimodal low-opioid anesthesia technique in performing coronary artery bypass graft operations with artificial blood circulation.Material and methodsNinety-six patients aged 61.8 ±10.4 years underwent coronary artery bypass grafting under artificial blood circulation. Group I: propofol, sevoflurane, fentanyl, pipecuronium bromide (standard doses). Group II: dexketoprofen trometamol (50 mg), intravenous lidocaine (1% – 1 mg/kg bolus) and continuous lidocaine infusion (1.5–2 mg/kg/h), propofol, ketamine (0.5 mg/kg), magnesia sulfate, minimal doses of fentanyl.ResultsAverage duration of anesthesia – 257.4 ±19.1 min; assisted blood circulation – 55 ±10 min. Mean dose of fentanyl in group I – 4.66 ±1.58 µg/kg/h, in group II – 1.29 ±0.32 µg/kg/h.Standard lab values and stress hormonal changes were within the normal range (mean cortisol: 479.3 ±26.4 nmol/l, lactate 1.61 ±0.2 mmol/l, glucose 6.42 ±0.9 mmol/l). Changes in heart rate within group I had a significant amplitude of dynamics, while in group II, these values were relatively at the same level throughout the entire anesthetic provision. Mean arterial pressure changes in group I were characterized by a significant reduction at the stage of induction, support and sternum reduction, whereas in group II it was relatively at the same level during the entire anesthetic management and significantly differed from baseline only at the stage of induction.ConclusionsMultimodal low-opioid anesthesia during coronary artery bypass surgery with artificial blood circulation allows one to ensure adequate analgesia and avoid the intraoperative usage of routine doses of fentanyl, as indicated by the absence of hemodynamic and endocrine-metabolic changes.

ANALGESIA FOR AGED AND GERIATRIC PATIENTS DURING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS

Balanced perioperative multimodal analgesia using multiple synergistic agents minimizes side effects that can be caused by high doses of only one aesthetic agent. The aim of the work was to determine the efficacy of perioperative multimodal low-opioid analgesia as anesthetic assurance techniques in aged and geriatric patients during cardiac surgery with cardiopulmonary bypass.Materials and methods. The study included 18 patients (11 (61.1%) men and 7 (38.9%) women) aged from 63 to 76 years old (mean age 69.5±6.2 years), who underwent coronary artery bypass grafting with cardiopulmonary bypass support. The average body weight was 89.6±13.9 kg (75 to 115 kg). The anaesthesia consisted of intravenous (iv) administration of propofol in a dose of 1.52±0.05 mg/kg and fentanyl in a dose of 1 μg/kg. Muscle relaxation was achieved by injecting pipecuronium bromide in a dose of 0.1 mg/kg. Sevoflurane inhalation was used to maintain anesthesia. Before making incision, the subnarcotic dose of ketamine (0.5 mg / kg) and lidocaine 1 mg/kg bolus were added with simultaneous administration of the continuous infusion of the latter in a dose of 1.5-2 mg/kg per hour. For postoperative analgesia ketorolac tromethamine was used. The intensity of the pain syndrome was assessed using a 10-point visual-analog scale of pain. The level of endocrine-metabolic response was determined by measuring the dynamics of lactate and cortisol.Results. The average dose of fentanyl, which was used for the patient during the whole time of anaesthesia, was 1.09±0.03 μg / kg per hour (on average 358.3±27.1 μg for all time of surgery). During the extracorporeal circulation and in the early postoperative period, the blood circulation parameters in all patients examined corresponded to the hemodynamic profile of the operated pathology. Positive verbal contact with patients was recorded in 18.6±3.4 minutes after the end of anaesthesia. The level of cortisol in the early postoperative period was 479.3±26.4 nmol/l. The average values of the intraoperative level of lactate were 1.61±0.2 mmol/l. The mean pain level in the first postoperative day in the examined patients was 4.6 ± 1.2 (3-6) scores by VAS, one day after the operation – 2.6±1.1 (1.5-4) scores by the VAS.Conclusions. Multimodal low-opioid analgesia provides an adequate analgesic effect in aged and geriatric patients that is confirmed by the absence of hemodynamic and endocrine-metabolic disorders. The use of ketorolac as a component of multimodal low-opioid analgesia is an effective method for achieving adequate postoperative analgesia and contributes to reducing the side effects associated with the use of narcotic analgesics.

Efficacy of inhalational sevoflurane anesthesia induction on inhibiting the stress response to endotracheal intubation in children with congenital heart disease.

