Effects of Ulinastatin on In Vitro Storage Lesions of Human Red Blood Cells.

BACKGROUND: The study aimed to investigate the influence of in vitro storage on erythrocyte complement receptor one (E-CR1), cell shrinkage and eryptosis of human red blood cells (RBCs), and to assess the possible effects of ulinastatin (UTI) on them. METHODS: After collection, RBCs were treated with saline (control group) and different concentrations of UTI (5,000 U/mL, 10,000 U/mL, and 50,000 U/mL in Group C1, Group C2, and Group C3, respectively). E-CR1, cell size, and phosphatidylserine (PS) exposure and intracellular Ca2+ concentration were analyzed by flow cytometer every 7 days up to Day 35. RESULTS: E-CR1 level and cell size of all groups decreased during storage. In the control group, E-CR1 began to decrease on Day 28 and cells shrank on Day 21. The E-CR1 level of Group C2 was significantly higher than that of the control group beginning on Day 21. The cells of Group C1 and Group C2 began to shrink remarkably on Day 21, and those of Group C3 on Day 35. PS-exposure levels of 4 groups started to increase on Day 7 (p < 0.05), while from Day 14 to 35 those of Group C3 were significantly lower than the control group (p < 0.05). The intracellular Ca2+ levels of the control group started to increase significantly on Day 7, one week earlier than the experimental groups. From Day 21 to 35, the intracellular Ca2+ levels of Group C2 and C3 were significantly lower than those of the control group (p < 0.05). CONCLUSIONS: RBCs underwent E-CR1 loss, cell shrinkage, and eryptosis during in vitro storage, which could be attenuated by UTI.

Comparison of cardio-protective effects induced by different modalities of sevoflurane conditioning in isolated rat hearts.

OBJECTIVE: To examine whether the combination of anesthetic preconditioning and anesthetic postconditioning could elicit additional cardio-protection as compared to either anesthetic preconditioning or anesthetic postconditioning alone and its underlying mechanism. METHODS: Isolated rat hearts were randomized into one of four groups: CTRL group (30 min of ischemia followed by 120 min of reperfusion alone); SpreC group (3% sevoflurane preconditioning was administered for 15 min followed by 10 min of washout before ischemia); SpostC group (3% sevoflurane postconditioning was administered during the first 15 min of reperfusion after ischemia); SpreC+SpostC group (the protocols of SpreC and SpostC were combined). Hemodynamics, myocardial infarct size, lactate dehydrogenase and creatine kinase-MB in collected effluent, phosphorylation of PKB/Akt and ERK 1/2 and content of nicotinamide adenine dinucleotide in the left ventricular tissue were compared among the four groups. RESULTS: When compared with unprotected Control hearts, those in the sevoflurane-treated groups (SpreC, SpostC and SpreC+SpostC) showed significantly better functional recovery, reduced myocardial infarct size and decreased lactate dehydrogenase and creatine kinase-MB release. Comparison of the above-mentioned variables among the three sevoflurane-treated groups showed that maximal cardio-protection was obtained in the SpreC+SpostC group. Both SpreC and SpreC+SpostC induced a biphasic response in protein kinase B (PKB/Akt) and extracellular signal-regulated kinase (ERK 1/2) phosphorylation, while SpostC induced only one phase. The effects on phosphorylation of both PKB/Akt and ERK 1/2 induced by SpreC and SpostC were found to be additive during reperfusion. The combination of SpreC and SpostC also had additive effects on inhibiting mitochondrial permeability transition pore (mPTP) opening induced by ischemia-reperfusion. CONCLUSION: These findings suggested that the cardio-protection induced by SpreC and SpostC could be additive via the involvement of PKB/Akt, ERK 1/2 and mPTP.

Restoration of autophagic flux in myocardial tissues is required for cardioprotection of sevoflurane postconditioning in rats.

