[Individualized use of levosimendan in cardiac surgery]. / Individualisierter Einsatz von Levosimendan in der Herzchirurgie.

BACKGROUND: Levosimendan is a cardiac inotrope that augments myocardial contractility without increasing myocyte oxygen consumption. Additionally, levosimendan has been shown to exhibit anti-inflammatory, antioxidative, and other cardioprotective properties and is approved for treatment of heart failure. Recent studies indicated that these beneficial effects can be achieved with doses lower than the standard dose of 12.5 mg. Patients with preoperatively diagnosed left ventricular ejection fraction (LVEF) ≤40% received 1.25 mg levosimendan after induction of anesthesia. After surgery, administration of low-dose levosimendan was repeated until cardiovascular stability was achieved. OBJECTIVE: This study aimed to evaluate if pharmacological preconditioning with 1.25 mg levosimendan in patients with LVEF ≤40% altered the postoperative need for inotropic agents, the incidence of newly occurring atrial fibrillation, renal replacement therapy, mechanical circulatory support and 30-day mortality. The cumulative dosage of levosimendan was recorded to assess the required dosage in the context of individualized treatment. MATERIAL AND METHODS: This retrospective study included patients with preoperatively diagnosed LVEF ≤40% who underwent cardiac surgery at this institution between January 2015 and December 2018 and who received 1.25 mg levosimendan after induction of anesthesia to prevent postoperative low cardiac output syndrome. Based on echocardiography results, invasive hemodynamic monitoring, and central venous or mixed venous oxygen saturation and lactate clearance, repetitive doses of levosimendan in 1.25 mg increments could be postoperatively administered until cardiovascular stability was achieved. The results were compared to the current literature. RESULTS: We identified 183 patients with LVEF <40% who received pharmacological preconditioning with 1.25 mg levosimendan. Maximum doses of epinephrine, incidence of atrial fibrillation, need for renal replacement therapy and 30-day mortality were found to be below the published rates of comparable patient collectives. In 73.2% of patients, a cumulative dosage of 5 mg levosimendan or less was considered sufficient. CONCLUSION: The presented concept of pharmacological preconditioning with 1.25 mg levosimendan followed by individualized additional dosing in cardiac surgery patients with preoperative LVEF ≤40% suggests that this concept is safe, with possible advantages regarding the need of inotropic agents, renal replacement therapy, and 30-day mortality, compared to the current literature. Individualized treatment with levosimendan to support hemodynamics and a timely reduction of inotropic agents needs further confirmation in randomized trials.

Commercial glucocorticoid formulations and skin dryness. Could it be caused by the vehicle?

Eczema craquelé can be induced by repeated open application of a topical glucocorticoid, viz. 0.05% clobetasole 17-propionate cream. This might not be invariably due to the active component. Comparison of the skin surface roughness as assessed by profilometry and as expressed by RZDIN showed a decrease after repeated open application of 0.1% betamethasone 17-valerate cream and 0.25% prednicarbate cream, but an increase following the vehicle of the latter preparation. Thus commercial oil-in-water emulsion preparations seem to be potentially injurious to human skin, though this may be masked when a glucocorticoid is added.

0.05% clobetasol 17-propionate cream and ointment but not the corresponding 0.1% triamcinolone acetonide preparations increase skin surface roughness: a possible dissociation of unwanted epidermal and dermal effects.

Repeated open application of clobetasol 17-propionate cream and ointment to normal skin over a period of 6 weeks induced an increase in skin surface roughness as assessed by profilometry (p < 0.05), while 6 weeks' application of triamcinolone acetonide cream and ointment did not. The increase in skin roughness with clobetasol 17-propionate cream turned out to be greater than with ointment containing identical amounts of clobetasol 17-propionate (p < 0.05). A clear-cut correlation between increase of skin surface roughness and skin thickness as assessed by high-frequency ultrasound could be demonstrated only with clobetasol 17-propionate cream and ointment.

Influence of skin cleansing preparation acidity on skin surface properties.

Synopsis Two long-term trials were conducted each over eight weeks to compare the effect of the regular application of skin cleansing preparations of pH 5.5 and pH 8.5 and pH 5.5 and pH 7.0 respectively on the surface pH, roughness and transepidermal water loss (TEWL) of normal human forehead and forearm skin. Both trials were based on a cross-over design: five healthy volunteers started with a pH 5.5 preparation and switched to the other after four weeks, five additional volunteers used the preparations in the opposite order. While the skin surface pH was markedly lower in those individuals using the pH 5.5 preparation at each examination, as compared to those using the pH 8.5 or pH 7.0 preparation, no such difference could be established with respect to skin roughness and TEWL. Hence the skin irritancy of a cleansing preparation does not seem to be linked to its pH within the pH ranges tested.