To investigate the efficacy of inhalational sevoflurane anesthesia induction on inhibiting the stress response to endotracheal intubation in pediatric patients with congenital heart disease (CHD). Forty ASA physical status I/II pediatric patients scheduled for interventricular septal defect repair or interatrial septal defect repair, were randomly divided into two groups (20 each): intravenous induction group (Group C) and inhalational sevoflurane anesthesia induction group (Group D). In group C, anesthesia was induced with midazolam, pipecuronium bromide and fentanyl, and the children were examined by radial artery monitoring after the consciousness extinction. Also, they were endotracheally intubated after muscle relaxation. In group D, anesthesia was induced with inhalation of 8% sevoflurane and 6 L/min oxygen, and the children were examined by radial artery monitoring after the consciousness extinction and were endotracheally intubated 4 min later. Before anesthesia induction (T0), consciousness extinction (T1), endotracheal intubation (T2), endotracheal intubation (T3), and after endotracheal intubation (T4), 1 and 3 min after intratracheal intubation (T5,6), HR and bispectral index (BIS) were monitored. The MAP of T2-T6 points was recorded. Ulnar vein blood samples were taken for determination of Endothelin (ET) and Thromboxane A2(TXA2) in the points of consciousness extinction, and 5 and 10 min after endotracheal. All the children were well examined by endotracheal intubation. Compared with the baseline value at T0, there was no significant difference of HR in group D, but the HR of group C was decreased at T2, T3, T4 and T6. The BIS of the two groups were decreased at T1-T6 (p<0.05). Compared with the values at T2, they were increased at T5 and T6 in group C, and increased at T6 in group D (p<0.05). Compared with group C, the MAP of group D was decreased at T5, and the BIS of the two groups was decreased at T2-T6 (p<0.05). There were no significant differences of ET and TXA2 between groups. It is well inhibited the endotracheal intubation stress response in children with congenital heart diseases using sevoflurane inhalational anesthesia induction.

СОЧЕТАННАЯ АНЕСТЕЗИЯ ПРИ РЕЗЕКЦИИ ЛЕГКИХ

In order to improve outcomes of surgical treatment of thoracic diseases, the peri-operative protection is to be constantly enhanced. Goal: to assess the effect of combined anesthesia with thoracic epidural analgesia in the peri-operative period on hemodynamics and respiratory exchange during radical pulmonary surgery. Subjects and methods. The prospective randomized study was performed aiming to assess the effect of various options of anesthesia in 46 patients who had planned radical pulmonary surgery. The patients were randomly divided into two groups. Group 1 (n = 23) had combined anesthesia. Analgesia was provided through segmental epidural block on the level of Th 4 ‒Th 5 by intermittent bolus dosing of 0.75% solution of ropivacaine (0.7-0.8 mg/kg) and fentanyl (1.3-1.5 mcg/kg), and during the surgery, the mixture of 0.02% solution of ropivacaine and fentanyl (4 mcg/kg) was continuously infused at the rate of 4-6 ml/h. In Group 2 (n = 23), analgesia was provided by infusions of fentanyl, epidural analgesia was used in the post-operative period as a component of multi-modal post-operative pain relief. In both groups, the cortical component was provided by the low-flow inhalation of sevoflurane under BIS monitoring. Pipecuronium bromide solution was intermittently administered in order to provide muscle relaxation. Conclusion. The positive impact on hemodynamics and respiratory exchange was observed when using combined anesthesia based on thoracic epidural analgesia and inhalation anesthesia with sevoflurane.

Effects of lidocaine in combination with sevoflurane on myocardial protection in patients undergoing off-pump coronary artery bypass grafting

