RESUMO
Objective Fluid therapy strategy on cardiac surgical patients has always been disputing. The aim of the present study was to observe the effects of goal-directed hemodynamic management strategy on the prognosis of patients undergoing off-pump coronary artery bypass graft. Methods The study was a prospective quality improvement study. Patients who underwent elective off-pump coronary artery bypass grafting in our hospital from January to December 2016 were included in the study, and the implementation of improvement approach was started on June 20, 2016. A total number of 98 patients were included: 56 cases before the improvement (control group) and 42 cases after the improvement (experimental group). The approach of optimizing hemodynamic was standardized vasoactive usage based on the goal-directed fluid therapy taking SVV (Stroke Volume Variation) and CI (Cardiac Index) as the target. Intraoperative and postoperative data were collected through the medical record system. Comparison was done between two groups in the aspects of liquid intake and output, length of postoperative stay in hospital and complications, postoperative awaken time, volume of thoracic drainage in 24h, extubation rate in 6h, time of ICU stay, concentration of Troponin I on the first day after surgery, mortality rate within 30 days and 6 months. Results There was no statistically difference in total fluid intake after the improvement, while the volume of voluven(676.79± 380.90 mL vs 890.48 ±222.58mL,P < 0.05) and urine volume (516.07±224.87 mL vs 695.24± 311.53mL,P < 0.05) increased significantly, the volume of crystal decreased significantly (663.84 ±224.97mL vs 430.24 ±201.76mL,P < 0.001). The positive liquid balance of intake and output volume was significantly reduced (683.82 ±556.08ml vs 456.43 ±505.36ml, P < 0.05). There were no significant differences in proportion of autologous blood or erythrocyte transfusion and volume of blood loss between the two groups (P > 0.05). There were no significant differences between the two groups in postoperative awaken time, volume of thoracic drainage within 24h, extubation rate within 6, concentration of Troponin I on the first day after surgery and ICU stay(P > 0.05). After the improvement, the length of postoperative stay in hospital was reduced compared with the control group (11.81 vs 13.82, P < 0.05). Multiple linear regression analysis was performed after the logarithmic transformation, and the standardized coefficient B of the improvement was -0.296 (SE=0.061, P < 0.05), indicating that the goal-directed hemodynamic management would reduce the length of postoperative stay in hospital by 19.4 %( 95%CI 7.3%~31.5%) with other conditions being equal. Postoperative complications decreased from 41.07% to 16.67 %( P < 0.05). Conclusion The implementation of goal-directed hemodynamic management strategy can reduce postoperative complications, postoperative hospital stay and improve short-term prognosis of patients undergoing off-pump coronary artery bypass surgery.
RESUMO
<p><b>BACKGROUND</b>p38 mitogen-activated protein kinases (MAPK) in ischemic preconditioning (IPC) may be essential to cardioprotection. We assessed whether protective effect of morphine-induced preconditioning (MPC) on myocardial ischemia and reperfusion injury in rat hearts involved p38 MAPK activation.</p><p><b>METHODS</b>Male Spargue-Dawley rats (weighing 300-350 g) were randomly assigned to 1 of the following 8 groups: control (CON, saline vehicle, n=9), SB 203580 (SB, a p38 MAPK inhibitor, n=6), MPC (n=6), IPC (n=9), SB+MPC, SB+IPC, MPC+SB, and IPC+SB (n=6). Infarct sizes (IS), a percentage of the area at risk (AAR), were determined by triphenyltetrazolium (TTC) staining. Tissue samples were processed from the entire AAR of left ventricle for the determination of p38 MAPK protein expression (5 hearts/group). The bands representing the proteins were visualized using an enhanced chemiluminescence detection system.</p><p><b>RESULTS</b>The IS/AAR was significantly reduced by IPC (12.9+/-1.6)% or MPC (25.3+/-2.9)% compared to the control (52.7+/-5.5)%. SB 203580 administered prior to preconditioning abolished the effect of IPC (SB+IPC: (43.8+/-2.6)%, P>0.05 vs CON, P<0.01 vs IPC), but not MPC (SB+MPC: (30.7+/-0.9)%, P<0.01 vs CON, P>0.05 vs MPC). Treatment with SB 203580 prior to sustained ischemia diminished the protective effect of both MPC (MPC+SB: (42.4+/-2.9)%, P>0.05 vs CON) and IPC (IPC+SB: (52.0+/-2.5)%, P>0.05 vs CON) on IS/AAR. In the IPC group, phospho-p38 MAPK protein increased significantly within 5 minutes into ischemia and remained elevated at 30 minutes into reperfusion, while phospho-p38 MAPK protein in the MPC group only increased significantly at 30 minutes into reperfusion.</p><p><b>CONCLUSION</b>The activation of p38 MAPK just acts as a mediator of MPC, whereas it acts as both a trigger and a mediator in IPC.</p>