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Biomedical subjects

F G Estafanous

Publications and source records attributed to F G Estafanous.

At least 19 recordsLinked to original sources
PubMed1992

Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score.

OBJECTIVE: To relate morbidity and mortality risk to preoperative severity of illness in patients undergoing coronary artery bypass grafting. DESIGN: Retrospective analysis of 5051 patients using univariate and logistic regression to identify risk factors associated with perioperative morbidity and mortality. Prospective application of models to a subsequent 2-year validation cohort (n = 4069). SETTING: Cleveland Clinic Foundation. PATIENTS: All adult patients undergoing coronary artery bypass graft surgery between July 1, 1986, and June 30, 1988 (reference group), and July 1, 1988, and June 30, 1990 (validation group). MAIN OUTCOME MEASURES: Mortality and morbidity (myocardial infarction and use of intra-aortic balloon pump, mechanical ventilation for 3 or more days, neurological deficit, oliguric or anuric renal failure, or serious infection). MAIN RESULTS: Emergency procedure, preoperative serum creatinine levels of greater than 168 mumol/L, severe left ventricular dysfunction, preoperative hematocrit of 0.34, increasing age, chronic pulmonary disease, prior vascular surgery, reoperation, and mitral valve insufficiency were found to be predictive of mortality. In addition to these factors, diabetes mellitus, body weight of 65 kg or less [corrected], aortic stenosis, and cerebrovascular disease were predictive of morbidity. Logistic regression equations were developed, and a simple additive score for clinical use was designed by allocating each of these risk-factor values of 1 to 6 points. Both methods predict mortality. Increased morbidity was demonstrated with increases in score. CONCLUSIONS: The logistic or clinical models developed are superior to the currently available methods for comparing mortality outcome and provide previously unavailable information on morbidity based on preoperative status. The clinical scoring system is useful for preoperative estimates of morbidity and mortality risks.

Aged↗
PubMed1992

Analysis of heart rate variability to assess hemodynamic alterations following induction of anesthesia.

Extensive changes in hemodynamics and cardiac rhythm during induction of anesthesia may be mediated by altered responses of the autonomic nervous system to anesthetic agents. Analysis of the power spectrum of the heart rate (PSHR) variability can supply information about the autonomic nervous system, and may be used in order to assess this phenomenon. In this study, 78 patients undergoing coronary artery bypass graft surgery were evaluated. Anesthesia was induced with sufentanil, and neuromuscular blockade with vecuronium, a combination that may cause a decrease in heart rate. Before and after induction of anesthesia, the heart rate (HR), blood pressure (BP), cardiac output (CO), cardiac index (CI), and PSHR components were recorded. PSHR was obtained by using a special algorithm and data acquisition system for real-time spectral analysis. A low-frequency component (LFa, mainly sympathetic) was analyzed from a band of 0.04 Hz to 0.1 Hz. A high-frequency component (RFa, parasympathetic) was identified by the respiratory frequency spectrum. Alterations of the heart rate after induction of anesthesia were defined in order to separate the patient population into two groups: slow heart rate (slow-HR) and stable heart rate (stable-HR). Slow heart rate was defined as a decrease in HR of more than 20% of the baseline value. The variables were analyzed and compared between the slow-HR (n = 25) and stable-HR (n = 53) groups in order to verify the possibility of identifying patients prone to hemodynamic changes after anesthesia induction. There were no differences in preoperative HR, BP, CO, or CI between groups before anesthesia induction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Effects of opioids on vasoresponsiveness of porcine coronary artery.

Myocardial ischemia during surgery can be caused by coronary vasospasm. Neurohumoral mechanisms are involved in this phenomenon, and various substances have been suggested as possible causes, including acetylcholine, histamine, and norepinephrine. The responses of isolated porcine coronary arteries (from 117 pig hearts) with (E+) and without (E-) endothelium to these agents were investigated in the presence of fentanyl, sufentanil, and morphine. Fentanyl significantly shifted to the right, in a concentration-dependent fashion, the concentration-response curve to acetylcholine. This effect was not different between E+ and E- rings. Neither sufentanil nor morphine altered acetylcholine-induced contraction of porcine coronary arteries. Naloxone did not antagonize the suppressive effect of fentanyl on acetylcholine-induced contraction. The response of porcine coronary arteries to norepinephrine was decreased only at very high concentrations of fentanyl. Neither sufentanil nor morphine altered norepinephrine-induced contraction of porcine coronary arteries. Fentanyl, sufentanil, and morphine had no effect on histamine-induced contraction. We conclude that fentanyl antagonized acetylcholine-induced contraction of porcine coronary arteries. This effect of fentanyl seems to be caused by a direct effect on smooth muscle cells and is not opioid-receptor mediated.

Acetylcholine↗
PubMed1992

Myocardial protection during cardiac operations. Decreased morbidity and lower cost with blood cardioplegia and coronary sinus perfusion.

The efficacy of myocardial protection with a single aortic crossclamp and blood cardioplegia was evaluated in 819 consecutive patients stratified for preoperative condition by means of a new clinical risk scoring system. A protocol using either antegrade or antegrade/retrograde blood cardioplegia was compared with antegrade crystalloid cardioplegia in 2582 similar, consecutive, and concurrent patients. In the blood cardioplegia cohort, 97 (11.8%) patients had 129 complications compared with 407 (15.8%) patients and 675 complications in the crystalloid cardioplegia group (p = 0.006). In high-risk patients, combined antegrade/retrograde cardioplegia significantly reduced myocardial infarction, stroke, and respiratory and wound complications. Despite the significantly longer aortic crossclamp time required for blood cardioplegia, patients undergoing crystalloid cardioplegia were 1.7 (95% confidence interval 1.3, 2.1) times more likely to have a morbid event. Time in the intensive care unit, length of hospitalization, and length-of-stay outlier status were significantly decreased in the blood cardioplegia compared with the crystalloid cardioplegia group. The net savings in hospital cost amounted to $2196 per case. When compared separately with crystalloid cardioplegia, combined antegrade/retrograde blood cardioplegia accounted for most of the morbidity reduction by significantly reducing perioperative myocardial infarction, wound complications, and length of stay in patients having reoperations. Antegrade/retrograde blood cardioplegia did not influence 1-year survival or event-free survival, even when risk was considered.

