Anesthesia and postoperative analgesia in pediatric patients undergoing cardiac surgery

Pediatric cardiac anesthesiologists care for patients ranging from premature infants weighing <2 kg to adults requiring surgical intervention for congenital heart disease. Along with their cardiac pathophysiologies, many of these patients also have other co-existing diseases that can affect their anesthetic management. Recent advances in monitoring include non-invasive neuromonitors, such as near-infrared spectroscopy and trans-cranial Doppler, which are assuming increasing importance in intraoperative management, particularly during cardiopulmonary bypass. A variety of anesthetic techniques, including regional anesthesia, can be used to facilitate early extubation in older infants and children with stable postoperative hemodynamics. In addition to regional anesthesia, other modalities for the management of postoperative pain include opioid infusions in critically ill children and the use of patient- or nurse-controlled analgesia pumps. Multiple pain assessment tools are available for children of varying ages and developmental levels to assist in providing appropriate postoperative pain management.     

低潮气量机械通气对肺功能正常心脏手术患者的影响

目的 比较低潮气量(LVT)机械通气与常规潮气量(CVT)机械通气对肺功能正常心脏手术患者的气管拔管的时间及预后影响.方法 72例行心脏瓣膜手术的患者随机均分为L组(VT6 ml/kg)和C组(VT 10 ml/kg);调节通气频率(RR),保持呼气末二氧化碳分压(PETCO2)35～45mm Hg.比较两组患者的气管拔管时间、呼吸参数、血气分析及血浆IL-6表达.结果 L组RR快于C组,入ICU 10 min后的PET CO2明显低于C组;术后在ICU期间的IL-6浓度明显低于C组(P＜0.05).两组平均气管拔管时间相仿(P＞0.05);L组6h内气管拔管病例的比例明显高于C组(17.3％ vs.25％)(P＜0.05),L组患者需二次插管率明显低于C组(2.7％vs.14.3％)(P＜0.05).结论 LVT也适用于肺功能正常心脏手术患者的CVT机械通气;且与CVT机械通气比较,LVT机械通气患者拔管早,需再次插管的少.     

国产舒芬太尼单剂量给药在心脏手术患者的药代动力学

目的研究国产舒芬太尼(阿片受体激动剂)单剂量给药在心脏手术患者的药代动力学特征。方法随机选择NYHAⅡ～Ⅲ级的成年心脏手术患者8例,麻醉后,经前臂静脉一次性静脉注射国产舒芬太尼5μg.kg-1;采集给药后1,3,5,10,20,30,60,120,240,360 min血标本,-40℃低温保存直至分析。用液相色谱-质谱联用法测定血浆舒芬太尼浓度,3P97药理学程序计算药代动力学参数。结果舒芬太尼血药浓度-时间衰减曲线的三指数函数方程表示为Cp(t)=14.77e-0.518t+3.78e-0.048t+0.32e-0.004t。主要药代动力学参数:t1/2π=(0.03±0.02)h,t1/2α=(0.25±0.07)h,t1/2β=(3.68±2.44)h,Vc=(0.29±0.09)L.kg-1,Vd=(8.24±5.07)L.kg-1,CL=(0.03±0.00)L.(kg.h)-1。结论国产舒芬太尼在心脏手术患者的药代动力学符合三室模型,体外循环可影响其药代动力学特征。     

Pharmacokinetic modeling of tranexamic acid for patients undergoing cardiac surgery with normal renal function and model simulations for patients with renal impairment

