The objective of study is to detect effect of remote ischemic preconditioning on serum lactate levels during and after cardiac surgery with cardiopulmonary bypass in addition to its effect on cardiac and renal clinical outcomes.
Remote ischemic preconditioning (RIPC) is a phenomenon where transient non-injurious ischemia/ reperfusion episodes applied to an organ away from the heart can protect the myocardium from ischemia/reperfusion injury. RIPC has been found to be an attractive strategy to reduce myocardial injury and improve outcome in patients undergoing cardiac surgery. The exact mechanisms of this protection are not yet known, although stimulation of prosurvival intracellular kinase responses and inhibition of inflammatory pathways each play a role. RIPC can be performed by noninvasive inflation and deflation of a standard blood pressure cuff or pneumatic tourniquet on the upper or lower limbs to induce brief ischemia and reperfusion, which is the mechanism by which injury in patients undergoing open cardiac surgery occurs. ANESTHETIC TECHNIQUE All patients will be preoperatively examined and investigated by complete blood count, coagulation profile, renal and kidney functions and electrolytes. Electrocardiography, chest x ray and echocardiography will be routinely done. Coronary angiography and carotid arterial duplex will be requested in patients prepared for coronary artery bypass graft (CABG). Patient will be premedicated by intramuscular injection of 10mg morphine in the morning of the operation. Before induction of anesthesia, a five-lead electrocardiography system will be applied to monitor heart rate, rhythm, and ST segments (leads II and V5). A pulse oximeter probe will be attached, and a peripheral venous cannula will be placed. For measurement of arterial pressure and blood sampling, a 20 G cannula will be inserted into either right or left radial artery under local anesthesia. General anesthesia will be induced by fentanyl (3-5 μg/kg), propofol titrated according to response, followed by atracurium (0.5 mg/kg). Trachea will be intubated, patients will be mechanically ventilated with oxygen in air so as to achieve normocarbia. This will be confirmed by radial arterial blood gas analysis. An esophageal temperature probe and a Foley catheter will also be placed. For drug infusion, a triple-lumen central venous catheter will be inserted via the right internal jugular vein. Anesthesia will be maintained by inhaled isoflurane, with additional fentanyl injected prior to skin incision as well as sternotomy and atracurium infusion for continued muscle relaxation. During extracorporeal circulation, patients will receive propofol infusion in addition to atracurium infusion. Before initiation of cardiopulmonary bypass (CPB), the patients will receive intravenously tranexamic acid (2 g) and heparin (300-500 units/kg body weight) to achieve an activated clotting time \> 400 s. CPB was instituted via an ascending aortic cannula and a two-stage right atrial cannula. Before, during, and after CPB (pump blood flow: 2.4 l/min/m2), mean arterial pressure was adjusted to exceed 60 mmHg. Cardiac arrest will be induced with cold antegrade crystalloid cardioplegia (St Thomas solution) or warm intermittent antegrade blood cardioplegia. Lactate-enriched Ringer's solution will be added to the CPB circuit to maintain reservoir volume when needed, and packed red blood cells will be added when hemoglobin concentration decrease to less than 7 g/dl. After rewarming the patient to 37°C and separation from CPB, reversal of heparin by protamine sulfate, and sternal closure, the patients will be transferred to the intensive care unit.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
DOUBLE
After patient being draped, applying cuff inflation will be done to the upper arm not having the arterial line inserted of about 200 mmHg or 15 mmHg above patient's systolic pressure 3 cycles 5 minutes each followed by 5 minutes of pressure relieve
non inflated cuff around the arm for the control group
Mohamed Hamed
Al Fayyum, Egypt
Serum lactate level
mmol/l from arterial blood gas sample
Time frame: 1 minute at the end of operation
Serum lactate level
mmol/l from arterial blood gas sample
Time frame: 3 minutes after induction of anesthesia
Serum lactate level
mmol/l from arterial blood gas sample
Time frame: 30 minutes, after cardiopulmonary bypass
Serum lactate level
mmol/l from arterial blood gas sample
Time frame: 1 minute before cardiopulmonary bypass
Serum lactate level
mmol/l from arterial blood gas sample
Time frame: 24 hours postoperatively.