AIM: Sevoflurane postconditioning (SpostC) has been shown to protect the heart from ischemia-reperfusion (I/R) injury. In this study, we examined whether SpostC affected autophagic flux in myocardial tissues that contributed to its cardioprotective effects in rats following acute I/R injury. METHODS: SD rats underwent 30 min of left anterior descending coronary artery ligation followed by 120 min of reperfusion. The rats were subjected to inhalation of 2.4% (v/v) sevoflurane during the first 5 min of reperfusion, and chloroquine (10 mg/kg, ip) was injected 1 h before I/R. Myocardial infarct size was estimated using TTC staining. Autophagosomes in myocardial tissues were detected under TEM. Expression of LC3B-II, beclin-1, p62/SQSTM1, cathepsin B, caspase-3 and cleaved PARP was assessed using Western blot analysis. Plasma cardiac troponin I was measured using ELISA. Cardiomyocyte apoptosis was evaluated with TUNEL staining. RESULTS: I/R procedure produced severe myocardium infarct and apoptosis accompanied by markedly increased number of autophagosomes, as well as increased levels of LC3B-II, beclin-1 and p62 in myocardial tissues. SpostC significantly reduced infarct size, attenuated myocardial apoptosis, restored intact autophagic flux and improved the lysosomal function in myocardial tissues. Administration of chloroquine that blocked autophagic flux abrogated the cardioprotective effects of SpostC. CONCLUSION: SpostC exerts its cardioprotective effects in rats following I/R injury via restoring autophagic flux in myocardial tissues.

[Anesthetic management for patients undergoing total thoracoabdominal aorta replacement without cardiopulmonary bypass].

OBJECTIVE: To summarize the experience in anesthetic management for total thoracoabdominal aorta replacement without cardiopulmonary bypass. METHODS: From October 2009 to September 2010, 10 patients of Fuwai Hospital received off-pump total thoracoabdominal aorta replacement. Of these patients, 5 were subjected to Standford B aortic dissection, 2 were Standford A aortic dissection received total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta.1 were Marfan's syndrome, and 2 were thoracoabdominal aorta. All operations used the technique which preserved blood was transfused back by pump via the femoral artery. RESULTS: The average surgery time was (7.4 ± 1.2) h and extubation time was (14.1 ± 2.5) h, the descending thoracic aorta cross clamp time was (11.5 ± 3.6) min, the intercostal artery reconstruction time was (16.4 ± 5.5) min, the required amount of blood products was fresh frozen plasma (600.5 ± 542.8) ml, platelet(1.7 ± 0.8) U, red blood cell (4.3 ± 2.4) U, auto blood salvage (465.7 ± 242.3) ml. Three patients occurred atelectasis and one patient occurred sero peritoneum postoperation. All of the 10 patients were discharged from hospital without any neurologic complications. CONCLUSION: The anesthetic management for total thoracoabdominal aorta replacement without cardiopulmonary bypass is feasible. It can reduce the side effects of deep hypothermia circulatory arrest and had a good effect.

[Effectiveness and safety of tranexamic acid in patients receiving on-pump coronary artery bypass grafting without clopidogrel and aspirin cessation].

OBJECTIVE: To evaluate the effectiveness and safty of tranexamic acid in patients receiving on-pump coronary artery bypass grafting (CABG) without clopidogrel and aspirin cessation. METHODS: The current study is a prospective, randomized and placebo-control trial. A total of 116 patients receiving selective on-pump CABG with their last ingestion of clopidogrle and aspirin within 7 days preoperatively were recruited. Despite 6 patients withdrawal their consent, the rest 110 were randomized to receive tranexamic acid or placebo. The tranexamic acid regimen was a bolus of 10 mg/kg followed by a maintenance of 10 mg·kg(-1)·h(-1) throughout the surgery. The primary outcome was the volume of allogeneic erythrocyte transfused perioperatively. RESULTS: Baseline characteristics were comparable between the groups. In patients receiving tranexamic acid and placebo respectively, the volume of allogeneic erythrocyte transfused was 4.0 (7.5) units and 6.0(6.0) units (W = 1021, P < 0.01). In these 2 groups respectively, blood loss was 930 (750) ml and 1210 (910) ml (W = 1042, P < 0.01), the incidence of major bleeding was 50.9% and 76.4% (χ(2) = 7.70, P < 0.01), the incidence of reoperation was 0 and 9.1% (χ(2) = 5.24, P = 0.02); the volume of plasma transfused was 400 (600) ml and 600 (650) ml (W = 1072, P = 0.01), the exposure of plasma was 60.0% and 85.5% (χ(2) = 8.98, P < 0.01) and the exposure to any allogeneic blood products was 85.5% and 98.2% (χ(2) = 5.93, P = 0.01). Perioperative mortality, morbidity and the incidence of adverse events were balanced between the groups without statistical significance. CONCLUSION: Tranexamic acid reduced significantly postoperative bleeding and transfusion in patients receiving on-pump CABG without clopidogrel and aspirin cessation.

