Glutamate infusion associated with reduced rises of p-Copeptin after coronary surgery: Substudy of GLUTAMICS II

Background

Glutamate plays a key role for post-ischaemic recovery of myocardial metabolism. According to post hoc analyses of the two GLUTAMICS trials, patients without diabetes benefit from glutamate with less myocardial dysfunction after coronary artery bypass surgery (CABG). Copeptin reflects activation of the Arginine Vasopressin system and is a reliable marker of heart failure but available studies in cardiac surgery are limited. We investigated whether glutamate infusion is associated with reduced postoperative rises of plasma Copeptin (p-Copeptin) after CABG.

Methods

A prespecified randomised double-blind substudy of GLUTAMICS II. Patients had left ventricular ejection fraction ≤0.30 or EuroSCORE II ≥3.0 and underwent CABG ± valve procedure. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h was commenced 10–20 min before the release of the aortic cross-clamp and then continued for another 150 min P-Copeptin was measured preoperatively and postoperatively on day one (POD1) and day three. The primary endpoint was an increase in p-Copeptin from the preoperative level to POD1. Postoperative stroke ≤24 h and mortality ≤30 days were safety outcomes.

Results

We included 181 patients of whom 48% had diabetes. The incidence of postoperative mortality ≤30 days (0% vs. 2.1%; p = .50) and stroke ≤24 h (0% vs. 3.2%; p = .25) did not differ between the glutamate group and controls. P-Copeptin increased postoperatively with the highest values recorded on POD1 without significant inter-group differences. Among patients without diabetes, p-Copeptin did not differ preoperatively but postoperative rise from preoperative level to POD1 was significantly reduced in the glutamate group (73 ± 66 vs. 115 ± 102 pmol/L; p = .02). P-Copeptin was significantly lower in the Glutamate group on POD1 (p = .02) and POD 3 (p = .02).

Conclusions

Glutamate did not reduce rises of p-Copeptin significantly after moderate to high-risk CABG. However, glutamate was associated with reduced rises of p-Copeptin among patients without diabetes. These results agree with previous observations suggesting that glutamate mitigates myocardial dysfunction after CABG in patients without diabetes. Given the exploratory nature of these findings, they need to be confirmed in future studies.     

Human factors in pelvic surgery

In the pelvis, anatomic complexity and difficulty in visualization and access make surgery a formidable task. Surgeons are prone to work-related musculoskeletal injuries from the frequently poor design and flow of their work environment. This is exacerbated by the strain of surgery in the pelvis. These injuries can result in alterations to a surgeons practice, inadvertent patient injury, and even early retirement. Human factors examines the relationships between the surgeon, their instruments and their environment. By bridging physiology, psychology, and ergonomics, human factors allows a better understanding of some of the challenges posed by pelvic surgery. The operative approach involved (open, laparoscopic, robotic, or perineal) plays an important role in the relevant human factors. Improved understanding of ergonomics can mitigate these risks to surgeons. Other human factors approaches such as standardization, use of checklists, and employing resiliency efforts can all improve patient safety in the operating theatre.     

Secondary Qualitative Analysis of Moral Injury in Obstetric and Neonatal Nurses

ObjectiveTo investigate the presence of symptoms of moral injury in obstetric and neonatal nurses.DesignA secondary qualitative analysis using an analytic expansion of three primary studies.SettingPostal mail and electronic surveys.ParticipantsI used three primary studies: participants in the first consisted of 78 labor and delivery nurses, participants in the second consisted of 75 nurse-midwives, and participants in the third consisted of 22 NICU nurses.MethodsI used Krippendorff’s content analysis method for qualitative data to reanalyze the three primary data sets. The categories I used in this analysis were the 10 symptoms of moral injury that are assessed by the Moral Injury Symptoms Scale–Health Professionals Version.ResultsWhen combining the three types of obstetric and neonatal participants, the top three most frequently cited symptoms of moral injury were moral concern, guilt, and self-condemnation. For participants in labor and delivery units and NICUs, moral concern was the most often described symptom, whereas for participants in midwifery it was guilt. None of the participants reported loss of meaning in their lives, loss of faith, or religious struggle. Participants who worked in NICUs did not describe any symptoms of shame or difficulty forgiving.ConclusionIn addition to the primary symptoms of moral injury, reported secondary consequences of moral injury can include depression, anxiety, anger, self-harm, and social problems. Interventions such as acceptance and commitment therapy are needed to help nurses address the potential for moral injury and repair its effects. Since the COVID-19 pandemic, now more than ever, moral injury needs to be recognized in obstetric and neonatal nurses and not just in the military population.     

Case Report: Transient Stress Hyperglycemia in the Patient With ST-Elevation Myocardial Infarction

Transient stress hyperglycemia in the setting of acute myocardial infarction is a frequent phenomenon. Its transient nature should not dissuade the clinician from management of elevated blood glucose in a patient after an ST-elevation myocardial infarction. This case presents an adult patient after an ST-elevation myocardial infarction with transient stress hyperglycemia and the evidence used to identify optimal pharmacologic management and secondary prevention.     

二维斑点追踪显像技术评估窒息新生儿左心室纵向收缩功能与心肌损害的相关性

【摘要】目的 探讨二维斑点追踪显像技术(2D-STI)评估新生儿窒息合并心肌损害后左心室整体及局部心肌的纵向收缩功能在早期诊断窒息新生儿心肌损害中的临床价值。方法 选择2019年07月至2020年12月期间在右江民族医学院附属医院新生儿科住院的足月窒息新生儿61例，经临床确诊合并心肌损害，根据Apgar评分分为轻度组31例和重度组30例，选择同期住院出生的正常足月新生儿30例作为对照组。检测受检者的血清肌酸激酶同工酶（CK-MB）、肌钙蛋白（cTnT）、左室舒张期前后径（LVDId）、左室射血分数（LVEF）、左室短轴缩短率（LVFS）、辛普森法左室射血分数（Simpson EF）、左室三腔心整体应变（GLS-LAX）、左室四腔心整体应变（GLS-A4C）、左室两腔心整体应变（GLS-A2C）、左室整体应变（GLS-AVG）,分析GLS-AVG和CK-MB、cTnT三者的相关性。结果 三组间CK-MB和cTnT比较差异有统计学意义（P<0.05）。三组间性别、体重、胎龄均无统计学差异（P>0.05）。三组间LVDId、LVEF、LVFS、Simpson EF比较差异无统计学意义（P>0.05）。GLS-AVG与CK-MB呈负性相关（r=-0.515，P=0.000），GLS-AVG与cTnT呈负性相关（r=-0.912，P=0.000）。结论 GLS-AVG与CK-MB、cTnT具有相关性，GLS-AVG可作为窒息新生儿心肌损害早期诊断指标。