Tranexamic acid (TXA), an effective anti‐fibrinolytic agent that is cleared by glomerular filtration, is used widely for cardiopulmonary bypass (CPB) surgery. However, an effective dosing regimen has not been fully developed in patients with renal impairment. The aims of this study were to characterize the inter‐patient variability associated with pharmacokinetic parameters and to recommend a new dosing adjustment based on the BART dosing regimen for CPB patients with chronic renal dysfunction (CRD). Recently published data on CPB patients with normal renal function (n = 15) were re‐examined with a two‐compartment model using the ADAPT5® and NONMEMVII® to identify covariates that explain inter‐patient variability and to ascertain whether sampling strategies might affect parameter estimation. A series of simulations was performed to adjust the BART dosing regimen for CPB patients with renal impairment. Based on the two‐compartmental model, the number of samples obtained after discontinuation of TXA infusion was found not to be critical in parameter estimation (p > 0.05). Both body weight and creatinine clearance were identified as significant covariates (p < 0.005). Simulations showed significantly higher than normal TXA concentrations in CRD patients who received the standard dosing regimen in the BART trial. Adjustment of the maintenance infusion rate based on the percent reduction in renal clearance resulted in predicted plasma TXA concentrations that were safe and therapeutic (~100 mg·L^?1). Our proposed dosing regimen, with consideration of renal function, is predicted to maintain effective target plasma concentrations below those associated with toxicity for patients with renal failure for CPB. Copyright © 2015 John Wiley & Sons, Ltd.     

经食道超声心动图(TEE)在心脏瓣膜手术中的应用

摘要 目的：评价经食管超声心动图(TEE)在心脏瓣膜手术中的临床应用价值。方法：对247例心脏瓣膜手术患者行TEE监测,与术前诊断比较、比较200例二尖瓣置换病人换瓣前后瓣膜返流并观察体外停机前后气体出现情况。结果：（1）补充诊断29例(占11.74％),更正诊断20例(占8.09％)。（2）200例二尖瓣置换病人术后返流量远比换瓣前返流量少(P<0.01),有5例(2.5%）返流量>3级,及时在体外循环下重新进行瓣周漏修补术,效果良好。（3）247例病人中有l88例(76.11％)左房发现微量气体。结论：TEE在心脏手术麻醉中的应用,不仅补充和更正术前诊断而且能即刻评估术后瓣膜状况及功能,监测左心气体。     

帕瑞昔布钠对颅脑手术患者血浆C反应蛋白的影响

目的探讨帕瑞昔布钠对颅脑手术患者血清超敏C反应蛋白(hs-CRP)的影响。方法 40例择期行神经外科肿瘤手术的患者按随机对照的原则分为使用帕瑞昔布钠组(A组)和不使用帕瑞昔布钠组(B组),每组20例。两组患者分别在麻醉诱导前、拔管后测定血清hs-CRP浓度。结果拔管后B组hs-CRP浓度较A组明显升高(P<0.05)。结论帕瑞昔布钠可以降低颅脑手术患者血清hs-CRP水平。     

CGRP and ET-1 plasma levels in normal subjects

OBJECTIVE: Calcitonin gene-related peptide (CGRP) is a 37 amino acid peptide displaying about 50% homology with amylin which is secreted from the pancreatic islets of Langerhans. The main form, the beta-CGRP, is produced by the enteric nervous system and perivascular nerves of the vasa-vasorum. It represents one of the most powerful vasodilator yet discovered but its role is not yet completely clarified. High levels of this peptide have been shown in patients affected with thyroid medullary carcinoma, phaemocromocytoma and lung carcinoma. Recently circulating levels of CGRP have been found in normal subjects. Endothelin-1 (ET-1), a potent vasoconstrictor peptide, isolated from porcine endothelial cells, is an important regulator of the vascular tone acting in physiological antagonism with atrial natriuretic hormone (ANH). With this study we intended to investigate the presence of any correlation between CGRP and ET-1 in normal subjects. PATIENTS: For the study we considered 20 normal subjects (11 males and 9 females) aged 23 to 50. MEASURES: Plasma levels of CGRP and ET-1 were measured by radioimmunological Kit. RESULTS: A positive and significant correlation between calcitonin gene-related peptide and endothelin-1 was found. CONCLUSIONS: Our results confirms that CGRP and ET-1 have opposing actions on vessels and that they can act together in haemodinamic regulation.     

Alteration of vancomycin pharmacokinetics during cardiopulmonary bypass in patients undergoing cardiac surgery.