The effect of sevoflurane postconditioning on cardioprotection against ischemia-reperfusion injury in rabbits.

Sevoflurane postconditioning is a potential clinical measure to protect myocardial. This experiment was designed to investigate the efficacy of sevoflurane postconditioning against ischemia-reperfusion injury. A total of 132 Japanese White Rabbits were enrolled into this study. They were underwent 15-, 30-, or 60-min left anterior descending coronary (LAD) artery occlusion, respectively. At the end of LAD artery occlusion, they randomly received a 5-min inhalation of air (control group), 1% sevoflurane (1% sev group), 2% sevoflurane (2% sev group), 4% sevoflurane (4% sev group) or an IV bolus injection of 5 mg/kg of NIM811 [a specific inhibitor of mitochondrial permeability transition pores (mPTP)]. Infarct size was determined after 2 h of reperfusion (triphenyltetrazolium chloride straining, percentage of risk area). The infarct sizes were significantly (P < 0.05) reduced after 15 min ischemia (5.5 ± 3.3%, 5.8 ± 3.6% vs. 20.3 ± 6.9% for 2% sev, 4% sev vs. control, respectively) and 30 min ischemia (23.5 ± 5.0%, 20.7 ± 5.9% vs. 50.9 ± 10.2%, for 2% sev, 4% sev vs. control, respectively; P < 0.05). However, it had no effect on infarct size after 60 min ischemia (64.1 ± 5.9%, 62.3 ± 7.6% vs. 72.7 ± 9.2% for 2% sev, 4% sev vs. control, respectively, P > 0.05).The efficacy of sevoflurane postconditioning gradually weakened with increasing ischemia duration and disappears after 60 min ischemia in rabbits in vivo.

Sevoflurane postconditioning attenuates reperfusion-induced ventricular arrhythmias in isolated rat hearts exposed to ischemia/reperfusion injury.

Sevoflurane postconditioning has been proven to protect the hearts against ischemia/reperfusion injury, manifested mainly by improved cardiac function, reduced myocardial specific biomarker release, and decreased infarct size. This study is to observe the effects of sevoflurane postconditioning on reperfusion-induced ventricular arrhythmias and reactive oxygen species generation in Langendorff perfused rat hearts. Compared with the unprotected hearts subjected to 25 min of global ischemia followed by 30 min of reperfusion, exposure of 3% sevoflurane during the first 15 min of reperfusion significantly improved cardiac function, reduced cardiac troponin I release, decreased infarct size and attenuated reperfusion-induced ventricular arrhythmia. Further analysis on arrhythmia during the 30 min of reperfusion showed that, sevoflurane postconditioning decreased both the duration and incidence of ventricular tachycardia and ventricular fibrillation. In the meantime, intracellular malondialdehyde and reactive oxygen species levels were also reduced. These above results demonstrate that sevoflurane postconditioning protects the hearts against ischemia/reperfusion injury and attenuates reperfusion-induced arrhythmia, which may be associated with the regulation of lipid peroxidation and reactive oxygen species generation.

[Postoperative delirium is associated with cognitive dysfunction one week after coronary artery bypass grafting surgery].

OBJECTIVE: To investigate the relationship between postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) after coronary artery bypass graft in Chinese population. METHODS: One hundred and seven patients who were referred for elective coronary artery bypass grafting (CABG) surgery were enrolled in this prospective cohort study. Baseline and perioperative variables as well as occurrence of postoperative complications were recorded. POD was diagnosed using the Confusion Assessment Method for the Intensive Care Unit twice daily during the first seven postoperative days. A neuropsychological test battery that included 7 tests with 9 subscales was administered at baseline and on the seventh day after surgery. POCD was defined using the same definition that was used in the ISPOCD1 study. RESULTS: The incidence of POD was 47.7% (51/107) while that of POCD was 55.3% (57/103). Multivariate Logistic regression analyses identified four independent risk factors of POD, i.e., increasing age (OR 1.174, 95% CI 1.085-1.269, P<0.001), preoperative history of diabetes mellitus (OR 4.224, 95% CI 1.543-11.563, P=0.005), occurrence of postoperative complications (OR 3.667, 95% CI 1.152-11.670, P=0.028), and prolonged duration of intensive care unit stay (OR 1.024, 95% CI 1.005-1.044, P=0.016). And two independent risk factors of POCD were identified, i.e., increasing age (OR 1.065, 95% CI 1.001-1.134, P=0.047) and prolonged duration of POD (OR 1.744, 95% CI 1.173-2.593, P=0.006). CONCLUSION: POD and POCD are common cognitive complications after CABG surgery in Chinese population. Prolonged duration of POD is an independent risk factor of the occurrence of POCD.