Objective To evaluate the effects of lidocaine in combination with sevoflurane on myocardial protection in patients undergoing off-pump coronary artery bypass grafting (OPCABG). Methods One hundred ASA physical status Ⅱ or Ⅲ and NYHA class Ⅰ or Ⅱ patients of both sexes, aged 45-70 yr, weighing 63-82 kg, scheduled for elective OPCABG, were randomly assigned into 4 groups (n=25 each): control group (group C), lidocaine group (group L), sevoflurane group (group S), sevoflurane combined with lidocaine group (group SL). Tracheal intubation was performed after induction of anesthesia. Anesthesia was maintained with iv infusion of propofol and intermittent iv boluses of sufentanil and pipecuronium. Bispectral index value was maintained at 45-55. Lidocaine 1.5 mg/kg was injected after intubation, followed by infusion at 2 mg/min until the end of surgery in L and SL groups. Sevoflurane was inhaled with end-tidal concentration of 2.2%-2.5% starting from the end of intubation until the end of operation in S and SL groups. Before induction of anesthesia, at skin incision, immediately after transsection of internal mammary artery, after completion of anastomosis of the proximal aortovein and distal coronary artery, at the end of operation and at 24 h during operation, venous blood samples were obtained to detect the levels of plasma creatine kinase (CK), creatine kinase isoenzyme-MB (CK-MB) and cardiac troponin I (cTnI). Lidocaine-related side effects such as arrhythmia, bradycardia or cardiac arrest were recorded during operation and within 24 h after operation. Results Compared with group C, the plasma CK, CK-MB and cTnI levels were decreased in the S, L and SL groups. The plasma CK-MB and cTnI levels were significantly lower in SL group than in L group. The plasma CK, CK-MB and cTnI levels were significantly lower in SL group than in S group. In L and SL groups, no patient developed lidocaine-related side effects. Conclusion Lidocaine 1.5 mg/kg injected intravenously after intubation, followed by infusion at 2 mg/min in combination with sevoflurane end-tidal concentration about 2.2%~2.5% provides myocardial protection in patients undergoing OPCABG, the efficacy is stronger than that of either alone. Key words: Lidocaine; Anesthetics, inhalation; Coronary artery bypass, off-pump; Myocardial injury

Intravenous dextromethorphan/quinidine inhibits activity of dura-sensitive spinal trigeminal neurons in rats.

Migraine is a chronic neurological disorder characterized by episodes of throbbing headaches. Practically all medications currently used in migraine prophylaxis have a number of substantial disadvantages and use limitations. Therefore, the further search for principally new prophylactic antimigraine agents remains an important task. The objective of our study was to evaluate the effects of a fixed combination of dextromethorphan hydrobromide and quinidine sulphate (DM/Q) on activity of the spinal trigeminal neurons in an electrophysiological model of trigemino-durovascular nociception. The study was performed in 15 male Wistar rats, which were anaesthetized with urethane/α-chloralose and paralysed using pipecuronium bromide. The effects of cumulative intravenous infusions of DM/Q (three steps performed 30 min apart, 15/7.5 mg/kg of DM/Q in 0.5 mL of isotonic saline per step) on ongoing and dural electrical stimulation-induced neuronal activities were tested in a group of eight rats over 90 min. Other seven animals received cumulative infusion of equal volumes of saline and served as control. Cumulative administration of DM/Q produced steady suppression of both the ongoing activity of the spinal trigeminal neurons and their responses to electrical stimulation of the dura mater. It is evident that the observed DM/Q-induced suppression of trigeminal neuron excitability can lead to a reduction in nociceptive transmission from meninges to higher centres of the brain. Since the same mechanism is believed to underlie the pharmacodynamics of many well-known antimigraine drugs, results of the present study enable us to anticipate the potential efficacy of DM/Q in migraine.

Effects of dexmedetomidine pretreatment on haemodynamics and bispectral index during anesthetic induction in patients undergoing cardiac valve replacement surgery with cardiopulmonary bypass

