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By contrast, hyperglycemia was greater after hypothermic CPB at closure of the chest and postoperatively. Hypothermia inhibits hepatic glucose production during CPB so that a greater glycogen reserve can be subsequently transformed into glucose after CPB. The residual moderate postoperative hypothermia may also limit glucose utilization although more shivering episodes were observed in this group.
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Plasma epinephrine concentration was almost unchanged by induction of anesthesia (Fig 2). However, these values significantly increased during CPB in the two groups but to a greater extent in group 2. After a slight decline at the end of CPB, epinephrine increased again postoperatively. The evolution of plasma norepinephrine levels was similar to epinephrine.
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Hyperglycemic Hormones
Plasma glucagon concentration did not change significantly throughout the study period in either group (Fig 1). However, a slight increase during CPB in group 2 and a slight decrease during hypothermic CPB in group 1 led to significantly greater values in group 2. In group 1, rewarming was accompanied by an increase in plasma glucagon so that glucagon was similar in the two groups at the completion of CPB. Subsequently, in group 1 glucagon decreased to less than group 2 levels (p<0.02) at the first postoperative hour.
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This rise was significant in the two groups 30 min after starting CPB (+15 and +39 percent, respectively) and at the end of CPB (+ 46 and + 48 percent, respectively). At the end of surgery and before administration of dextrose, blood glucose levels were 19 percent higher in group 1 than in group 2 (p<0.02).
Postoperatively, after administration of dextrose 125 mg/kg over 1 h, blood glucose increased additionally by 18 and 22 percent, respectively, and reached similar values in group 1 and group 2 (244 ±47 and 213 ±46 mg/dl, respectively). However, after administration of dextrose, 375 mg/kg over 3 h, blood glucose increased more in group 1 than in group 2 and reached 271 ±30 mg/dl and 221 ±51 mg/dl, respectively (p<0.01). The lowest blood glucose concentration was 108 mg/dl and was found before induction of anesthesia.
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Pulmonary artery temperature was similar in the two groups before and after the induction of anesthesia (Fig 1), while it decreased to 25.6±3.2°C in group 1 and 34.3±2.8°C in group 2 (intergroup difference: p<0.001) 15 min after starting CPB and increased to 36.6±0.7°C and 36.1±0.7°C (p>0.05), respectively, at the end of CPB. After the end of surgery, pulmonary artery temperature continued to increase to 37.3±0.7°C in group 2 and was significantly higher than in group 1 (Fig 1).
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No significant differences in the amount of injected anesthetics and muscle relaxant were found. The group 1 patients were administered 1.5 ± 1.4 (range: 0 to 4) blood units and the group 2 patients 1.6 ± 1.5 (range: 0 to 4) blood units during the study duration.
No patient died during the study period. Sympathomimetic drugs were administered in four group 1 patients after CPB (epinephrine: one, dopamine: three) and in two group 2 patients (epinephrine: one, dobutamine: two). The patient in group 1 to whom epinephrine was administered required intra-aortic balloon pumping. In group 1, nitroglycerine was administered intravenously to five patients and sodium nitroprusside was administered to two patients during the study period. Nitroglycerine was administered to two group 2 patients. No patient received sympathomimetic drugs before or during CPB.
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The normal values in adults at 8:00 am. are as follows: glucose—65 to 100 mg/dl; epinephrine—39 to 51 pg/ml; norepinephrine—195 to 295 pg/ml; insulin—<30 |iU/ml; cortisol—350 to 650 pmol/ml; GH—<5 ngfail; glucagon—25 to 100 pg/ml. Blood glucose and hormones were not assayed when patients received sympathomimetic drugs.
During the 4 h following surgery, episodes of shivering were recorded by a nurse unaware of the patient’s group.
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Postoperative Period
After transfer to the ICU the patients were ventilated overnight with the same ventilator adjusted according to blood gas levels. Sedation consisted of subcutaneously administered morphine chlor-hydrate (0.1 mg/kg). A 10 g/L dextrose infusion was started at the arrival in the ICU at the rate of 1.25 ml/kg/h.
Protocol
Pulmonary artery temperatures were measured and blood samples were drawn at the following interval times: control, 15 min after insertion of catheters (A); 5 min after tracheal intubation, before incision (B); 15 min (C) and 30 min (D) after starting CPB; at termination of CPB when cardiac mechanical activity had resumed (E); immediately (F), 1 h (G) and 3 h (H) after closure of the chest.
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A CML membrane oxygenator (Cobe, Arvada, Colo) and a nonpulsatile pump (Saras, Ann Arbor, Mich) were used. As Stephens et als have shown that Ringers lactated solution priming does not modify blood glucose, the priming consisted of Ringers lactated solution (1,500 ml), sodium bicarbonate 1.4 percent (300 ml) and heparin (5,000 U). Saint Thomas’ Hospital crystalloid cardioplegic solution without glucose was injected at 4°C into the aortic root immediately after aortic cross-clamping and every 20 mn thereafter until unclamping. As is standard practice in our institution, mean arterial pressure was maintained between 50 and 80 mm Hg by adjusting perfusion index and use of nitroglycerin. Vasopressor agents were not used in these patients during CPB.
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Orally administered diazepam (0.35 mg/kg) was given as premedication and induction of anesthesia consisted of fentanyl (50 M-g/kg), diazepam (0.25 mj^ kg) and pancuronium (0.1 mg/kg). Anesthesia was maintained with increments of fentanyl and diazepam. Artificial ventilation was provided by a Servo ventilator A (Siemens-Elema, Germany) (n = 10/ min, Vt= 10 ml/kg, oxygen = 100 percent). Radial artery and pulmonary artery Swan-Ganz catheters were inserted prior to induction with the patient under local anesthesia. Central temperatures were monitored through rectal and pulmonary artery catheter probes. Ringers lactated solution and vasodilators (nitroglycerin, sodium nitroprusside) were administered as needed. No dextrose was administered throughout surgery except 820 mg per blood unit.
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