Attenuation of ischemia-reperfusion injury by sevoflurane postconditioning involves protein kinase B and glycogen synthase kinase 3 beta activation in isolated rat hearts.

Volatile anesthetic ischemic postconditioning reduces infarct size following ischemia/reperfusion. Whether phosphorylation of protein kinase B (PKB/Akt) and glycogen synthase kinase 3 beta (GSK3ß) is causal for cardioprotection by postconditioning is controversial. We therefore investigated the impact of PKB/Akt and GSK3ß in isolated perfused rat hearts subjected to 40 min of ischemia followed by 1 h of reperfusion. 2.0% sevoflurane (1.0 minimum alveolar concentration) was administered at the onset of reperfusion in 15 min as postconditioning. Western blot analysis was used to determine phosphorylation of PKB/Akt and its downstream target GSK3ß after 1 h of reperfusion. Mitochondrial and cytosolic content of cytochrome C checked by western blot served as a marker for mitochondrial permeability transition pore opening. Sevoflurane postconditioning significantly improved functional cardiac recovery and decreased infarct size in isolated rat hearts. Compared with unprotected hearts, sevoflurane postconditioning-induced phosphorylation of PKB/Akt and GSK3ß were significantly increased. Increase of cytochrome C in mitochondria and decrease of it in cytosol is significant when compared with unprotected ones which have reversal effects on cytochrome C. The current study presents evidence that sevoflurane-induced cardioprotection at the onset of reperfusion are partly through activation of PKB/Akt and GSK3ß.

Sevoflurane postconditioning protects isolated rat hearts against ischemia-reperfusion injury: the role of radical oxygen species, extracellular signal-related kinases 1/2 and mitochondrial permeability transition pore.

The roles of reactive oxygen species (ROS), extracellular signal-regulated kinase 1/2 (ERK 1/2) and mitochondrial permeability transition pore (mPTP) in sevoflurane postconditioning induced cardioprotection against ischemia-reperfusion injury in Langendorff rat hearts were investigated. When compared with the unprotected hearts subjected to 30 min of ischemia followed by 1 h of reperfusion, exposure of 3% sevoflurane during the first 15 min of reperfusion significantly improved functional recovery, decreased infarct size, reduced lactate dehydrogenase and creatine kinase-MB release, and reduced myocardial malondialdehyde production. However, these protective effects were abolished in the presence of either ROS scavenger N-acetylcysteine or ERK 1/2 inhibitor PD98059, and accompanied by prevention of ERK 1/2 phosphorylation and elimination of inhibitory effect on mPTP opening. These findings suggested that sevoflurane postconditioning protected isolated rat hearts against ischemia-reperfusion injury via the recruitment of the ROS-ERK 1/2-mPTP signaling cascade.

High serum cortisol level is associated with increased risk of delirium after coronary artery bypass graft surgery: a prospective cohort study.

INTRODUCTION: The pathophysiology of postoperative delirium remains poorly understood. The purpose of this study was to examine the relationship between serum cortisol level and occurrence of early postoperative delirium in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: A total of 243 patients undergoing elective CABG surgery were enrolled. Patients were examined twice daily during the first five postoperative days and postoperative delirium was diagnosed by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Blood samples were obtained between 7 a.m. and 8 a.m. on the first postoperative day and serum cortisol concentrations were then measured. Multivariate logistic regression analyses were performed to identify risk factors of postoperative delirium. RESULTS: Postoperative delirium occurred in 50.6% (123 of 243) of patients. High serum cortisol level was significantly associated with increased risk of postoperative delirium (OR 3.091, 95% CI 1.763-5.418, P < 0.001). Other independent risk factors of postoperative delirium included increasing age (OR 1.111, 95% CI 1.065-1.159, P < 0.001), history of diabetes mellitus (OR 1.905, 95% CI 1.001-3.622, P = 0.049), prolonged duration of surgery (OR 1.360, 95% CI 1.010-1.831, P = 0.043), and occurrence of complications within the first day after surgery (OR 2.485, 95% CI 1.184-5.214, P = 0.016). Patients who developed postoperative delirium had a higher incidence of postoperative complications and a prolonged duration of postoperative ICU and hospital stay. CONCLUSIONS: Delirium was a common complication after CABG surgery. High serum cortisol level was associated with increased risk of postoperative delirium. Patients who developed delirium had outcomes worse than those who did not.