Objective To evaluate the influence of dexmedetomidine(Dex)(highly selective α2-adrenergic receptor agonist) on haemodynamics and bispectral index (BIS) during anesthetic induction in patients undergoing valve replacement surgery.Methods Thirty NYHA class Ⅱ or Ⅲ patients,aged between 30 y and 70 y,undergoing cardiac value replacement with cardiopulmonary bypass,were randomly divided into two groups (n=15):Dex group(group D) and control group(group C).In group Dex,pump diluted with saline to 50 ml of Dex (4 mg/L)0.5 μg/kg was administered iv 10 min before the induction of anesthesia,while in group C,same volume of 0.9％ normal saline was given.The patients were premedicated with intramuscular morphine and scopolamine.Anesthesia was induced with 0.06 mg/kg,fentanyl 6 μg/kg,etomidate 0.3 mg/kg and pipecuronium 0.10 mg/kg.Anesthesia was maintained with midazolam,fentanyl,intermittently.In two group,heart rate(HR),arterial blood pressure(ABP)[systolic blood pressure(SBP),diastolic blood pressure(DBP),mean arterial pressure(MAP)] and bispectral index(BIS) were recorded at the time before Dex infusion(T1),5 min after loading dose(T2),10 min after loading dose(T3),1,3 min after anesthesia induction(T4,T5),just before endotracheal intubation(T6),endotracheal intubation(T7) and 1,3,5 min after endotracheal intubation(T8-10).Results BIS of T2,T3 in group D was decreased significantly [from(92.6±2.5) to (73.2±1.9) and (70.1±2.3)](P＜0.05 or P＜0.01) compared with T1.During anesthesia induction compared with T3,BIS in both groups were decreased significantly.During endotracheal intubation compared with T6,BIS of T7 (34.8±2.2) was increased significantly in group C(P＜0.05 or P＜0.01),while BIS in group C were similar to the initial values.Compared with group C,BIS decreased significantly at time T2～5、T7 in group D (P＜0.05 or P＜0.01).Before anesthesia induction compared with T1,ABP of T2、T3 in group D was increased slightly,HR of T2、T3 was decreased significantly (P＜0.05 or P＜0.01); During anesthesia induction compared with T3,ABP and HR in both groups were decreased significantly.Compared with T6,DBP,MAP and HR of T7,T8 were increased slightly,that of T9,T10 were similar to the values in group D.During endotracheal intubation,while ABP and HR of T7-T1o was increased significantly in group C (P＜0.05 or P＜0.01).Compared with group C,SBP,MAP of T4-T10 and DBP of T3-T10 were increased significantly in group D.HR of T2-T10 were decreased significantly in group D (P＜0.05 or P＜0.01).Conclusions Dex pretreatment might decrease BIS and alleviate haemodynamics reaction during anesthetic induction in patients undergoing valve replacement surgery with cardiopulmonary bypass. Key words: Dexmedetomidine; Valve replacement; Bispectral index; Stress reaction; Hemodynamics

Effects of different sedation depths of propofol on brain injury in patients undergoing cardiac valve replacement with cardiopulmonary bypass

Objective To evaluate the effects of different sedation depths of propofol on brain injury in patients undergoing cardiac valve replacement with cardiopulmonary bypass (CPB).Methods Forty-five ASA physical status Ⅲ or Ⅳ patients of both sexes,aged 26-64 yr,weighing 50-85 kg,scheduled for elective cardiac valve replacement with CPB,were divided into 3 groups according to intraoperative sedation depths (n =15each):30 ≤ bispectral index (BIS) value ＜ 40 (group A) ; 40 ≤ BIS value ≤ 50 (group B) ; 50 ＜ BIS value ≤ 60(group C).Anesthesia was induced with iv injection of lidocaine,midazolam,sulfentanil,etomidate and vecuronium.The patients were tracheally intubated and mechanically ventilated.PET CO2 was maintained at 35-45 mm Hg.Anesthesia was maintained with iv infusion of propofol at a rate of 7,5 and 3 mg· kg-1 · h-1 in A,B and C groups,respectively,intermittent iv boluses of sulfentanil and pipecuronium,and intermittent inhalation of sevoflurane.The infusion rate of propofol was adjusted to maintain the corresponding anesthesic depth in each group.Before CPB (T1),at 30 min of CPB (T2),immediately after termination of CPB (T3) and at 1 h after the end of CPB (T4),blood samples were obtained from the jugular bulb vein and radial artery for determination of plasma S-100β protein concentration and for blood gas analysis,and the arterial to venous blood oxygen content difference (Dj-aO2),cerebral O2 extraction rate (CERO2) and jugular bulb venous to arterial blood lactic acid content difference (Dj-aL) were calculated.Results Compared with group C,the plasma S-100β protein concentrations were significantly decreased,SjvO2 was increased,and Dj-aO2 and CERO2 were decreased at T3-4,and Da-jL was decreased at T3 in groups A and B (P ＜ 0.05).Compared with group B,the plasma S-100β protein concentrations were significantly decreased at T3-4,SjvO2 was increased at T2,Da-jO2 and CERO2 were decreased at T2,and DajL was decreased at T3 in group A (P ＜ 0.05).Conclusion Moderately deepened anesthetic depth of propofol (30≤ BIS value ＜ 40) is helpful in attenuating the brain injury in patients undergoing cardiac valve replacement with CPB. Key words: Propofol; Conscious sedation; Cardiopulmonary bypass; Brain injuries

Efficacy of penehyelidine hydrochloride for prevention of postoperative pulmonary complications in patients undergoing off-pump coronary artery bypass grafting

