Intraoperative Maintenance of Normoglycemia with Insulin and Glucose Preserves Verbal Learning after Cardiac Surgery.

 Schricker T, Sato H, Beaudry T, Codere T, Hatzakorzian R, Pruessner JC.

 PLoS One. 2014 Jun 18;9(6)

 

Patients were randomly assigned to receive combined administration of insulin and glucose, titrated to preserve normoglycemia (3.5-6.1 mmol L-1; experimental group), or standard metabolic care (blood glucose 3.5-10 mmol L-1; control group), during open heart surgery. The patients' cognitive function was assessed during three home visits, approximately two weeks before the operation, and two months and seven months after surgery.  Questionnaires measuring specific traits known to affect cognitive performance, such as self-esteem, depression, chronic stress and social support, were also administered. The primary outcome was to assess the effect of hyperinsulinemic-normoglycemic clamp therapy versus standard therapy on specific cognitive parameters in patients receiving normoglycemic clamp, or standard metabolic care.

Twenty-six patients completed the study with 14 patients in the normoglycemia and 12 patients in the control group. Multiple analysis of covariance (MANCOVA) for the RAVLT showed a significant effect for the interaction of group by visit (F = 4.07, p = 0.035), and group by visit by recall (F = 2.21, p = 0.04). The differences occurred at the second and third visit. MANCOVA for the digit span task, trail making and word pair association test showed no significant effect.

CONCLUSIONS:

Preserving intraoperative normoglycemia by intravenous insulin and glucose may prevent the impairment of memory function, both short and long-term, after cardiac surgery.

Clevidipine compared with nitroglycerin for blood pressure control in coronary artery bypass grafting: a randomized double-blind study.

Merry AF, Avery EG, Nussmeier NA, Playford HR, Warman GR, Wang Y, Sladen RN.

Can J Anaesth. 2014 May;61(5):398-406

The investigators tested the hypothesis that clevidipine, a rapidly acting dihydropyridine calcium channel blocker, is not inferior to nitroglycerin (NTG) in controlling blood pressure before cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG).

100 patients undergoing CABG with CPB were randomized at four centres to receive intravenous infusions of clevidipine (0.2-8 μg·kg(-1)·min(-1)) or NTG (0.4 μg·kg(-1)·min(-1) to a clinician-determined maximum dose rate) from induction of anesthesia through 12 hr postoperatively. 

The study drug was titrated in the pre-CPB period with the aim of maintaining mean arterial pressure (MAP) within ± 5 mmHg of a clinician-predetermined target.

Total mean [standard deviation (SD)] dose pre-bypass was 4.5 (4.7) mg for clevidipine and 6.9 (5.4) mg for NTG (P < 0.05).

CONCLUSION:

During CABG, clevidipine was not inferior to NTG for blood pressure control pre-bypass.

Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: An analysis of national surgical quality improvement program database.

Kfoury E, Dort J, Trickey A, Crosby M, Donovan J, Hashemi H, Mukherjee D

.

Vascular. 2014 May 29. 

Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database

Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality.

Hypothermic vs normothermic cardiopulmonary bypass on patients with valvular heart disease
Vladimir V Lomivorotov et al

Journal of Cardiothoracic and Vascular Anesthesia
Volume 28, Issue 2 , Pages 295-300, April 2014

Prospective randomized study.
140 patients who had valvular heart disease, with/without coronary artery disease, surgically treated under CPB.

 Normothermic CPB in patients with valvular heart disease was as effective as hypothermic perfusion in terms of myocardial protection after the surgery assessed by cTnI release.
Ventilation time was significantly lower in the hypothermic group

Perioperative dexmedetomidine improves mortality in patients undergoing coronary artery bypass surgery
Fuhai Ji et al

Journal of Cardiothoracic and Vascular Anesthesia
Volume 28, Issue 2 , Pages 267-273, April 2014

Retrospective investigation.
Perioperative dexmedetomidine was used as an intravenous infusion (0.24 to 0.6 µg/kg/hour) initiated after cardiopulmonary bypass and continued for less than 24 hours postoperatively in the intensive care unit.
Dexmedetomidine infusion during CABG surgery was more likely to achieve improved in-hospital, 30-day, and 1-year survival rates, and a significantly lower incidence of delirium.

Effect of adding statins before surgery on mortality and major morbidity : a meta analysis
Joanne Guay et al

 Journal of Cardiothoracic and Vascular Anesthesia
Volume 28, Issue 2 , Pages 255-266, April 2014

 A search for all randomized controlled trials ,adult patients undergoing any type of procedure.
The search produced 29 trials.
Statins reduced the 0-30 days’ risk of myocardial infarction: risk ratio (RR) 0.48 (95%CI 0.38, 0.61); I-square 13.2%; p<0.001; number needed-to-treat 17 (14, 24)
There were no statistical differences at 0-30 days for stroke , acute renal insufficiency or reoperation. There was a trend for a reduced mortality at 1 year.

General anesthesia soon after dialysis may increase postoperative hypotension - A pilot study

J Deng, J Lenart, and R L Applegate

Heart Lung Vessel. 2014; 6(1): 52–59.

Post-anesthetic hypotension within 48 hours was more common in those with < 7 hours interval between dialysis and anesthesia. Therefore, if surgical urgency permits, a delay of ≥7 hours may limit postoperative hypotension

Clonidine in Patients Undergoing Noncardiac Surgery

 P.J. Devereaux, M.D et al

N Engl J Med 2014; 370:1504-1513April 17, 2014

Administration of low-dose clonidine in patients undergoing noncardiac surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, increase the risk of clinically important hypotension and nonfatal cardiac arrest. 

Central venous oxygen saturation and carbon dioxide gap as resuscitation targets in a hemorrhagic shock
M. NÉMETH,K. TÁNCZOS,G. DEMETER,D. ÉRCES,J. KASZAKI,A. MIKOR,Z. MOLNÁR

 Acta Anaesthesiologica Scandinavica Volume 58, Issue 5, pages 611–619, May 2014

 In this SV-guided bleeding and fluid resuscitation model, both ScvO₂ and dCO₂ correlated well with changes in SV, but only the dCO₂ returned to its baseline, normal value, while ScvO₂ remained significantly lower than at baseline. These results suggest that dCO₂( venous-to-arterial carbon dioxide gap ) may be a good hemodynamic endpoint of resuscitation, while ScvO₂ is not strictly a hemodynamic parameter, but rather an indicator of the balance between oxygen delivery and consumption.

The Risk of Hypertension after Preoperative
Discontinuation of Angiotensin-Converting Enzyme
Inhibitors or Angiotensin Receptor Antagonists
in Ambulatory and Same-Day Admission Patients
Rebecca S. Twersky, MD, MPH, Vasudha Goel, MD, Preeti Narayan, MD,
and Jeremy Weedon, PhD, MA, BS
Anesth Analg 2014;118:938–44


Discontinuing ACEIs and ARBs in patients on the day of surgery did not result
in a substantively increased incidence of pre- or postoperative HTN compared with patients who
continued these medications on the day of surgery. The results provide an evidentiary basis for
the safety of discontinuing ACEIs and ARBs on the day of surgery without increasing adverse
hemodynamic outcomes.