Serum lactate level
mmol/l from arterial blood gas sample
Time frame: 48 hours postoperatively.
Serum lactate level
mmol/l from arterial blood gas sample
Time frame: 72 hours postoperatively.
Heart rate
beat per minute from electrocardiogram
Time frame: 2 minutes before induction of general anesthesia
Heart rate
beat per minute from electrocardiogram
Time frame: 3 minutes after induction of general anesthesia
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.
Heart rate
beat per minute from electrocardiogram
Time frame: Every 30 minutes for 6 hours during surgery except at cardiopulmonary bypass as there is cardioplegia
Systolic blood pressure
Measured by mmHg from invasive arterial blood pressure
Time frame: 2 minutes before induction of general anesthesia
Systolic blood pressure
Measured by mmHg from invasive arterial blood pressure
Time frame: 3 minutes after induction
Systolic blood pressure
Measured by mmHg from invasive arterial blood pressure
Time frame: Every 30 minutes for 6 hours during surgery except at cardiopulmonary bypass as there is cardioplegia and no pulsatile blood pressure
Diastolic blood pressure
Measured by mmHg from invasive arterial blood pressure
Time frame: 2 minutes before induction of general anesthesia
Diastolic blood pressure
Measured by mmHg from invasive arterial blood pressure
Time frame: 3 minutes after induction
Diastolic blood pressure
Measured by mmHg from invasive arterial blood pressure
Time frame: Every 30 minutes for 6 hours during surgery except at cardiopulmonary bypass as there is cardioplegia and no pulsatile blood pressure
Left ventricular fractional shortening (LVFS)
measured in percentage derived from echocardiography
Time frame: 12 hours before the operation
Left ventricular fractional shortening (LVFS)
measured in percentage derived from echocardiography
Time frame: 2 hours after the operation
Left ventricular fractional shortening (LVFS)
measured in percentage derived from echocardiography
Time frame: 4 hours after the operation
Left ventricular fractional shortening (LVFS)
measured in percentage derived from echocardiography
Time frame: 12 hours after the operation
Left ventricular fractional shortening (LVFS)
measured in percentage derived from echocardiography
Time frame: 24 hours after the operation
Left ventricular fractional shortening (LVFS)
measured in percentage derived from echocardiography
Time frame: 48 hours after the operation
Left ventricular fractional shortening (LVFS)
measured in percentage derived from echocardiography
Time frame: 72 hours after the operation
Left ventricular ejection fraction (LVEF)
measured in percentage derived from echocardiography
Time frame: 12 hours before the operation
Left ventricular ejection fraction (LVEF)
measured in percentage derived from echocardiography
Time frame: 2 hours after the operation
Left ventricular ejection fraction (LVEF)
measured in percentage derived from echocardiography
Time frame: 4 hours after the operation
Left ventricular ejection fraction (LVEF)
measured in percentage derived from echocardiography
Time frame: 12 hours after the operation
Left ventricular ejection fraction (LVEF)
measured in percentage derived from echocardiography
Time frame: 24 hours after the operation
Left ventricular ejection fraction (LVEF)
measured in percentage derived from echocardiography
Time frame: 48 hours after the operation
Central venous pressure
from central venous catheter measured in cm H2O
Time frame: Baseline 2 minutes after insertion of central venous catheter
Central venous pressure
from central venous catheter measured in cm H2O
Time frame: 2 minutes before cardiopulmonary bypass
Central venous pressure
from central venous catheter measured in cm H2O
Time frame: 2 minutes after cardiopulmonary bypass
Central venous pressure
from central venous catheter measured in cm H2O
Time frame: 1 minute after the end of operation
Serum urea level
mmol/L
Time frame: 5 minutes before beginning of operation
Serum urea level
mmol/L
Time frame: 5 minutes after ICU admission
Serum creatinine level
mmol/L
Time frame: 5 minutes before beginning of operation
Serum creatinine level
mmol/L
Time frame: 24 hours postoperatively
Serum creatinine level
mmol/L
Time frame: 48 hours postoperatively
Serum creatinine level
mmol/L
Time frame: 72 hours postoperatively
Acute kidney injury (AKI) score
Grade 1: serum creatinine rise of 150%-200% of baseline and/or urine output \<0.5 mL/kg/h for \>6 contiguous hours. Grade 2: serum creatinine rise of 200%-300% of baseline and/or urine output \<0.5 mL/kg/h for \>12 contiguous hours. Grade 3: serum creatinine rise of \>300% of baseline and/or urine output \<0.3 mL/kg/h for \>24 h or anuria for 12 h.
