Category Archives: Cardiac Disease

Corticosteroids and Cardiopulmonary Bypass: Future Directions

Thus, this constellation of findings indicate that methylprednisolone offers no clinical benefits to patients undergoing cardiac surgery with CPB and in fact may be detrimental by initiating postoperative hyperglycemia and possibly hindering early postoperative tracheal extubation for undetermined reasons.
Additional well-designed (prospective, randomized, double-blind, placebo-controlled) clinical investigations (with large numbers of patients and tightly-controlled perioperative management) involving corticosteroids and patients undergoing cardiac surgery with CPB need to be done. Whether or not suppression of the SIRS associated with CPB with corticosteroids (or any other drug/technique) is clinically desirable and beneficial remains to be determined.

Corticosteroids and Cardiopulmonary Bypass: Summary

Corticosteroids and Cardiopulmonary Bypass: SummaryProspective, randomized, double-blind, placebo-controlled clinical investigations involving methyl-prednisolone and patients undergoing cardiac surgery with CPB are summarized in Table 2. As can be seen, all involved small numbers of patients and most did not tightly control perioperative management (intraoperative baseline anesthetic technique, mechanical ventilation parameters, technique of CPB, etc.). Despite these facts, the results of these clinical investigations, along with the results of less well-controlled clinical investigations, suggest certain conclusions. It appears that methylprednisolone is able to reliably (and beneficially) alter the balance of proinflammatory and anti-inflammatory mediators in the blood of patients subjected to CPB, indicating that the drug decreases the SIRS associated with CPB.

Corticosteroids and Cardiopulmonary Bypass: The immediate postoperative period

These unexpected results stimulated the same group to perform another investigation in this area. In this study, 90 patients were prospectively randomized into three groups: one group received methyl-prednisolone (30 mg/kg twice), one group received the drug at half that dose (15 mg/kg twice), and the last group received placebo in a blinded fashion. Once again, the perioperative care was standardized including intraoperative baseline anesthetic and mechanical ventilation parameters. The results on this investigation were similar. Patients receiving meth-ylprednisolone (either dose) exhibited significantly increased CI (p = 0.0006), significantly decreased SVR (p = 0.0005), and significantly increased shunt (p = 0.002) during the immediate postoperative period. All three groups exhibited significant increases in P(A-a)O2 (p < 0.0001), significant decreases in dynamic lung compliance (p < 0.0001), and significant decreases in static lung compliance (p < 0.0001) during the immediate postoperative period, with no differences between groups read generic claritin.

Corticosteroids and Cardiopulmonary Bypass: Tracheal extubation

Corticosteroids and Cardiopulmonary Bypass: Tracheal extubationMost recent clinical investigations by Chaney et al indicate that routine administration of meth-ylprednisolone to patients undergoing cardiac surgery with CPB not only offers no clinical benefits, its use in the era of early tracheal extubation may in fact be contraindicated. In their first studies, these investigators in prospective, randomized, blinded fashion administered methylprednisolone (30 mg/kg twice) to 30 patients undergoing elective CABG while 30 similar patients received placebo. Perioperative care was standardized, including intraoperative baseline anesthetic and mechanical ventilation parame-ters.

Corticosteroids and Cardiopulmonary Bypass: The effects of methylprednisolone

Most recent clinical investigations continue to assess the effects of methylprednisolone on the SIRS yet also have begun to assess clinical outcomes. In 1997, Mayumi et al revealed that, when compared to control subjects receiving placebo, patients receiving methylprednisolone (20 mg/kg twice) had significantly increased blood levels of WBCs (p = 0.04) and natural killer cells (p = 0.01) yet significantly decreased blood levels of IL-2 (p = 0.04), C-reactive protein (p < 0.0001), and phytohemagglutinin response (p < 0.01) following exposure to CPB. Because their constellation of findings suggested that T-cell functions were synergistically suppressed by methylprednisolone and CPB, the authors conclude that the drug may promote an immunocompromised state (yet no postoperative wound infections were observed) comments canadian family pharmacy. Postoperatively, patients receiving methylprednisolone had significantly higher blood glucose (p < 0.01) and lactate (p < 0.05) levels and a significantly decreased incidence of postoperative hyperthermia (p = 0.001) when compared to control subjects receiving placebo. There was no difference between the methylprednisolone and placebo groups regarding perioperative CI, water balance, arterial blood gas levels, electrolytes, nor extubation time (1.42 ± 0.64 days vs 1.30 ± 0.46 days, respectively).

