Cardiac Anaesthesia, Cardiopulmonary Bypass
Conditions
Keywords
Cardiopulmonary bypass (CPB) -Tricuspid annular plane systolic excursion (TAPSE)-, Epinephrine - Milrinone
Brief summary
Cardiopulmonary bypass (CPB) is a critical technology in cardiac surgery, allowing for the temporary replacement of the heart and lung functions during intricate surgical procedures. it has significant post-surgical complications, the most important complications of CPB is right ventricle (RV) dysfunction. Diagnosis and management of RV dysfunction is crucial for maintenance of hemodynamic stability and organ function in early post-operation period and prognostic for later phase.
Detailed description
Epinephrine is the most potent adrenergic agonist which has positive inotropic and chronotropic effects and enhanced conduction in the heart (β1), smooth muscle relaxation in the vasculature and bronchial tree (β2), and vasoconstriction (α1). Low doses of this agent (\<0.1-0.2 μg/kg/min) mainly activate the β adrenoceptors with inotropic effects. Higher doses result in vasoconstrictor effect which takes the lead. Other effects include bronchial dilation, mydriasis, glycogenolysis, tachyarrhythmia, myocardial ischemia, pulmonary hypertension, hyperglycemia, and lactic acidosis. Epinephrine also reduces splanchnic and hepatic perfusion and increases metabolic workload of the liver. So this hypermetabolism that impairs oxygen exchange, glycolysis, and suppression of insulin cause lactic acidosis. Milrinone is a phosphodiesterase-III inhibitor. This effect decreases the degradation of cyclic adenosine monophosphate (cAMP), increases the cAMP levels in cells, and then increases activation of protein kinase A. Therefore, its cardiac effects are positive inotropy and improved diastolic relaxation. Milrinone also causes potent vasodilation, with reduction in preload, afterload and pulmonary vascular resistance. Considering its characteristics, milrinone might be a useful agent for cardiac surgery patients.
Interventions
DRUGEpinephrine
Normal saline bolus over 10 min followed by Epinephrine intravenous infusion of 0.05-0.1 mcg/kg/min.of epinephrine 5-10 minutes before aortic unclamping
Milrinone initial bolus doses of 50 µg/kg, followed by 0.40 - 0.80 µg/kg/min of milrinone 5-10 minutes before aortic unclamping
Sponsors
Mansoura University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Investigator)
Masking description
anesthesiologist who performed TEE measurements and who was responsible for data collection will be blinded to patient group allocation
Intervention model description
Epinephrine group (group E): the patients receive 0.05-0.1 mcg/kg/min.of epinephrine 5-10 minutes before aortic unclamping. Milrinone group (group M): the patients receive initial bolus doses of 50 µg/kg, followed by 0.40 - 0.80 µg/kg/min of milrinone 5-10 minutes before aortic unclamping
Eligibility
Sex/Gender
ALL
Age
18 Years to 70 Years
Healthy volunteers
No
Inclusion criteria
* American Society of Anesthesiologists (ASA) physical status II \& III * Age between 18 and 70 years * Both Gender * Body mass index less than 40 kg/m2 * Ejection fraction of \>40% * Tricuspid annular plane systolic excursion (TAPSE) \< 1.7cm
Exclusion criteria
* Patient refusal. * Preoperative RV impairment * Pulmonary hypertension (estimated pulmonary artery systolic pressure \> 50 mmHg) * Patients with any contraindications to Transesophageal echocardiography (TEE) * Redo or Re-exploration surgery * Patients with chronic kidney disease (serum creatinine \> 1.5 mg/ dl) * Patients with chronic liver disease (child pugh B and C)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The incidence of change in Tricuspid annular plane systolic excursion (TAPSE) within 5 minutes post-cardiopulmonary Bypass from the basal value | Basal then within 5 mins post-cardiopulmonary bypass | measured by Transesophageal echocardiography (TEE) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Tricuspid annular plane systolic excursion (TAPSE) | within 30-60 minutes post-cardiopulmonary bypass | measured by Transesophageal echocardiography (TEE) |
| Incidence of Right Ventricular Dysfunction after Cardiac Surgery | 24 hours postoperative | detected by ECHO when Tricuspid annular plane systolic excursion (TAPSE) ≤1.7 cm |
| Incidence of Arrhythmias | intraoperatively and 24 hours postoperative | occurrence of any Arrhythmia |
| Vasoactive-Inotrope Score (VIS) | recorded at 6, 12, 24, and 48 hours postoperative | Vasoactive-Inotrope Score = Dopamine (µg/kg/min) + Dobutamine (µg/kg/min) +100 x Epinephrine (µg/kg/min) +100 x Norepinephrine (µg/kg/min) + 10 x Milrinone (µg/kg/min) + 10,000 x Vasopressin |
| Total consumption doses of Vasopressors | 48 hours postoperative | cumulative dose of any needed Vasopressors (Norepinepherine) |
Contacts
CONTACTMaha A AboZeid, Assistant professor
Outcome results
None listed