Time frame: 24 hours postoperatively
Acute kidney injury (AKI) score
Grade 1: serum creatinine rise of 150%-200% of baseline and/or urine output \<0.5 mL/kg/h for \>6 contiguous hours. Grade 2: serum creatinine rise of 200%-300% of baseline and/or urine output \<0.5 mL/kg/h for \>12 contiguous hours. Grade 3: serum creatinine rise of \>300% of baseline and/or urine output \<0.3 mL/kg/h for \>24 h or anuria for 12 h.
Time frame: 48 hours postoperatively
Acute kidney injury (AKI) score
Grade 1: serum creatinine rise of 150%-200% of baseline and/or urine output \<0.5 mL/kg/h for \>6 contiguous hours. Grade 2: serum creatinine rise of 200%-300% of baseline and/or urine output \<0.5 mL/kg/h for \>12 contiguous hours. Grade 3: serum creatinine rise of \>300% of baseline and/or urine output \<0.3 mL/kg/h for \>24 h or anuria for 12 h.
Time frame: 72 hours postoperatively
Serum sodium level
milliequivalent/L
Time frame: 5 minutes after ICU admission.
Serum sodium level
milliequivalent/L
Time frame: 5 minutes before beginning of operation
Serum potassium level
milliequivalent/L
Time frame: 5 minutes before beginning of operation
Serum potassium level
milliequivalent/L
Time frame: 5 minutes after ICU admission
Arterial oxygen pressure
From arterial blood gas sampling
Time frame: 5 minutes before operation
Arterial oxygen pressure
From arterial blood gas sampling
Time frame: 2 minutes before cardiopulmonary bypass
Arterial oxygen pressure
From arterial blood gas sampling
Time frame: 2 minutes after cardiopulmonary bypass
Arterial oxygen pressure
From arterial blood gas sampling
Time frame: 1 minute after end of operation
Arterial oxygen pressure
From arterial blood gas sampling
Time frame: Every 6 hours for 24 hours in the ICU
Arterial carbon dioxide pressure
From arterial blood gas sampling
Time frame: 5 minutes before operation
Arterial carbon dioxide pressure
From arterial blood gas sampling
Time frame: 2 minutes before cardiopulmonary bypass
Arterial carbon dioxide pressure
From arterial blood gas sampling
Time frame: 2 minutes after cardiopulmonary bypass
Arterial carbon dioxide pressure
From arterial blood gas sampling
Time frame: 1 minute after end of operation
Arterial carbon dioxide pressure
From arterial blood gas sampling
Time frame: Every 6 hours for 24 hours in the ICU
Power of hydrogen (pH)
From arterial blood gas sampling
Time frame: 5 minutes before operation
Power of hydrogen (pH)
From arterial blood gas sampling
Time frame: 2 minutes before cardiopulmonary bypass
Power of hydrogen (pH)
From arterial blood gas sampling
Time frame: 2 minutes after cardiopulmonary bypass
Power of hydrogen (pH)
From arterial blood gas sampling
Time frame: 1 minute after end of operation
Power of hydrogen (pH)
From arterial blood gas sampling
Time frame: Every 6 hours for 24 hours in the ICU
Standard bicarbonate level
From arterial blood gas sampling
Time frame: 5 minutes before operation
Standard bicarbonate level
From arterial blood gas sampling
Time frame: 2 minutes before cardiopulmonary bypass
Standard bicarbonate level
From arterial blood gas sampling
Time frame: 2 minutes after cardiopulmonary bypass
Standard bicarbonate level
From arterial blood gas sampling
Time frame: 1 minute after end of operation
Standard bicarbonate level
From arterial blood gas sampling
Time frame: Every 6 hours for 24 hours in the ICU