Corticosteroids and Cardiopulmonary Bypass: Patients

Corticosteroids and Cardiopulmonary Bypass: PatientsOne can assess the SIRS that is associated with CPB in a wide variety of ways. Most commonly, this is performed by assaying blood levels of numerous proinflammatory and/or anti-inflammatory mediators. While a few investigations have shown no effect, the vast majority of investigations performed have revealed the ability of methylpred-nisolone to beneficially alter the balance of these mediators in the blood of patients following exposure to CPB (by attenuating increases in proinflammatory mediators and/or augmenting increases in antiinflammatory mediators). Canadian neighbor pharmacy fully Numerous observational studies have shown that methylprednisolone (in a wide variety of dosing schedules) can attenuate increases in the proinflammatory mediators IL-1, IL-6, IL-8, tumor necrosis factor, and plasma endotoxin, yet augment increases in the anti-inflammatory mediators IL-414 and IL-1014 associated with CPB.

Corticosteroids and Cardiopulmonary Bypass: Corticosteroids and Cardiopulmonary

However, two investigations in the late 1980s revealed that methylprednisolone may inhibit complement activation associated with CPB and bubble oxygenators.” Cavarocchi et al in 1986 randomly divided 91 patients undergoing a wide variety of cardiac surgeries into three groups: 30 patients received bubble oxygenators, 31 patients received bubble oxygenators and methylprednisolone (30 mg/kg prior to CPB), and 30 patients received membrane oxygenators. The two groups receiving methylpred-nisolone or membrane oxygenators behaved similarly; both groups, when compared to the bubble oxygenator group, exhibited significantly decreased (p < 0.0001) complement activation and significantly decreased (p < 0.0001) transpulmonary leukocyte sequestration associated with CPB. Another small observational study using bubble oxygenators revealed that, when compared to control subjects, patients receiving methylprednisolone, 30 mg/kg, prior to CPB exhibited significantly decreased (p < 0.01) complement activation and significantly increased (p < 0.01) blood levels of circulating endotoxins during CPB.

Corticosteroids and Cardiopulmonary Bypass: CPB initiation

Corticosteroids and Cardiopulmonary Bypass: CPB initiationIn the early 1980s, important research performed at the University of Alabama in Birmingham revealed the pivotal role that complement activation plays in the basic physiologic insults caused by CPB.” These investigators discovered that initiation of CPB was associated with complement activation, neutrophilia, transpulmonary neutropenia, and pulmonary-vascular sequestration of complement-activated granulocytes, and theorized that the major postoperative morbidity associated with CPB (neurologic dysfunction, pulmonary dysfunction, renal dysfunction, and/or hematologic abnormalities) was related in part to complement activation.- Subsequently, a majority of the investigations involving methylprednisolone and CPB in the 1980s focused on complement activation. Canadian family pharmacy Here Many small observational studies involving adult and pediatric patients during this time indicated that a single dose of methylprednisolone, 30 mg/kg, prior to CPB was unable to prevent complement activation associated with CPB.

Corticosteroids and Cardiopulmonary Bypass: Initiation of CPB

Two investigations by the same group from London in the early 1980s revealed the importance of administering a supplemental dose of methylpred-nisolone with initiation of CPB to compensate for hemodilution (and thus maintain blood levels of the drug). In the first observational investigation, Thompson and Broadbent found that, when compared to patients receiving saline solution, patients receiving methylprednisolone, 30 mg/kg, prior to CPB exhibited significantly increased (p < 0.001) V02 immediately following CPB and significantly increased (p < 0.05) serum phosphate levels in the immediate postoperative period. The authors attributed the increased V02 associated with methylpred-nisolone to improved tissue perfusion because at this time there was no difference between groups regarding CI in detail canadian family pharmacy. Additionally, there was no difference between groups regarding perioperative hemoglobin 2,3-diphosphoglycerate levels, standard partial oxygen pressure values, or oxygen availability.

Corticosteroids and Cardiopulmonary Bypass: Methylprednisolone

Corticosteroids and Cardiopulmonary Bypass: MethylprednisolonePatients receiving methylprednisolone exhibited a higher mean CI before (p < 0.01) and after (p < 0.05) CPB as well as a lower mean total peripheral vascular resistance before (p < 0.10) and after (p < 0.20) CPB when compared to the other two groups. While there was no difference between the three groups regarding perioperative oxygen consumption (Vo2), postoperative blood levels of lactic acid were higher in patients receiving methylpred-nisolone (p < 0.005), a finding the authors attributed to improved microcirculatory flow (“washout” phenomenon). Patients receiving dexamethasone behaved no differently than patients receiving placebo regarding all important perioperative physiologic variables.

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