Objective To evaluate the efficacy of penehyelidine hydrochloride for prevention of postoperative pulmonary complications (PPCs) in patients undergoing off-pump coronary artery bypass grafting (OPCABG).Methods One hundred and forty ASAⅡ or Ⅲ patients of both sexes,aged 35-80 yr,weighing 55-80 kg,undergoing OPCABG,were randomly divided into 2 groups (n =70 each):control group (group C) and penehyelidine hydrochloride group (group P).Anesthesia was induced with iv injection of midazolam,etomidate,sufentanil and rocuronium.The patients were mechanically ventilated after tracheal intubation.PET CO2 was maintained at 35-40 mm Hg.Penehyelidine hydrochloride 20μg/kg (5 ml) was injected intravenously and slowly immediately after tracheal intubation in group P.While the equal volume of normal saline was administered instead in group C.Anesthesia was maintained with iv infusion of propofol,intermittent iv boluses of sufentanil and pipecuronium,and inhalation of sevoflurane.BIS value was maintained at 40-50.The occurrence of PPCs was recorded within 72 h after operation.Results The incidences of PPCs were 33％ and 16％ in groups P and C,respectively.The incidence of PPCs was significantly lower in group P than in group C (P ＜ 0.05).Conclusion Intravenous injection of penehyelidine hydrochloride 20μg/kg before operation can prevent the occurrence of PPCs in patients undergoing OPCABG. Key words: Cholinergic antagonists; Coronary artery bypass, off-pump; Postoperative complications

Effects of sevoflurane pretreatment on inflammatory response in patients undergoing cardiac valve replacement with cardiopulmonary bypass

Objective To investigate the effects of sevoflurane pretreatment on the inflammatory response in patients undergoing cardiac valve replacement with cardiopulmonary bypass (CPB) and the mechanism of myocardial protection.Methods Twenty NYHA class Ⅱ or Ⅲ patients of both sexes,aged ＜ 60 yr,undergoing cardiac valve replacement with CPB,were randomly divided into 2 groups (n=10 each): sevoflurane group (group S) and control group (group C).The patients were premedicated with intramuscular morphine 0.1 mg/kg and scopolamine 0.3 mg.Anesthesia was induced with iv injection of midazolam 0.05-0.08 mg/kg,fentanyl 10-15 μg/kg and pipecuronium 0.08-0.10 mg/kg.The patients were tracheal intubated and mechanically ventilated.Anesthesia was maintained with intermittent iv boluses of midazolam0.03-0.06 mg/kg,fentanyl 5-10μg/kg and pipecuronium 0.04-0.08 mg/kg.Sevoflurane was inhaled before aortic clamping and the end-tidal concentration was rapidly adjusted to 1.0％ and maintained at this level for 30 min in group S.Blood samples were taken from the central vein before skin incision,immediately after aortic clamping,immediately after aortic unclamping and at 30 min after aortic unclamping,at 2,6,12 and 24 h (T1-8) after operation for determination of the concentrations of plasma tumor necrosis factor-α (TNF-α),interleukin-6 (IL) and interleukin-8 (IL-8),intercellular adhesion molecule-1 (ICAM-1),cardiac troponin I (cTnI) and activity of creatine kinase MB (CK-MB).The requirement for cardiovascular drugs was recorded after release of aortic cross clamp.Results Compared with group C,the plasma concentrations of TNF-α,IL-6 and IL-8 were significantly decreased at T3-8,the plasma concentrations of ICAM-1 and cTnl were significantly decreased at T4-8,the activity of plasma CK-MB was significantly decreased at T8,and the requirement for cardiovascular drugs was significantly reduced after release of aortic cross clamp in group S (P ＜0.05).Conclusion Sevoflurane pretreatment can inhibit the inflammatory response and provide myocardial protection to some extent in patients undergoing cardiac valve replacement with CPB. Key words: Anesthetics,inhalation; Cardiopulmonary bypass; Myocardial; Inflammation

Effects of sevoflurane pretreatment on myocardial injury in patients undergoing cardiac valve replacement with cardiopulmonary bypass

