Jongmyeong Shim

Effect of low-dose ketamine on inflammatory response in off-pump coronary artery bypass graft surgery.

BACKGROUND Off-pump coronary artery bypass graft surgery (OPCAB) is still associated with a marked systemic inflammatory response. The aim of this study was to investigate whether pre-emptive, low dose of ketamine, which has been reported to have anti-inflammatory activity in on-pump coronary artery bypass surgery, could reduce inflammatory response in low-risk patients undergoing OPCAB. METHODS In this prospective randomized-controlled trial, 50 patients with stable angina and preserved myocardial function undergoing OPCAB were randomly assigned to receive either 0.5 mg kg(-1) of ketamine (Ketamine group, n=25) or normal saline (Control group, n=25) during induction of anaesthesia. Inflammatory markers including C-reactive protein (CRP), interleukin (IL)-6, tumour necrosis factor-alpha (TNF-alpha), and cardiac enzymes were measured previous to induction (T1), 4 h after surgery (T2), and the first and second days after the surgery (T3 and T4). RESULTS There were no significant intergroup differences in the serum concentrations of the CRP, IL-6, and TNF-alpha and cardiac enzymes. Pro-inflammatory markers and cardiac enzymes, except TNF-alpha, were all increased after the surgery compared with baseline values in both groups. CONCLUSIONS Low-dose ketamine administered during anaesthesia induction did not exert any evident anti-inflammatory effect in terms of reducing the serum concentrations of pro-inflammatory markers in low-risk patients undergoing OPCAB.

Effect of ketamine as an adjunct to intravenous patient-controlled analgesia, in patients at high risk of postoperative nausea and vomiting undergoing lumbar spinal surgery

BACKGROUND We evaluated the effect of ketamine as an adjunct to a fentanyl-based i.v. patient-controlled analgesia (IV-PCA) on postoperative nausea and vomiting (PONV) in patients at high risk of PONV undergoing lumbar spinal surgery. METHODS Fifty non-smoking female patients were evenly randomized to either the control or ketamine group. According to randomization, patients received either ketamine 0.3 mg kg(-1) i.v. or normal saline after anaesthetic induction with fentanyl-based IV-PCA either with or without ketamine mixture (3 mg kg(-1) in 180 ml). The incidence and severity of PONV, volume of IV-PCA consumed, and pain intensity were assessed in the postanaesthesia care unit, and at postoperative 6, 12, 24, 36, and 48 h. RESULTS The overall incidence of PONV during the first 48 h after surgery was similar between the two groups (68 vs 56%, ketamine and control group, P=0.382). The total dose of fentanyl used during the first 48 h after operation was lower in the ketamine group than in the control group [mean (SD), 773 (202) μg vs 957 (308) μg, P=0.035]. The intensity of nausea (11-point verbal numerical rating scale) was higher in the ketamine group during the first 6 h after operation [median (interquartile range), 6 (3-7) vs 2 (1.5-3.5), P=0.039], postoperative 12-24 h [5 (4-7) vs 2 (1-3), P=0.014], and postoperative 36-48 h [5 (4-7) vs 2 (1-3), P=0.036]. Pain intensities were similar between the groups. CONCLUSIONS Ketamine did not reduce the incidence of PONV and exerted a negative influence on the severity of nausea. It was, however, able to reduce postoperative fentanyl consumption in patients at high-risk of PONV.

Peri‐operative oral triiodothyronine replacement therapy to prevent postoperative low triiodothyronine state following valvular heart surgery

This study evaluated the effect of oral triiodothyronine (T3) replacement therapy, starting on the day of the surgery, on thyroid hormone concentrations and clinical outcome in high‐risk patients undergoing valvular heart surgery. Fifty patients were randomly allocated to either T3 or placebo. In the treatment (T3) group patients received 20 μg of oral or nasogastric T3 every 12 h starting just before induction of anaesthesia and until the first day after surgery. T3 concentrations were significantly higher in the T3 group than the placebo group from 1 to 36 h after removal of the aortic cross clamp. The number of patients requiring vasopressin after discontinuing cardiopulmonary bypass was significantly greater in the placebo group than the T3 group. Significantly fewer patients required vasopressors in the T3 group on the first day after surgery.

Myocardial protection by glucose–insulin–potassium in acute coronary syndrome patients undergoing urgent multivessel off-pump coronary artery bypass surgery

BACKGROUND The aim of this randomized and controlled trial was to investigate the effect of a glucose-insulin-potassium (GIK) solution on myocardial protection in acute coronary syndrome (ACS) patients undergoing urgent multivessel off-pump coronary artery bypass (OPCAB) surgery. METHODS Sixty-six patients were randomly allocated either to receive 0.3 ml kg(-1) h(-2) GIK solution (potassium 80 mEq and regular insulin 325 IU in 500 ml of 50% glucose) or equivalent volume of normal saline (control) upon anaesthetic induction until 6 h after reperfusion. The primary endpoints were to compare the concentrations of creatine kinase-MB (CK-MB) and troponin-T between the groups after reperfusion. The secondary endpoints were to compare the incidences of postoperative troponin-T >0.8 ng ml(-1) and myocardial infarction (MI) between the groups. RESULTS Highest CK-MB [8.7 (4.4) vs 13.1 (7.9) ng ml(-1), P=0.006] and troponin-T [0.20 (0.13-0.49) vs 0.48 (0.18-0.91) ng ml(-1), P<0.0001] values after reperfusion were significantly lower in the GIK group compared with the control group. The area under the curve of serially measured troponin-T was also significantly smaller in the GIK group compared with the control group [0.83 (0.43-1.81) vs 0.46 (0.31-1.00), P=0.036]. Significantly fewer patients in the GIK group showed troponin-T >0.8 ng ml(-1) after reperfusion compared with the control group (3 vs 11, P=0.033). The incidence of postoperative MI was similar between the groups. CONCLUSIONS GIK administration in ACS patients undergoing urgent multivessel OPCAB significantly attenuated the degree of ensuing myocardial injury without complications related to glycaemic control. Clinical Trial Registry. URL: http://clinicaltrials.gov/ct2/show/NCT01384656?term=GIK+AND+OPCAB&rank=1. Unique identification number NCT01384656.