The alteration of vancomycin pharmacokinetics during cardiopulmonary bypass (CPB) in patients undergoing cardiac surgery was studied. Eighteen patients were enrolled in the study. Vancomycin (1 g) was intravenously infused one to two hours before surgery. Blood samples were taken before, during, and after CPB. Serum drug concentrations were determined by an automated fluorescence polarization immunoassay and adjusted, with a bayesian analysis, to a bi-compartmental model implemented in a pharmacokinetic system program. Serum creatinine, hematocrit, and plasma proteins were also measured before, during, and after CPB. During CPB, serum creatinine, hematocrit, and plasma protein values all decreased significantly (p < 0.05). Serum vancomycin concentration also diminished abruptly with CPB (7.04 micrograms/mL; 95% confidence interval, 5.70-8.38 micrograms/mL) but increased moderately during the next 30 minutes, probably attributable to redistribution into plasma from tissue stores. Vancomycin's apparent volume of distribution showed an important increase during CPB (58.8%) (p < 0.0005), and its systemic clearance also increased significantly after CPB (19.7%) (p < 0.0005). The decrease in serum vancomycin concentration seems mediated by the hemodilution associated with the pump prime volume. Vancomycin's mean +/- S.D. nadir serum concentration before the next dose was 7.13 +/- 2.1 micrograms/mL. In patients undergoing cardiac surgery and treated prophylactically with a 1-g preoperative i.v. dose of vancomycin, the onset of CPB was associated with a drop in serum vancomycin concentration.     

异氟醚对心内直视手术缺血后心肌酶的影响

目的　本研究旨在通过在体外循环下心内直视手术中观察心肌酶的变化 ,探讨异氟醚对体外循环心脏手术所致的心肌顿抑的影响。方法　选择 30例先天性心脏病 (室缺或房缺 )患者 ,随机分为异氟醚 (ISO)组和对照 (CON)组 ,每组各 15例。分别于术前、主动脉开放后 30min、60min和 2 4h从锁骨下静脉抽取血样测定乳酸脱氢酶 (LDH)、肌酸激酶同功酶 (CK MB)和α 羟丁酸脱氢酶 (HBDH)。另外 ,在复跳期间记录室颤发生例数。结果　ISO组主动脉开放后出现室颤 6例 ,通过除颤复跳 ,CON组为 9例 ,其中 6例通过除颤复跳 ,两组差异无显著性 (P >0 .0 5 )。主动脉开放 30min ,ISO组CK MB和HBDH均明显低于CON组 ,在 2 4h ,ISO组LDH、CK MB和HBDH均明显降低 (与CON组比较P <0 .0 5 )。结论　异氟醚麻醉可以降低主动脉开放后心肌酶的水平 ,对心肌顿抑产生保护作用     

正常人和心脏病患者血清α1—酸性糖蛋白,唾液酸及丙吡胺蛋白…

目的：研究日本人充血性心力衰竭（ＣＨＦ）和急性心肌梗塞（ＡＭＩ）病人对血清α１－酸性糖蛋白（ＡＧＰ）、唾液酸（ＳＡ）浓度及ＡＧＰ与丙吡胺（Ｄｉｓ）结合的影响。方法：对正常人、ＣＨＦ及ＡＭＳ患者血清样本９７例，采用免疫化学法测定ＡＧＰ浓度，高效液相层析法测定ＳＡ浓度及超滤膜技术和高效液相层析法测定Ｄｉｓ的体外游离浓度。结果：ＣＨＦ及ＡＭＩ患者血清ＡＧＰ浓度较正常人升高。Ｄｉｓ药物游离浓度降低。血清Ｓ     

The pharmacokinetic profile of recombinant human erythropoietin is unchanged in patients undergoing cardiac surgery

Background

In anticipation of future studies, we examined the pharmacokinetics profile of erythropoietin (EPO) in patients undergoing cardiac surgery.

Methods

Cardiac surgical patients were enrolled into one of six groups: four cardiopulmonary bypass (CPB) groups [placebo (n?=?6), 250 IU/kg EPO (n?=?3), 500 IU/kg EPO (n =?3), and 500 IU/kg EPO, two doses (n =?6)] and two off-pump coronary artery bypass (OPCAB) groups [placebo (n?=?3) and 500 IU/kg EPO (n?=?3)]. The EPO was administered prior to anesthesia and 10 min after CPB (if required). Blood samples for serum EPO were collected at baseline, 10 min after dosing, 5 min after sternotomy, during CPB or the equivalent for OPCAB (5, 15, 45, 60 min), and post-CPB (5, 15, 45, and 60 min, 6, 12 and 24 h, and daily until day 5).