Objective To investigate the effects of sevoflurane pretreatment on the myocardial injury in patients undergoing cardiac valve replacement with cardiopulmonary bypass (CPB).Methods Twenty NYHA class Ⅱ or Ⅲ patients,aged ＜ 60 yr,undergoing cardiac valve replacement with CPB,were randomly divided into 2 groups (n =10 each):sevoflurane group (group S) and control group (group C).The patients were premeditated with intramuscular morphine and scopolamine.Anesthesia was induced with iv injection of midazolam 0.05-0.08 mg/kg,fentanyl 10-15 μg/kg and pipecuronium 0.08-0.10 mg/kg.Anesthesia was maintained with intermittent iv boluses of midazolam,fentanyl and pipecuronium and in addition sevoflurane was inhaled before aortic clamping and the end-tidal concentration was rapidly increased to 1.0％ and maintained at the level for 5 min in group S.Blood samples were taken from the central vein before skin incision (T1),immediately after aortic clamping (T2 ),at 0 and 30 min after aortic unclamping (T3-4),and at 2,6,12 and 24 h after operation (T5-8) for determination of the concentration of serum cardiac troponin Ⅰ (cTnI) and activities of creatine kinase (CK) and creatine kinase isoenzyme-MB (CK-MB).Myocardial specimens were taken from right auricle before aortic clamping and at 10 min after aortic unclamping for electron microscopic examination.Results The concentration of serum cTnI and activities of CK and CK-MB were significantly increased at T4-8 in both groups ( P ＜ 0.05).The serum cTnI concentration at T4-8 and the activities of CK and CK-MB at T8 were significantly lower in group S than in group C ( P ＜0.05).Different degrees of mitochondrial swelling were observed after aortic unclamping in both groups,but the changes were milder in group S than in group C.Conclusion Sevoflurane pretreatment can attenuate the myocardial injury in patients undergoing cardiac valve replacement with CPB. Key words: Anesthetics, inhalation; Cardiopulmonary bypsss; Myocardial reperfusion injury; Heart valve prosthesis implantation

Effects of dexmedetomidine conmbined with small-dose of sulfentanil on hemodynamics during anesthesia induction in patients undergoing off-pump coronary artery bypass grafting

Objective To investgate the effects of dexmedetomidine combined with small-dose of sufentanil on the hemodynamics during anesthesia induction in patients undergoing off-pump coronary artery bypass grafting.Methods Seventy-five ASA Ⅱ or Ⅲ and NYHA Ⅱ or Ⅲ patients aged 46-72 yr,weighing 59-86 kg,ejection fraction ≥45％,undergoing off-pump coronary artery bypass grafting,were randomly divided into 3 groups ( n =25):dexmedetomidine combined with small-dose of sufentanil group (group DS),small-dose of sufentanil group (group S1 ) and large-dose of sufentanil group (group S2 ).In group DS,dexmedetomidine 0.8 μg/kg (diluted with normal saline to 15 ml) was injected for 15 min at a rate of60 ml/h,while the same volume of normal saline were given in groups S1 and S2.Anesthesia was induced with midasolam 0.08 mg/kg and pipecuronium 0.12 mg/kg.After administration of the total dose of 1/3 midazolam and 1/8 pipecuronium,sufentanil 0.5,0.5 and 0.8μg/kg (diluted with narmalsaline to 10 ml) were injected in groups DS,S1 and S2 respectively.Then the rest of midazolam was injected.When BIS value ≤ 75,the rest of pipecuronium was injected.When BIS value ≤ 55,the patients were tracheal intubated and mechanically ventilated.PETCO2 was maintained at 30-35 mm Hg.The adverse ardiovascular events (hypertension,hypotension,tachycardia and bradycardia) and drugs intervention were recorded during anesthesia induction.Results Compared with group S2,the incidence of hypertension and tachycardia was significantly increased in group S1,the incidence of hypotension decreased in groups S1 and DS,the incidence of drug intervention decreased in group DS (P ＜ 0.05).Compared with group S1,the incidence of hypertension,hypotension and tachycardia was significantly decreased,the incidence of bradycardia increased,theincidence of drug intervention decreased in group DS (P ＜ 0.05).Conclusion Dexmedetomidine (0.8 μg/kg) combined with small-dose of sufentanil (0.5 μg/kg) is beneficial for keep the stable of hemodynamics during anesthesia induction in patients undergoing off-pump coronary artery bypass grafting. Key words: Dexmedetomidine; Sufentanil; Coronary artery bypass, off-pump; Hemodynamics