[Anesthetic management for 1-stop hybrid revascularization of coronary artery disease].

OBJECTIVE: To summarize the anesthesia managements on 63 CAD patients undergoing 1-stop hybrid revascularization from July 2007 to June 2009 in Fuwai Hospital. METHODS: ECG, direct BP, SpO2, P(ET)CO2, CVP and body temperature were monitored during anesthesia. The management of intraoperative anesthesia should preferably use a small dosage of opioids with inhalation or intravenous anesthesia. At the same time, specific anticoagulation management was administered. RESULTS: The hemodynamics were stabilized. the time of tracheal intubation were shorter. 6 patients were immediate extubated in the operating room with application of fast-track technology. No patient died. CONCLUSIONS: Such minimally invasive surgery has little effect on the circulation. The difficulty of anesthetic management is smaller. Specific anticoagulation management is administered. Implementation of the Fast-track technology can demonstrate the further advantages in such surgery.

[Efficacy of one-stop hybrid revascularization for treatment of unprotected left main coronary artery disease].

OBJECTIVE: To evaluate the efficacy of one-stop hybrid coronary revascularization [simultaneous minimally invasive direct coronary artery bypass surgery (MIDCAB) and percutaneous coronary intervention (PCI) procedures performed in an enhanced (or called "hybrid") operative unit] for the treatment of unprotected left main coronary artery (ULMCA) disease. METHODS: From June 2007 to April 2009, 14 patients [13 male, mean age: (60.4 +/- 15.4) years] underwent the one-stop hybrid approach in the "hybrid" operating room. Proximal lesions were evidenced in 5 patients and distal or bifurcation lesions in 11 patients. MIDCAB procedure for grafting of the left intramammary artery (LIMA) with the left anterior descending (LAD) artery was first performed via lower partial ministernotomy on the beating heart, followed by PCI on the LMCA disease and non-LAD coronary lesions. RESULTS: Operation was successful in all patients underwent the one-stop hybrid procedure. LIMA grafts were used in all 14 patients and confirmed to be patent by angiography. A total of 25 non-LAD coronary lesions were treated by PCI and 29 stents (27 drug-eluting stents and 2 bare-mental stents) were implanted to 23 lesions and coronary angioplasty was performed in the remaining lesions. There was no death, perioperative myocardial infarction, stroke or repeat revascularization during the procedure and the follow-up period. All the patients remained free from angina during the 7.9 months (range 1 - 15 months) follow-up period. LIMA grafts and stents were patent in 5 patients at 1-year follow-up. CONCLUSIONS: Our initial experience demonstrates that one-stop hybrid coronary revascularization provides a reasonable, feasible and safe alternative for selected patients with LMCA diseases.

Ulinastatin reduces postoperative bleeding and red blood cell transfusion in patients undergoing cardiac surgery: A PRISMA-compliant systematic review and meta-analysis.