Effects of propofol on the expression of matric metalloproteinases in rat cardiac fibroblasts after hypoxia and reoxygenation

BACKGROUND Propofol is known to protect the myocardium against ischaemia/reperfusion (I/R) injury through its antioxidant and anti-inflammatory properties. Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) are involved in cell migration and invasion, and mediate tissue remodelling during I/R injury. They are regulated by various mechanisms including oxidative stress and AKT and ERK pathways. We investigated whether propofol affected the expression of MMPs and subsequent cell migration and invasion and the signalling pathways involved in primary rat cardiac fibroblasts undergoing hypoxia and reoxygenation. METHODS The phosphorylation of ERK and AKT signalling pathways was examined by western blot analysis in rat primary cardiac fibroblasts after hypoxia and reoxygenation. mRNA expression of MMP and TIMPS was analysed by real-time PCR, and proteolytic activities of MMP-2 and -9 were assessed. The effects of propofol on migration, invasion, wound healing, and cell proliferation activity were evaluated after reoxygenation. RESULTS Propofol induced AKT and ERK1/2 activation. Subsequent activation of MMPs resulted in increased cell migration, invasion, and wound-healing activity under hypoxia-reoxygenation, which was decreased by LY294002 (AKT inhibitor) and U0126 (ERK inhibitor) in rat cardiac fibroblasts. However, propofol had no effect on proliferation or viability of cardiac fibroblasts after hypoxia-reoxygenation. CONCLUSIONS Propofol affected the expression of MMPs and TIMPs and subsequently induced cell migration and invasive ability, through activation of the ERK and AKT signalling pathway in hypoxia-reoxygenated rat cardiac fibroblasts.

Effect of N-acetylcystein on pulmonary function in patients undergoing off-pump coronary artery bypass surgery

Background: Pulmonary dysfunction related to inflammatory response and radical oxygen species remains a problem in off‐pump coronary bypass graft surgery (OPCAB), especially in patients with reduced left ventricular (LV) function. The aim of this study was to evaluate the effect of N‐acetylcystein (NAC) on pulmonary function following OPCAB.

Effect of N-acetylcysteine on pulmonary function in patients undergoing off-pump coronary artery bypass surgery.

Background: Pulmonary dysfunction related to inflammatory response and radical oxygen species remains a problem in off‐pump coronary bypass graft surgery (OPCAB), especially in patients with reduced left ventricular (LV) function. The aim of this study was to evaluate the effect of N‐acetylcystein (NAC) on pulmonary function following OPCAB.

Cardiac displacement-induced hemodynamic instability during off-pump coronary artery bypass surgery and its predictors.

Background: Emergent conversion to an on‐pump procedure during an off‐pump coronary artery bypass surgery (OPCAB) due to hemodynamic instability is associated with increased morbidity and mortality. The aim of this study was to evaluate the predictors of hemodynamic instability associated with mechanical heart displacement during OPCAB and the fate of these patients.

Distinct capnographic waveform in a pulmonary embolism caused by intravenous leiomyomatosis

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Sodium bicarbonate does not prevent postoperative acute kidney injury after off-pump coronary revascularization: a double-blinded randomized controlled trial

BACKGROUND Acute kidney injury (AKI) is a common morbidity after off-pump coronary revascularization. We investigated whether perioperative administration of sodium bicarbonate, which might reduce renal injury by alleviating oxidative stress in renal tubules, prevents postoperative AKI in off-pump coronary revascularization patients having renal risk factors. METHODS Patients (n=162) having at least one of the following AKI risk factors were enrolled: (i) age >70 yr; (ii) diabetes mellitus; (iii) chronic renal disease; (iv) congestive heart failure or left ventricular ejection fraction <35%; and (v) reoperation or emergency. Patients were evenly randomized to receive either sodium bicarbonate (0.5 mmol kg-1 for 1 h upon induction of anaesthesia followed by 0.15 mmol kg-1 h-1 for 23 h) or 0.9% saline. Acute kidney injury within 48 h after surgery was assessed using the Acute Kidney Injury Network criteria. RESULTS The incidences of AKI were 21 and 26% in the bicarbonate and control groups, respectively (P=0.458). Serially measured serum creatinine concentrations and perioperative fluid balance were also comparable between the groups. The length of postoperative hospitalization and incidence of morbidity end points were similar between the groups, whereas significantly more patients in the bicarbonate group required prolonged mechanical ventilation (>24 h) relative to the control group (20 vs 6, P=0.003). CONCLUSIONS Perioperative sodium bicarbonate administration did not decrease the incidence of AKI after off-pump coronary revascularization in high-risk patients and might even be associated with a need for prolonged ventilatory care. CLINICAL TRIAL REGISTRATION NCT01840241.