Blood-saving effect of tranexamic acid in off-pump coronary artery bypass

Objective To investigate the blood-saving effect of tranexamic acid in off-pump coronary artery bypass (OPCAB). Methods Two hundred and sixty ASA Ⅰ- Ⅲ and NYHA Ⅰ- Ⅲ patients of both sexes,aged 18-64 yr, with body mass index 16-22 kg/m2 , undergoing OPCAB, were randomly divided into 2 groups (n = 130 each): control group (group C) and tranexamic acid group (group T) . Anesthesia was induced with iv injection of midazolam 0.1 mg/kg, fentanyl 5-10μg/kg and pipecuronium 0.1 mg/kg. The patients were tracheal intubated and mechanically ventilated. PEr CO2 was maintained at 35-45 mm Hg. A bolus of tranexamic acid 1 g was infused intravenously within 30 min after indution followed by continuous infusion at 400 mg/h until the end of operation in group T. While equal volume of normal saline was given in control group. Anesthesia was maintained with inhalation of isoflurane and intermittent iv injection of fentanyl and pipecuronium. Venous blood samples were taken before induction, at the end of operation and at 24 h after operation for determination of Hb, platelet count (P1t), prothrombin time (PT) and international normalized ratio (INR). The volume of chest tube drainage was collected and recorded at 6 and 24 h after operation. The requirement for transfusion of allogeneic red blood cells and fresh frozen plasma was also recorded. Results There was no significant difference in Hb, Plt, PTand INR at each time point between the two groups ( P ＞ 0.05). The requirement for transfusion of allogeneic red blood cells and fresh frozen plasma was significantly reduced in group T as compared with group C ( P ＜ 0.05 or 0.01 ). No deaths and complications occurred during hospital stay in the two groups. Conclusion Tranexamic acid exerts the blood-saving effect in OPCAB. Key words: Tranexamic acid; Coronary artery bypass, off-pump; Postoperative hemorrhage; Blood transfusion

Effect of propofol on brain injury in children undergoing open heart surgery under cardiopulmonary bypass

Objective To investigate the effect of propofol on the brain injury in children undergoing open heart surgery under cardiopulmonary bypass (CPB).Methods Thirty children aged 4-10 yr undergoing repair of ventricular septal defect or atrial septal defect under CPB were randomly divided into 2 groups ( n = 15 each):control group (group C) and propofol group (group P). Anesthesia was induced with iv injection of sufentanil 1 μg/kg, propofol 2.5 mg/kg (midazolam 0.2 mg/kg in group C) and pipecuronium 0.1 mg/kg in group P. Anesthesia was maintained with iv infusion of 1％ propofol 6 mg·kg-1 ·h-1 (0.05％ midazolam 0.2 mg·kg-1 ·h-1 in group C) until the end of operation. Isoflurane ( 1％-2％ ) were inhaled during the operation in all patients. Sufentanil 1 μg/kg and pipecuronium 0. 1 mg/kg were injected intravenously after the start of CPB. A catheter was inserted into right internal jugular vein and advanced cephalad until jugular bulb for blood sampling before CPB, at 30 min of CPB, at the end of CPB, at 30 min after termination of CPB, at the end of operation, and at 24 h after termination of CPB to detect the plasma concentrations of 8-iso-PGF2 and S-100β by ELISA. Arterial and jugular bulb venous blood samples were collected for determination of SjvO2 before CPB, when naso-pharyngeal temperature was reduced to 30 ℃, when naso-pharyngeal temperature returned to 36 ℃ and at the end of CPB. Cerebral arterial venous oxygen content differences ( Da-jvO2 ) and cerebral oxygen extraction rate of oxygen ( CEO2 ) were calculated. Results Plasma concentrations of 8-iso-PGF2α and S-100β were significantly lower, SjvO2 was significantly higher, Da-jvO2 and CEO2 were significantly lower in group P than in group C (P ＜ 0.05＝. ConclusionPropofol can reduce the brain injury in children undergoing open heart surgery during CPB and the mechanism is related to decrease in cerebral oxygen metabolic rate and lipid peroxidation. Key words: Propofol; Gardiopulmonary bypass; Brain; Cardiac surgical procedures

Anesthetic management for repair of tetralogy of Fallot in adults

Two hundred and thirty-five patients of both sexes （123 male, 112 female） aged 18-54 yr, weighing 35-62 kg underwent repair of tetralogy of Fallot from January 1996 to July 2009 in Fuwai hospital. Direct BP, ECG, CVP, SpO2, naso-pharyngeal temperature and TEE were continuously monitored during operation. Anesthesia was induced with midazolam and/or etomidate, fentanyl and pipecurenium and maintained with isoflurane/sevoflurane inhalation and intermittent iv boluses of fentanyl and pipecuronium. The total amount of fentanyl administered ranged from 30-50 ug/kg. Cardiac function was supported and hemodynamic stability was maintained with vasoactive and inotropic drugs. Measures were taken to strengthen blood conservation and respiratory function support. Seven patients （2.9%） needed urgent CPB during operation because of serious cyanotic spells. Perfusion-induced lung injury occurred in 18 patients （7.6%）. Circulation was assisted by ECMO in 2 patients （0.9%）. Three patients （1.3%） died of serious low cardiac output and perfusion-induced lung injury. Key words: Tetralogy of Fallot ; Cardiac surgical procedures ; Adult ; Anesthesia

