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Protective effect of sevoflurane preconditioning on ischemia-reperfusion injury in patients undergoing reconstructive plastic surgery with microsurgical flap, a randomized controlled trial.
Claroni, C, Torregiani, G, Covotta, M, Sofra, M, Scotto Di Uccio, A, Marcelli, ME, Naccarato, A, Forastiere, E
BMC anesthesiology. 2016;(1):66
Abstract
BACKGROUND In many clinical conditions that involve free flaps and tissue transplantations the possibility of minimizing ischemia-reperfusion injury can be a determinant factor for the success of the surgery itself. We hypothesize that preconditioning with sevoflurane is a protective factor against ischemia-reperfusion injury. METHODS In this randomized controlled trial, patients ASA I-II undergoing breast reconstruction with deep inferior epigastric perforator flaps were allocated into two groups and analyzed: group BAL included patients who received balanced anesthesia with sevoflurane for 30 min before removal of the flap and throughout the surgery. The TCI group included patients who received a total intravenous anesthesia with propofol and remifentanil. We evaluated regional tissue oximetry at the end of the surgery and at 4, 12 and 20 h after surgery. Other assessed parameters were: blood lactate clearance, alanine aminotransferase, aspartate aminotransferase, lactic dehydrogenase, creatine phosphokinase. RESULTS In total 54 patients, twenty-seven per group, were analyzed. There was a significant increase of the average value of regional tissue oximetry measured 4 h after surgery in the BAL group compared to the TCI group: BAL: 84.05 % (8.96 SD); TCI 76.17 % (12.92 SD) (P = 0.03), but not at the other time frames. The creatine phosphokinase value was significantly lower in the BAL group at the end of surgery, but not at the other time-frames. There were no significant differences in blood levels of other markers. CONCLUSIONS From our results, the positive preconditioning impact of sevoflurane on ischemia-reperfusion injury in patients undergoing free flap surgery is expressed in the early postoperative hours, but it does not persist in the long-term. TRIAL REGISTRATION ClinicalTrial.gov identifier: NCT01905501 . Registered July 18, 2013.
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Conditioning techniques and ischemic reperfusion injury in relation to on-pump cardiac surgery.
Holmberg, FE, Ottas, KA, Andreasen, C, Perko, MJ, Møller, CH, Engstrøm, T, Steinbrüchel, DA
Scandinavian cardiovascular journal : SCJ. 2014;(4):241-8
Abstract
OBJECTIVES The objective was to investigate the potential protective effects of two conditioning methods, on myocardial ischemic and reperfusion injury in relation to cardiac surgery. DESIGN Totally 68 patients were randomly assigned to either a control group (n = 23), a remote ischemic preconditioning (RIPC) group (n = 23) or a glucagon-like peptide-1 (GLP-1) analogue group (n = 22). The RIPC protocol consisted of three cycles of upper limb ischemia. The GLP-1 analogue protocol consisted of intravenous infusion with exenatide. The primary endpoint was postoperative cardiac enzyme release. The other secondary endpoints were metabolic parameters related to myocardial ischemia, measured using microdialysis technique, as well as other operative- and postoperative data. RESULTS Postoperative cardiac enzyme release indicated a possible beneficial effect of the interventions, but the difference did not reach statistical significance. RIPC showed a trend toward lower levels (p = 0.07). We managed to establish a functional myocardial microdialysis model, but we were unable to demonstrate clear protective effects. CONCLUSIONS We were in this prospective randomized proof-of-concept trial, unable to show distinct protective effects of the studied conditioning methods. However, this trial can hopefully contribute to generate a productive discussion concerning limitations and future use of cardiac conditioning as well as microdialysis technique.
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3.
Renal protection: preconditioning for the prevention of contrast-induced nephropathy.
Ozsvath, KJ, Darling, RC
Seminars in vascular surgery. 2013;(4):144-9
Abstract
As the numbers of interventional procedures are rising exponentially, identification of those patients at risk for renal complications has become even more important. Renal complications have been associated with increased morbidity and mortality after interventions. Risk factors have been studied to help identify those patients at increased risk for developing contrast-induced nephropathy. Hydration and medications have been studied as protective measures to decrease risk of renal complications. Preconditioning patients with intravenous hydration has been found to be the most helpful in circumventing postprocedural contrast-induced nephropathy.