BACKGROUND: Ulinastatin is a type of glycoprotein and a nonspecific wide-spectrum protease inhibitor like antifibrinolytic agent aprotinin. Whether Ulinastatin has similar beneficial effects on blood conservation in cardiac surgical patients as aprotinin remains undetermined. Therefore, a systematic review and meta-analysis were performed to evaluate the effects of Ulinastatin on perioperative bleeding and transfusion in patients who underwent cardiac surgery. METHODS: Electronic databases were searched to identify all clinical trials comparing Ulinastatin with placebo/blank on postoperative bleeding and transfusion in patients undergoing cardiac surgery. Primary outcomes included perioperative blood loss, blood transfusion, postoperative re-exploration for bleeding. Secondary outcomes include perioperative hemoglobin level, platelet counts and functions, coagulation tests, inflammatory cytokines level, and so on. For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio and 95% CI. Statistical significance was defined as P < .05. RESULTS: Our search yielded 21 studies including 1310 patients, and 617 patients were allocated into Ulinastatin group and 693 into Control (placebo/blank) group. There was no significant difference in intraoperative bleeding volume, postoperative re-exploration for bleeding incidence, intraoperative red blood cell transfusion units, postoperative fresh frozen plasma transfusion volumes and platelet concentrates transfusion units between the 2 groups (all P > .05). Ulinastatin reduces postoperative bleeding (WMD = -0.73, 95% CI: -1.17 to -0.28, P = .001) and red blood cell (RBC) transfusion (WMD = -0.70, 95% CI: -1.26 to -0.14, P = .01), inhibits hyperfibrinolysis as manifested by lower level of postoperative D-dimer (WMD = -0.87, 95% CI: -1.34 to -0.39, P = .0003). CONCLUSION: This meta-analysis has found some evidence showing that Ulinastatin reduces postoperative bleeding and RBC transfusion in patients undergoing cardiac surgery. However, these findings should be interpreted rigorously. Further well-conducted trials are required to assess the blood-saving effects and mechanisms of Ulinastatin.

Hypocretin-1 potentiates NMDA receptor-mediated somatodendritic secretion from locus ceruleus neurons.

Our previous observations showed that several stimuli, including high-K(+) solution, glutamate, and voltage pulses, induce somatic noradrenaline (NA) secretion from locus ceruleus (LC) neurons. Hypocretin (orexin), a hypothalamic peptide critical for normal wakefulness, has been shown to evoke NA release from the axon terminals of LC neurons. Here, we used amperometry to test the effect of hypocretin-1 (HCRT) on NMDA receptor-mediated somatodendritic release in LC neurons. Either HCRT or NMDA applied alone dose-dependently induced somatodendritic secretion. Bath application of HCRT notably potentiated NMDA receptor-mediated somatodendritic NA release. This potentiation was blocked by SB 334867, a selective HCRT receptor (Hcrtr 1) antagonist, or bisindolylmaleimide, a specific protein kinase C (PKC) inhibitor, indicating the involvement of Hcrtr 1 and PKC. Consistent with this, phorbol 12-myristate 13-acetate, a PKC activator, mimicked the HCRT-induced potentiation. Furthermore, HCRT enhanced NMDA-induced intracellular Ca(2+) elevation via activation of Hcrtr 1 and PKC, which may contribute to HCRT-potentiated somatodendritic secretion. These results suggest that HCRT modulates LC activity not only by regulating noradrenergic input to its targets, but also by affecting noradrenergic communication in the soma and dendrites.

The effects of cardiopulmonary bypass on the number of cerebral microemboli and the incidence of cognitive dysfunction after coronary artery bypass graft surgery.

BACKGROUND: Postoperative cognitive dysfunction (POCD) can be a debilitating complication after coronary artery bypass graft (CABG) surgery. Cerebral microemboli during cardiopulmonary bypass (CPB) are believed to be an important etiologic factor of POCD. In this study, we examined whether avoidance of CPB with "off-pump" surgery reduces the number of cerebral microemboli and the incidence of POCD after CABG surgery in Chinese population. METHODS: Two hundred twenty-seven patients were enrolled in this prospective cohort study. Fifty-nine patients underwent CABG surgery with CPB and 168 underwent off-pump surgery. Cerebral microemboli were measured continuously with bilateral transcranial Doppler ultrasonography of the middle cerebral arteries. A neuropsychological test battery that included seven tests with nine subscales was administered at baseline, as well as at 1 wk and 3 mo after surgery. POCD was defined using the international study of POCD1 definition. RESULTS: The median total number of cerebral microemboli for the case was 430 (range: 155-2088) in patients undergoing surgery with CPB and 2 (0-66) in the off-pump patients (P < 0.001). There were no differences in the incidence of POCD between the patients having surgery with or without CPB either at 1 wk (55.2% or 32 of 58 patients [95% confidence interval: 41.5%-68.3%] vs 47.0% or 78 of 166 patients [39.2%-54.9%], P = 0.283) or 3 mo (6.4% or 3 of 47 patients [1.3%-17.5%] vs 13.1% or 16 of 122 of patients [7.7%-20.4%], P = 0.214) after surgery. Increasing age and shorter duration of postoperative hospital stay were independently associated with cognitive dysfunction at 1 wk after surgery. Increasing age and a history of diabetes mellitus were independently associated with cognitive dysfunction 3 mo after surgery. CPB or cerebral microemboli were not significantly related to the occurrence of POCD. CONCLUSIONS: In Chinese population, avoidance of CPB during CABG surgery significantly decreased the number of cerebral microemboli, but it did not decrease the incidence of POCD at either 1 wk or 3 mo after CABG. Neither CPB nor cerebral microemboli was independently associated with the risk of POCD.