Results

Endogenous EPO increased within 24 h of surgery in the placebo group and remained elevated. There was approximately a 40% decrease in serum EPO concentration at the initiation of CPB due to an increase in circulatory blood volume. There were no differences in apparent volume of distribution in the plasma (Vc) (42.2?±?9.9, 39.8?±?6.3, 42.3?±?14.0 mL/kg), clearance (CL) (4.63?±?1.14, 3.44?±?0.68, 4.27?±?0.52 mL h/kg), and t_½ (16.4?±?8.0 16.9?±?10.6, 22.4?±?9.3 h) between the CPB treatment groups. The pharmacokinetic profile of EPO in the OPCAB group was similar to that for the CPB groups: Vc = 39.3?±?7.0 mL/kg, CL = 4.98?±?0.17 mL h/kg and t_½ = 17.1?±?18.1 h.

Conclusions

CPB had no apparent effect on the pharmacokinetics of EPO.

     

左卡尼汀对维持性透析患者心功能和血C反应蛋白的影响

目的探讨左卡尼汀对维持性血液透析患者心功能和C反应蛋白(CRP)的影响。方法维持性透析患者120例随机分为治疗组和对照组,对照组给予常规血液透析治疗,治疗组在对照组治疗基础上于透析结束后缓慢静脉注射左旋卡尼汀1 g/次,2次/周,疗程3个月。观察2组患者治疗前后心功能改善情况,左心室射血分数(LVEF)、二尖瓣前向血流E峰与A峰比值(E/A)、心排出量(Co);血CRP,并进行比较。结果治疗组血CRP较治疗前和对照组治疗后明显下降;LVEF、Co、E/A较治疗前和对照组治疗后明显提高。结论左卡尼汀可以改善维持性透析患者心功能,降低血CRP。     

Rhythm of carnitine levels in serum and urine of normal subjects

A study of the diurnal serum and urine levels of L-carnitine and acetylcarnitine was carried out in eleven healthy volunteers. No significant difference was found between the levels in the morning and in the afternoon, although a higher carnitinaemia was shown in the waking hours when the energy demands were higher.     

A comparative dose-effect study with cardiac glycosides assessing cardiac and extracardiac responses in normal subjects

We tested the hypothesis that differences exist in the pharmacodynamic pattern of different cardiac glycosides. We conducted a randomized, placebo-controlled study in normal volunteers and evaluated the effects of weekly increased oral dosing of digoxin (n = 10; from 0.25 to 1.0 mg/day), meproscillarin (n = 10; from 0.5 to 2.0 mg/day), and placebo (n = 5). To determine the glycoside effects, corrected electromechanical systole (QS2c) was used to measure inotropy and the PQ interval to test dromotropy. Red-green discrimination and critical flicker fusion (CFF) assessed visual functions. Subjective complaints were collected using rating lists. Both glycosides dose dependently shortened QS2c and prolonged PQ interval. PQ prolongations over +20 ms occurred in seven of 10 digoxin subjects, in two of 10 meproscillarin, and in one of five placebo. Equi-inotropic response, identified at 12 ms mean QS2c shortening, revealed the relative potency of digoxin to be 2.4 times higher than meproscillarin; this ratio increased to sevenfold for equi-effective negative dromotropic effects at 12 ms mean PQ prolongation. Each drug was associated with a dominant subjective complaint: digoxin with anergy and meproscillarin with diarrhea. Red-green discrimination was better under meproscillarin and CFF was depressed by digoxin. The results indicate that pharmacodynamic differences exist between cardiac glycosides. A differential use of various glycosides should be considered and tested clinically.     

Pharmacotherapeutic management of macular edema in diabetic subjects undergoing cataract surgery

ABSTRACT

Introduction: Cataracts and diabetes are widespread pathologies that are of growing concern to the global population. In diabetic patients who have had cataract surgery, the worsening of preexisting diabetic macular edema or occurrence of pseudophakic cystoid macular edema are common causes of visual impairment even with the most advanced surgical techniques available today for phacoemulsification.

Areas covered: In this review, the authors assess the available literature to evaluate and compare different drugs, with the aim of establishing the best pharmacological strategies for the prevention and treatment of macular edema in diabetic patients undergoing cataract surgery.