Accuracy of mixed venous oxygen saturation in reflecting change in cardiac output during off-pump coronary artery bypass grafting

Objective To assess the accuracy of mixed venous oxygen saturation ( S(-v)O2 ) in reflecting the change in CO during off-pump coronary artery bypass grafting (OPCABG) .Methods Twenty-five NYHA Ⅰ -Ⅲ patients of both sexes, aged 50-75 yr, weighing 55-85 kg, undergoing OPCABG, were studied. Anesthesia was induced with midazolam, fentanyl, etomidate and pipecuronium and maintained with propofol infusion and intermittent iv boluses of fentanyl and pipecuronium supplemented with isoflurane if necessary. The patients were mechanically ventilated (VT 8-10 ml/kg, RR 8-10 bpm, I:E 1:2). PETCO2 was maintained at 35-45 mm Hg.Radial artery was cannulated and pulmonary catheter was placed. CI, S(-v)O2 and Hb were monitored and recorded before skin incision, during anastomosis with left anterior descending artery (LAD), right coronary artery (RCA)and left circumflex coronary artery (LCX), when the chest was closed, when the patients' body position was changed and the heart was manipulated. S(-v)O2 and CI were scaled immediately after the pulmonary artery catheter was placed and before anastomosing LAD. Results The CO change in S(-v)O2 was real-time and accurate in reflecting the body positioning and elevation of hearts. There was no simultaneous significant change in CI.Conclusion The CO change in S(-v)O2 is real-time and accurate in reflecting the body positioning and elevation of hearts during OPCABG. Key words: Oximetry; Cardiac output; Coronary artery bypass, off-pump

Cerebral protective effect of remifentanil preconditioning during cardiopulmonary bypass in patients undergoing coronary artery bypass grafting

Objective To investigate the cerebral protective effect of remifentanil preconditioning during cardiopulmonary bypass in patients undergoing coronary artery bypass grafting (CABG). Methods Forty ASA Ⅱ or Ⅲ patients of both sexes aged 55-64 yr weighing 50-85 kg undergoing elective CABG were randomized into 4 groups (n = 10 each) : control group (group C) and remifentanil groups (group R_1, R_2, R_3). Anasthesia was induced with midazolam 0.04 mg/kg, remifentanil 1 μg/kg, propofol 1 mg/kg and pipecuronium 0.1 mg/kg and maintained with isoflurane inhalation,intravenous continuous propofol infusion at 6-10 mg·kg~(-1)·h~(-1) and intermittent iv boluses of sufentanil and pipecurpnium after tracheal intubation. The patients were mechanically ventilated. P_(ET) CO_2 was maintained at 35-45 mm Hg. A catheter was inserted into internal jugular vein and advanced cranially until jugular bulb for blood sampling. The remifentanil groups received three 5 min episodes of iv remifentanil infusion at 0.6 μg/kg~(-1) ·min(-1) (group R_1),1.2μg/kg~(-1) ·min(-1)(group R_2) and 1.8μg/kg~(-1) ·min(-1)(group R_3) at 5 min intervals after induction of anesthesia before operation.Blood samples were obtained from jugular bulb before induction of anesthesia (T_0, baseline), before CPB (T_1), 30 min after initiation of CPB (T_2) and at the end of CPB (T_3) for determination of plasma S-100βprotein and MDA concentrations arid SOD activity. Results Plasma S-100β protein and MDA concentrations were significantly increased while plasma SOD activity was significantly decreased at T as compared with the baseline values at T_0 in all 4 groups. Plasma S-100β protein and MDA concentrations were significantly lower while plasma SOD activity was significantly higher at T_2 and T_3 in group R_3 than in the other 3 groups. Conclusion Preconditioning with larger doses of remifentanil (1.8 μg/kg~(-1) ·min(-1)) can attenuate brain injury induced by CPB in patient undergoing CABG through inhibiting oxidative stress response. Key words: Piperidines; Brain; Cardiopulmonary bypass; Coronary artery bypass