Sevoflurane versus propofol for myocardial protection in patients undergoing coronary artery bypass grafting surgery: a meta-analysis of randomized controlled trials.

OBJECTIVE: To systematically review randomized controlled trials to compare myocardial protection profiles of sevoflurane with propofol in patients undergoing coronary artery bypass grafting (CABG) surgery. METHODS: Electronic databases were searched to identify all randomized controlled trials comparing sevoflurane with propofol for protecting myocardium in adult patients undergoing CABG surgery. Two authors independently extracted patients' perioperative data, including patients' baseline characteristics, surgical variables, and outcome data. For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio (OR) and 95% CI. Each outcome was tested for heterogeneity, and randomized-effects or fixed-effects model was used in the presence or absence of significant heterogeneity (Q test P<0.05). Sensitivity analyses were done by examining the influence of statistical model on estimated treatment effects. Publication bias was explored through visual inspection of funnel plots of the outcomes. Statistical significance was defined as P<0.05. RESULTS: Our search yielded 13 studies including 696 patients, and 402 patients were allocated into sevoflurane group and 294 into propofol group. There was no significant difference in postoperative mechanical ventilation time, inotropic support, mortality, myocardial infarction, and atrial fibrillation between the two groups (all P>0.05). Patients randomized into sevoflurane group had higher post-bypass cardiac index (WMD=0.39, 95% CI: 0.18 to 0.60, P=0.0003), lower troponin I level (WMD=-0.82, 95% CI: -0.87 to -0.85, P=0.0002), lower incidence of myocardial ischemia (OR=0.37, 95% CI: 0.16 to 0.83, P=0.02), shorter ICU and hospital stay length (WMD=-10.99, 95% CI: -12.97 to -9.01, P<0.00001; WMD=-0.78, 95% CI: -1.00 to -0.56, P<0.00001, respectively). CONCLUSION: This meta-analysis has found some evidence showing that sevoflurane has better myocardial protection than propofol in CABG surgery.

Noninfectious fever following aortic surgery: incidence, risk factors, and outcomes.

OBJECTIVE: To determine the incidence, course, potential risk factors, and outcomes of noninfectious fever developed in patients after aortic surgery. METHODS: patients who received operation for aortic aneurysm or dissection in our center from January 2006 to January 2008 were reviewed. Patients who met one of the following criteria were excluded: having a known source of infection during hospitalization; having a preoperative oral temperature greater than or equal to 38.0 degrees C; undertaking emergency surgery; having incomplete data. Univariate analysis was performed in patients with noninfectious postoperative fever and those without, with respect to demographics, intraoperative data, etc. Risk factors for postoperative fever were considered for the multivariate logistic regression model if they had a P value less than 0.10 in the univariate analysis. RESULTS: Totally 463 patients undergoing aortic surgery were enrolled for full review. Among them, 345 (74.5%) patients had noninfectious postoperative fever, the other 118 (25.5%) patients didn't develop postoperative fever. Univariate analysis demonstrated that several risk factors were associated with the development of noninfectious postoperative fever, including weight, surgical procedure, minimum intraoperative bladder temperature, temperature upon intensive care unit (ICU) admission, discharge, and during ICU stay, as well as blood transfusion. In a further multivariate analysis, surgical site of thoracic and thoracoabdominal aorta (odds ratio: 4.861; 95% confidence interval: 3.029-5.801; P=0.004), lower minimum intraoperative bladder temperature (odds ratio: 1.117; 95% confidence interval: 1.01-1.24; P=0.04), and higher temperature on admission to the ICU (odds ratio: 2.57; 95% confidence interval: 1.28-5.18; P=0.008) were found to be significant predictors for noninfectious postoperative fever. No difference was found between the febrile and afebrile patients with regard to postoperative hospitalization duration (P=0.558) or total medical costs (P=0.896). CONCLUSION: Noninfectious postoperative fever following aortic surgery is very common and closely related with perioperative interventions.