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Effect of remote ischaemic preconditioning on renal protection in patients undergoing laparoscopic partial nephrectomy: a 'blinded' randomised controlled trial.
Huang, J, Chen, Y, Dong, B, Kong, W, Zhang, J, Xue, W, Liu, D, Huang, Y
BJU international. 2013;(1):74-80
Abstract
OBJECTIVE To evaluate whether remote ischaemic preconditioning (RIPC) reduces renal injury in patients undergoing laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS In all, 82 patients undergoing LPN were randomly assigned to either the RIPC or control group, with 40 and 38 patients, respectively completing 6-months follow-up. RIPC was conducted after induction of anaesthesia, which consisted of three 5-min cycles of right lower limb ischaemia and 5 min of reperfusion during each cycle. The primary outcome was the absolute change in glomerular filtration rate (GFR) of the affected kidney by renal scintigraphy from baseline to 6 months. The secondary outcomes included urinary retinol-binding protein (RBP) levels measured at 24 and 48 h, serum creatinine, and estimated GFR (eGFR) at 1 and 6 months, and changes in GFR by renal scintigraphy. RESULTS There were no differences in the change of GFR of the affected kidney at 6 months, while it was significantly decreased by 15.0% in the control group vs 8.8% in the RIPC group at 1 month (P = 0.034). The urinary RBP levels increased 8.4-fold at 24 h in the control group compared with a lower increase of 3.9-fold in the RIPC group (P < 0.001). There were no differences in the serum creatinine level or eGFR at 1 and 6 months between the two groups. CONCLUSIONS In patients undergoing LPN, RIPC using transient lower limb ischaemia may reduce renal impairment in the short term, but failed in the longer term despite a non-significant trend in favour of RIPC. These novel data support the need for a larger study of RIPC during LPN surgery.
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5.
Bradykinin preconditioning in coronary artery bypass grafting.
Wei, M, Wang, X, Kuukasjärvi, P, Laurikka, J, Rinne, T, Honkonen, EL, Tarkka, M
The Annals of thoracic surgery. 2004;(2):492-7
Abstract
BACKGROUND Experimental studies have shown that activation of bradykinin B2 receptor is one of the most important triggers of ischemic preconditioning. However, the effect of exogenous administration of bradykinin in cardiac surgery is not yet known. The present prospective randomized study was designed to investigate the effect of bradykinin pretreatment in patients undergoing elective coronary artery bypass surgery. METHODS Forty-one patients with multiple-vessel coronary artery disease and stable angina, admitted for the first time for elective coronary artery bypass surgery, were randomized into control or bradykinin (BK) groups. Patients in the BK group received bradykinin infusion for 7 minutes (total dose 25 microg) before the initiation of cardiopulmonary bypass. Perioperative cardiac specific troponin I (cTnI) and creatine kinase cardiac isoenzyme (CKMB) release and hemodynamics were recorded. RESULTS Bradykinin infusion caused acute decrease of blood pressure in most of the cases and the mean minimum mean blood pressure during bradykinin infusion was 72.7% of the original mean blood pressure (MBP) level (74.7 +/- 7.9 vs 54.4 +/- 12.1 mm Hg, p < 0.01). There were no differences in baseline levels of cTnI and CKMB between the groups. The postoperative cTnI levels were lower than 10 ng/mL in most patients in both groups (18 in the BK group and 15 in the control group). There was no difference in cTnI between the groups. However, patients who received bradykinin released significantly less CKMB than did the controls postoperatively (6 hours, BK, 22.1 +/- 9.5 vs control, 23.6 +/- 12.7 U/L; 12 hours, BK, 19.4 +/- 12.4 vs control, 28.7 +/- 23.8 U/L; 24 hours, BK, 21.5 +/- 14.7 vs control, 35.5 +/- 28.9 U/L; 48 hours, BK, 14.4 +/- 7.5 vs control, 23.5 +/- 13.6 U/L; analysis of variance [ANOVA] for repeated measurement, p = 0.036). Maximum CKMB was also lower in the BK group (22.4 +/- 14.4 vs 37.7 +/- 27.5 U/L, p = 0.044). There was no significant difference between the groups in any of the hemodynamic variables. CONCLUSIONS Exogenous bradykinin infusion showed weak cardioprotective effect in the low-risk patients undergoing coronary artery bypass surgery but the dose used in the study caused acute decrease of systemic blood pressure.