Effect of helium pre- or postconditioning on signal transduction kinases in patients undergoing coronary artery bypass graft surgery

Background: The noble gas helium induces pre- and postconditioning in animals and humans. Volatile anesthetics induce cardioprotection in humans undergoing coronary artery bypass graft (CABG) surgery. We hypothesized that helium induces pre-and postconditioning in CABG-patients, affecting signaling molecules protein kinase C-epsilon (PKC-epsilon), p38 mitogen activated protein kinase (p38 MAPK), extracellular signal-regulated kinase 1/2 (ERK-1/2) and heat shock protein 27 (HSP-27) within cardiac tissue, and reducing postoperative troponin levels. Methods: After ethical approval and informed consent, 125 elective patients undergoing CABG surgery were randomised into this prospective, placebo controlled, investigator blinded, parallel arm single-centre study. Helium preconditioning (3 x 5 min of 70 % helium and 30 % oxygen) was applied before aortic cross clamping; postconditioning (15 min of helium) was applied before release of the aortic cross clamp. Signaling molecules were measured in right atrial appendix specimens. Troponin-T was measured at 4, 12, 24 and 48 h postoperatively. Results: Baseline characteristics of all groups were similar. Helium preconditioning did not significantly alter the primary outcome (molecular levels of kinases PKC-e and HSP-27, ratio of activated p38 MAPK or ERK 1/2). Postoperative troponin T was 11 arbitrary units [5, 31; area-under-the-curve (interquartile range)] for controls, and no statistically significant changes were observed after helium preconditioning [He-pre: 11 (6, 18)], helium postconditioning [He-post: 11 (8, 15)], helium pre-and postconditioning [He-PP: 14 (6, 20)] and after sevoflurane preconditioning [APC: 12 (8, 24), p = 0.13]. No adverse effects related to study treatment were observed in this study. Conclusions: No effect was observed of helium preconditioning, postconditioning or the combination thereof on activation of p38 MAPK, ERK 1/2 or levels of HSP27 and PKC-e in the human heart. Helium pre-and postconditioning did not affect postoperative troponin release in patients undergoing CABG surgery

European implementation of the '2014 ESC/ESA guideline on non-cardiac surgery: cardiovascular assessment and management'

BACKGROUND: Substandard implementation of a guideline is a major factor contributing to poor guideline adherence and has the potential to result in preventable patient harm. This study aims to quantify the uptake of the European guideline on non-cardiac surgery by European anesthetists. METHODS: This is a questionnaire-based cross-sectional study. Data was collected during Euroanaesthesia, the annual congresses of the Dutch Society of Anaesthesiology, European Association of Cardiothoracic Anaesthesiologists and European Society for Regional Anaesthesia and Pain Therapy in 2015. Primary endpoints were the implementation and knowledge scores derived from the questionnaires. RESULTS: The implementation score from 488 questionnaires was excellent in 4%, good in 14%, average in 22%, poor in 32% and very poor in 28% of the cases. The knowledge score was excellent in 1%, good in 27%, moderate in 49%, poor in 18% and very poor in 5% of the cases. CONCLUSIONS: Current implementation and knowledge of the guideline on non-cardiac surgery in Europe needs to be improved

Morphine induces preconditioning via activation of mitochondrial KCa channels

PURPOSE: Mitochondrial calcium sensitive potassium (mK(Ca)) channels are involved in cardioprotection induced by ischemic preconditioning. In the present study we investigated whether morphine-induced preconditioning also involves activation of mK(Ca) channels. METHODS: Isolated rat hearts (six groups; each n = 8) underwent global ischemia for 30 min followed by a 60-min reperfusion. Control animals were not further treated. Morphine preconditioning (MPC) was initiated by two five-minute cycles of morphine 1 muM infusion with one five-minute washout and one final ten-minute washout period before ischemia. The mK(Ca) blocker, paxilline 1 muM, was administered, with and without morphine administration (MPC + Pax and Pax). As a positive control, we added an ischemic preconditioning group (IPC) alone and combined with paxilline (IPC + Pax). At the end of reperfusion, infarct sizes were determined by triphenyltetrazoliumchloride staining. RESULTS: Infarct size was (mean +/- SD) 45 +/- 9% of the area at risk in the Control group. The infarct size was less in the morphine or ischemic preconditioning groups (MPC: 23 +/- 8%, IPC: 20 +/- 5%; each P < 0.05 vs Control). Infarct size reduction was abolished by paxilline (MPC + Pax: 37 +/- 7%, P < 0.05 vs MPC and IPC + Pax: 36 +/- 6%, P < 0.05 vs IPC), whereas paxilline alone had no effect (Pax: 46 +/- 7%, not significantly different from Control). CONCLUSION: Cardioprotection by morphine-induced preconditioning is mediated by activation of mK(Ca) channel

Effect of remote ischemic conditioning on atrial fibrillation and outcome after coronary artery bypass grafting (RICO-trial)

Background: Pre- and postconditioning describe mechanisms whereby short ischemic periods protect an organ against a longer period of ischemia. Interestingly, short ischemic periods of a limb, in itself harmless, may increase the ischemia tolerance of remote organs, e.g. the heart (remote conditioning, RC). Although several studies have shown reduced biomarker release by RC, a reduction of complications and improvement of patient outcome still has to be demonstrated. Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass graft surgery (CABG), affecting 27-46% of patients. It is associated with increased mortality, adverse cardiovascular events, and prolonged in-hospital stay. We hypothesize that remote ischemic pre- and/or post-conditioning reduce the incidence of AF following CABG, and improve patient outcome.Methods/design: This study is a randomized, controlled, patient and investigator blinded multicenter trial. Elective CABG patients are randomized to one of the following four groups: 1) control, 2) remote ischemic preconditioning, 3) remote ischemic postconditioning, or 4) remote ischemic pre- and postconditioning. Remote conditio

Drug Eluting Stents und Antikoagulation in der perioperativen Phase - Eine interdisziplinäre Aufgabe

Drug eluting stents are nowadays more frequently used in cardiac risk patients undergoing coronary artery interventions. These stents make prolonged anticoagulation up to one year or longer necessary to avoid acute stent thrombosis. Anti-platelet drugs like clopidogrel and aspirin should therefore be continued perioperatively if possible. Decission to stop anti-plateletts should be made for each individual patient only after interdisciplinary discussion with the cardiologist, surgeon and anaesthesiologis

Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice

Purpose of review WHO makes clear recommendations on how to improve patient safety during surgical procedures by using the WHO Surgical Safety Checklist. We will review the scientific basis of these recommendations and the practical problems encountered during introduction. Recent findings Perioperative severe complications and death are a major health issue in both developed and developing countries. Nearly half of these complications can be avoided. The systematic use of checklists and structured preprocedural and postprocedural briefings like a time-out procedure reduces perioperative morbidity and mortality. A broader use of checklists to cover the whole surgical pathway gives additional benefit, further reducing perioperative morbidity and mortality. Introducing patient safety procedures can be met with some resistance from healthcare workers and is helped by an organization-wide safety policy and a systematic approach. Summary There is sufficient scientific evidence to make the use of checklists and structured perioperative briefings and debriefings mandatory for the broad spectrum of operative procedure