[Predictors of prolonged intensive care unit stay in patients undergoing aortic arch replacement].

OBJECTIVE: To identify the predictors of prolonged intensive care unit (ICU) stay in patients undergoing aortic arch replacement. METHODS: The clinical data of 173 consecutive patients undergoing aortic arch replacement requiring deep hypothermic circulatory arrest plus antegrade selective cerebral perfusion were reviewed retrospectively. Patients who had undergone one-stage total or subtotal aortic replacement were excluded. Data collected from records were used to identify univariate and multivariate predictors for prolonged ICU stay, which was defined as longer than 5 days in ICU postoperatively. RESULTS: Patients aged (45.4 +/- 10. 6) years and male accounted for 76.3%. The incidence of prolonged ICU stay was 22.0%. The incidences of postoperative stroke and acute renal failure were 6.4% and 4.6%, respectively. The in-hospital mortality rate was 2.9%. Univariate predictors for prolonged ICU stay included body mass index, preoperative serum creatinine level, emergent surgery, coronary artery bypass grafting at the same time, cardiopulmonary bypass time, myocardial ischemic time, and occurrence of postoperative stroke and/or acute renal failure. Multivariable modeling identified that emergent surgery (odds ratio [95% confidence interval] -3.1 [1.3, 7.6]), cardiopulmonary bypass time longer than 180 min (3.3 [1.4, 8.1]), postoperative stroke (6.9 [1.1, 43.1]) and acute renal failure (14.5 [1.3, 161.6]) were the independent predictors for prolonged ICU stay. CONCLUSIONS: The incidence of prolonged ICU stay is high after aortic arch replacement. Patients with identified multivariate predictors carry a higher risk of prolonged ICU stay and may benefit from enhanced perioperative protection of brain and kidney.

Postoperative neuropsychological change and its underlying mechanism in patients undergoing coronary artery bypass grafting.

BACKGROUND: The high incidence of neuropsychologic deficits after cardiac surgery, including cognitive dysfunction and mood status, has significantly influenced the prognosis, outcome of treatment and long-term quality of life of patients. With a circadian secretion pattern, melatonin and cortisol are capable of modulating the human physiological processes and neuropsychological status, whereas disorder of their secretion pattern may lead to many diseases. However, it is unclear whether neuroendocrine variations are related to the neuropsychologic status in patients undergoing coronary artery bypass grafting (CABG). METHODS: Forty male patients scheduled for CABG with hypothermic cardiopulmonary bypass (CPB) (n = 20) or off-pump coronary artery bypass (OPCAB) (n = 20) were studied. Blood samples were taken intraoperatively at specific time-points and every 3 hours within the first postoperative 24 hours to determine plasma concentrations of melatonin and cortisol. A neuropsychologic test battery including depression and anxiety was administered preoperatively and 7 to 10 days postoperatively. Statistical methods included the nonparametric analysis, multiple linear regression and cosinor analysis. RESULTS: The patients in the CPB group exhibited more severe neuropsychologic deficits and more anxious than those in the OPCAB group after surgery. In both groups, patients were more depressed postoperatively than preoperatively and recovered 3 months after surgery. Depression and anxiety were correlated with some factors of cognitive dysfunctions. In the postoperative 24 hours, 2 patients in the CPB group, and 6 patients in the OPCAB group showed a circadian rhythm of melatonin secretion. As for cortisol secretion, there were 3 patients in the CPB group and 7 in the OPCAB group respectively. Parameters of circadian rhythm of melatonin in the CPB group and those of secretion rhythm of cortisol in both groups were correlated with depression and some neuropsychologic tests. CONCLUSIONS: The incidence of neuropsychological deficits was higher in patients receiving CABG with CPB than in those without CPB. The status of mood may contribute to the perioperative cognitive dysfunctions. The disordered circadian rhythm of melatonin secretion in patients undergoing CABG with CPB and the disordered cortisol secretion may correlate directly or indirectly through mood with neuropsychological deficits.