Expert opinion: Guidelines for the optimal management of diabetic macular edema in conjunction with cataract surgery or treatment of pseudophakic cystoid macular edema in diabetic patients are still lacking. To treat these conditions, clinicians need to understand the pharmacokinetics, posology, and efficacy of available drugs: topical non-steroidal anti-inflammatory drugs (NSAIDs), intravitreal anti-vascular endothelial growth factors (VEGFs), and both topical and intravitreal steroids. Diabetic patients undergoing cataract surgery should receive topical NSAIDs to prevent pseudophakic cystoid macular edema. Intravitreal anti-VEGFs and steroids, in association with cataract surgery, are indicated for patients with preexisting diabetic macular edema or those at high risk of macular edema after surgery.     

黄芪注射液对腹腔镜手术患者围术期NK细胞水平的影响

目的探讨黄芪注射液对腹腔镜手术患者围术期NK细胞水平的影响。方法选择40例择期全麻下行腹腔镜手术患者,年龄20～50岁,ASA分级Ⅰ-Ⅱ级,无血液病和免疫、内分泌系统等疾病,将其随机分成黄芪注射液组（A组）和对照组（C组）。A组静滴黄芪注射液10ml＋生理盐水90ml,15min滴完后静注芬太尼、丙泊酚、艾可松行气管插管控制呼吸,术中以丙泊酚及七氟醚维持麻醉,维持生命征在正常水平,术毕前腹腔冲洗液加入黄芪注射液10ml,术毕待病人自主呼吸恢复,清醒后拔管。C组静滴生理盐水100ml后麻醉,腹腔冲洗液中不加黄芪注射液,余同A组。采集手术前（TO）、术毕（T1）、术后1d（T2）、术后3d（T3）的静脉血,流式细胞仪测定NK细胞（CD16＋56）的水平。结果C组NK细胞水平在T0、T1、T2、T3时分别为（18±7）％、（29±9）％、（17±7）％、（11±5）％;A组NK细胞水平在T0、T1、T2、T3时分另0为（16±5）％、（28±8）％、（22±7）％、（15±4）％。与T0时比较,C组NK细胞水平T1时明显升高,T2时下降至T0时水平,T3明显下降,A组T1、T2时均明显升高,至T3时仍在T0时水平,在T2、T3时A组明显高于C组（P〈0．05）。结论C组术后NK细胞水平相对A组抑制明显,表明黄芪注射液在腹腔镜手术的应用对患者细胞免疫具有一定的保护作用。     

Serum lidocaine levels in patients undergoing fibrobronchoscopy

Serum lidocaine levels were determined in 29 patients undergoing fibrobronchoscopy after drug doses ranging from 180 to 400 mg. The results showed rapid absorption of the anaesthetic by the tracheobronchial mucosa with an average absorption constant of 4.77 +/- 1.99 h-1. Maximum lidocaine levels in serum averaged 1.21 +/- 0.64 microgram/ml, lower than the levels established as toxic for this anaesthetic. The serum half-life of lidocaine averaged 1.55 +/- 0.72 h. The percentage of dose absorbed in this kind of patient ranged between 20.89 and 60.88% of the dose administered.     

Lignocaine kinetics in cardiac patients and aged subjects.

1 The pharmacokinetics following long term intravenous infusion of lignocaine to cardiac patients have been examined. 2 Plasma levels and half-lives of lignocaine and monoethylglycinexylidide (MEGX) showed wide inter-patient variability. 3 Toxicity reactions to therapy were associated with elevated lignocaine and/or MEGX plasma levels. 4 In a separate study the effect of age on the pharmacokinetics of lignocaine was examined using bolus doses (50 mg) of the drug to young and aged subjects. 5 Elderly subjects had significantly longer half-lives for lignocaine compared to younger individuals although no change in plasma clearance occurred. 6 The drug appeared to distribute differently in the aged as reflected by significantly increased apparent volumes of distribution. 7 The 24 h urinary recovery of the major metabolite (total 4-hydroxyxylidine) showed a significant reduction in the elderly when compared to the young. 8 The clinical significance of these studies with respect to lignocaine therapy has been discussed.