Journal of Cellular & Molecular Anesthesia

Coronary Artery Bypass Graft surgery(CABG) has an important value in the management of patients with coronary or valvular heart disease. Because of increasing the interest to perform less invasive interventions in these patients, CABG is now performed for patients with higher comorbidities and more severe cases having more post operative complications¹. Thus, clinical risk stratification has a great role in preoperative evaluation of patients undergoing CABG². Electrocardiography, hemodynamic parameters, biochemical markers like creatinin kinase (CK), myoglobulin creatinin kinase (CK-MB) and troponins and transthoracic/transesophageal echocardiography are routinely used for the diagnosis of preoperative cardiac problems and prediction of perioperative comorbidities³. BNP is secreted by ventricular myocytes due to increased ventricular wall tension related to volume expansion. BNP is a simple blood test, which can easily be performed in most biochemistry laboratories as part of a routine preoperative assessment. Previous studies showed that increased level of preoperative BNP is associated with higher morbidities and mortality after cardiac surgeries^4-6.  Postoperative BNP has the potential to show the preoperative condition of heart and cardiac injury induced by surgical intervention but its value as a prognostic marker has not been largely evaluated^7,8.

Totonchi et al evaluated the association of preoperative and post operative BNP with morbidity in 50 adult patients who were scheduled for elective CABG in Tehran Shahid Rajaie heart center from Sep 2016 to May 2017. Patients with emergency situations, hematocrit less than 25 and patients on inotropic therapy were excluded. Samples were taken for BNP levels 24 hours pre and post operative. They showed that perioperative BNP didn’t have any correlation with other comorbidities and major complications after cardiac surgeries except for ejection fraction. Their results showed that patients with higher perioperative BNP levels had significantly higher risk factor for low ejection fraction and heat failure after CABG⁹. Fox and coworkers in their prospective longitudinal study of 1,183 patients undergoing primary coronary artery bypass  grafting surgery, compared the utility of preoperative with postoperative BNP for predicting hospital LOS and mortality after primary PCI. After multivariable adjustment for preoperative  BNP and clinical covariates, peak postoperative BNP predicted hospital LOS (hazard ratio [HR] = 1.28, 95% CI = 1.002-1.64, P = 0.049) but not mortality. Whereas preoperative BNP independently predicted hospital LOS (HR = 1.09, CI = 1.01-1.18, P = 0.03) and was defined as an independent predictor of mortality (HR = 1.36, CI = 0.96-1.94, P = 0.08). When preoperative and peak postoperative BNP were separately adjusted for the clinical multivariable models, each independently predicted hospital LOS and mortality¹⁰. Previous studies showed that post operative BNP levels which measured 24 hours after surgery did not significantly predict adverse cardiovascular events and peak post operative BNP measurement should be considered as a surrogate for cardiovascular complications. Peak postoperative BNP tends to occur later in the postoperative course, around day 3 or 5.

The study of Totonchi et al has some major limitations. It has been performed in a single center which has inherent limitations. The study’s HF outcome did not delineate specific etiologies of observed postoperative HF events (e.g., systolic vs. diastolic dysfunction or left atrial enlargement).  BNP has been affected by kidney function and pulmonary disease but patients with kidney and lung disease were enrolled in this study. Moreover, the authors didn’t perform long term follow up after discharge. The authors measured BNP by electrochemiluminescence immunoassay, which measures only nonglycoNT-proBNP. This method understimates the BNP level compared to NT-proBNP assay system currently being used. Therefore, careful interpretation of the BNP levels and clinical application may be required. Finally, the authors didn’t use logistic regression analysis for adjustment of clinical risk factors; so, interpreting and globalization of these results is not possible.

Based on literature review, there is little added benefit to measure postoperative BNP either instead of or in combination with preoperative BNP. So, it seems that we do not need to measure both preoperative and postoperative BNP together for the purposes of risk stratifying of CABG patients. But if preoperative BNP measurement is not possible, we can use peak post operative BNP measurement for prediction of major cardiovascular complications. Patients at high risk should be considered for less invasive procedures and must receive optimized perioperative care. Further research with a larger number of patients having various types of surgeries and good methodologic design is needed to confirm the clinical utility of this prognostic test.

Introduction: B-type natriuretic peptide (BNP) is a cardiac hormone which it^’s levels before and after as a marker predictor of morbidity in patients who have undergone CABG is controversial.  This study aimed to investigate the relationship between changes pre- and postoperative BNP and morbidity in adult patients undergoing CABG.

Patients and methods: in this descriptive-analytical study, 50 patients underwent elective CABG at the Heart Center of Rajaei from September 2016 to May 2017 were enrolled. To determine the serum levels of BNP, blood samples were sent to laboratory at 24 hours before and 24 hours after induction of anesthesia. Duration of intubation, duration of  the ICU stay, ejection fraction and serum creatinine as morbidity factors were considered. Data were analyzed with SPSS Ver 22 software and significance level of 5%.

Results: of the patients, 33 patients (66%) were men and 17 (34%) female. The mean age ± SD of patients was 61 ± 9 (range 36-82 years). Mean ± SD preoperative BNP level was 919.81±2264.22 pg / ml and postoperative BNP level was 2951.22 ± 4291.27 pg / ml. A significant correlation between pre- and postoperative BNP levels and the amount of creatinine, surgical time and length of stay in ICU was not observed. The ejection fraction was correlated with pre- and postoperative BNP levels.

Conclusion: increased serum levels of BNP at 24 hours before and after heart surgery is a good marker for prognosis and early diagnosis of heart failure in adults.

Keywords: B- natriuretic peptide, coronary bypass surgery, morbidity

Introduction: During cardiopulmonary bypass, oxidative stress happens in the patient's cells due to blood contact with various levels of synthetic materials. It can activate inflammatory process and release factors such as IL-6, CRP, and Neutrophils witch may hurt different organs. In recent years, many efforts have been made to prevent this type of damage, however, no single treatment has been proposed to reduce this risk. Antioxidant substances such as Thiamine is important in cell defense against free oxygen radicals. Regarding this issue, in this study, the effect of thiamine on lactate levels in patients undergoing coronary artery bypass graft surgery has been investigated.

Materials and methods: In this study, 140 patients from 25 to 65 years old with mild systolic dysfunction (EF = 45-55%) who were candidates for elective CABG surgery in two groups: control and purpose (patients receiving Thiamine) were examined. All of these patients were anesthetized in an identical manner, and were subjected to a heart-lung pump. Serum lactate levels were measured before, during and 6, 12, 18, and 24 hours after surgery. All data collected in a questionnaire were recorded and evaluated using spss statistical software.

Results: Study groups showed no significant differences regarding demographics and underlying diseases. Serum lactate was significantly lower in thiamine group during the first 24 hours after surgery (except before operation and 2 hours later) (p <0.05).Creatinine level in two groups before surgery was not significantly different ,However, it was significantly lower in case group 24 hours after surgery(1.54±0.14 vs. 1.24±0.19; p: 0.001).Also, dose of Inotropes in  patients who received thiamine, was significantly lower than the control group (p= 0.001). Extubation was longer in control group (15.4±4.9 vs. 13.15±4.1; p=0.003) while ICU stay was not different.

Conclusion: It seems that thiamine administration before cardiopulmonary bypass, in patient with decreased left ventricular function, can decrease serum lactate as tissue perfusion marker and also improve kidney function.

Congenital prothrombin deficiency is an extremely rare hemorrhagic disorder with estimated prevalence of 1 per 2,000,000 in the general population. Since the disorder is an autosomal recessive disorder, the disorder is more frequent in areas with high rate of consanguinity. Clinical manifestations of disorder are highly variable ranging from mild bleeding episodes to severe life-threatening hemorrhages. The disorder can be diagnosed based on routine and specific tests. No specific factor II concentrate is available, but patients can receive fresh frozen plasma and prothrombin complex concentrate (PCC). Traditionally patients with prothrombin deficiency receive on-demand therapy, but secondary prophylaxis can be used for those patients with high risk of severe life-threatening bleeding. With timely diagnosis and appropriate management of disorder, the quality of life in these patients can significantly improve.   

Keywords: Prothrombin deficiency, Clinical manifestations, Diagnosis, Treatment

Up until now, hydroxyethyl starch (HES) solutions have mainly been indicated as "volume expanders". Recent unfavorable reports of these solutions such as probability of kidney injury or inducing coagulopathy have relatively ejected these solutions in many centers, particularly in European countries. Despite several confirming studies, multiple anecdotal letters or reviews has challenged total disappearance of these colloids from medicine practice. Also, some novel observations emphasized the distinguished ability of HES to preserve the microvascular integrity even at the presence of an inflammatory process. Despite extreme statements has been published demanding immediate suspension of these fluids from the market, it seems logical to revise the most recent studies which may declare new pathways to approach HES family of solutions. 

Churg-Strauss syndrome (CSS) or allergic granulomatosis is a necrotizing vasculitis with different presentations. In this case highlights the anesthetic management of a known case of CSS who underwent posterior spinal fixation surgery. Our patient fulfilled the ACR diagnosis criteria because of  showing asthma, paranasal sinusitis, positive skin biopsy and eosinophilia.Before anesthesia induction, laryngeal nerves block by lidocaine was conducted. Fiber-optic bronchoscopy was preceded by inserting a No. 7.5 spiral cuffed endotracheal tube.

Morphine is used as analgesics medication to reduce pain by inhibting transmission of pain impulses especially in spinal cord and modulation of central pain processing. Unfortunately, the increase abuse of opioids such as morphine or heroin often leads to various side effects such as addiction, tolerance and physical dependence. One of the proposed mechanisms that lead to morphine dependency and withdrawal is oxidative stress. Recent research has shown that olive fruit oil contains phenolic compounds which have higher antioxidant properties. In current study, we are trying to explore the ability of Olea Europaea (Olive) fruit oil to increase the antioxidant activity level subsequently alleviate morphine dependence and withdrawal. Better understanding on the effect of olive fruit oil on oxidative stress produced by olive to morphine dependency and withdrawal need to be further explored especially on the cellular and molecular level.