Aged↗
PubMed1991

Bleeding hearts.

Explore the source record for details and available documents.

Blood Coagulation Disorders↗
PubMed1991

Effects of propranolol on myocardial performance during acute normovolemic hemodilution.

The effects of propranolol and hemodilution on myocardial performance and oxygen delivery were evaluated in 36 anesthetized rats. Oral propranolol treatment consisted of 64 mg/kg/d for 6 weeks prior to the experiments, whereas intravenous (IV) propranolol treatment consisted of 5 micrograms/kg/min for 60 minutes after hemodilution. The hematocrit was reduced to 20% by a hetastarch-for-blood exchange. Animals were divided into six equal groups as follows: (1) no oral drug (water), no hemodilution, no IV drug (saline); (2) oral water, hemodilution, IV saline; (3) oral water, no hemodilution, IV propranolol; (4) oral water, hemodilution, IV propranolol; (5) oral propranolol, no hemodilution, IV saline; and (6) oral propranolol, hemodilution, IV saline. Left ventricular (LV) pressure, maximal dP/dt, ascending aortic blood flow, and response to preload (peak cardiac and stroke volume indices) and afterload (LV-developed pressure) stress were measured. In group 2, hemodilution significantly increased cardiac index, stroke volume index, and dP/dt, and decreased blood pressure, peripheral resistance, and oxygen delivery compared with group 1. Compared with group 2, IV propranolol after hemodilution in group 4 significantly decreased cardiac index, dP/dt, LV-developed pressure, and peak cardiac index, and increased peripheral resistance. Stroke volume index and peak stroke volume index after preload stress remained elevated in group 4, despite the negative inotropic effects of IV propranolol. Oral propranolol in group 6 did not prevent the hemodilution-induced increase in stroke volume index and peak stroke volume index in response to preload stress, although it did decrease cardiac index and dP/dt compared with group 2. Oxygen delivery was reduced in the hemodiluted animals in proportion to the decrease in hemoglobin, regardless of propranolol treatment. It is concluded that reduced myocardial contractility and cardiac performance by nonselective pharmacological beta-adrenoceptor blockade does not interfere with the compensatory increase in stroke volume index after hemodilution.

Administration, Oral↗
PubMed1991

Comparison of cardiovascular effects of pipecuronium versus vecuronium in patients receiving sufentanil anesthesia for myocardial revascularization.

This study was designed to compare the cardiovascular effects of pipecuronium bromide (PIP) to vecuronium (V) when combined with sufentanil (SF) in patients undergoing coronary artery bypass surgery. Eighty-two patients were studied; 40 were normotensive and 42 had hypertension currently controlled by pharmacological therapy. All patients were randomly assigned to receive either intravenous V, 0.12 mg/kg, or PIP, 0.10 mg/kg. Anesthesia was induced with SF, 6 micrograms/kg, while breathing 100% oxygen. Hemodynamic data including heart rate, mean arterial pressure, pulmonary capillary wedge pressure, central venous pressure, cardiac index, systemic vascular resistance, pulmonary vascular resistance, and left ventricular stroke work index were collected at five points: prior to induction, 3 and 6 minutes after the complete administration of PIP or V, and 3 and 6 minutes after intubation. There were no statistical differences in hemodynamic changes associated with either PIP or V. In addition, there were no statistical differences in the hemodynamic parameters measured at the five time points between the normotensive and hypertensive patient groups. This study demonstrates that there are no significant hemodynamic changes between SF/PIP and SF/V when used during coronary artery surgery. Due to its associated stable hemodynamics, as well as its long duration of action, PIP could become a commonly used muscle relaxant for anesthesia for cardiac surgery.

Androstane-3,17-diol↗
PubMed1991

Attenuated vascular reactivity in dogs with anteroventral third ventricle lesions.

Lesion of the anteroventral portion of the third cerebral ventricle causes hypernatremia, adipsia, and attenuation of the pressor response to intravenous administration of angiotensin II and norepinephrine. In addition, these lesions prevent the development of several experimental models of hypertension. In this study, a lesion of the third cerebral ventricle region was made in 14 dogs. In seven dogs in which hypernatremia developed the lesions included the organum vasculosum of the lamina terminalis; seven animals in which the circumventricular organ was spared by the lesion remained normonatremic. Vascular responsiveness of isolated right carotid artery rings to angiotensin II and phenylephrine was assessed 3 days after lesioning the anteroventral portion of the third cerebral ventricle. In endothelium-denuded ring vessels, vasoconstrictor responses to phenylephrine were significantly decreased in animals both with and without inclusion of the organum vasculosum of the lamina terminalis. A similar effect was observed in intact vessels of dogs in which the circumventricular organ was spared but not in those with lesions that included this area. In contrast, angiotensin II-induced vasoconstriction was significantly decreased in the arteries with intact endothelium of both groups of lesioned animals. These data show that lesion of the anteroventral third ventricle area alters alpha 1-adrenergic and angiotensin II vascular responsiveness in isolated carotid artery rings with the possible participation of the endothelium.

Acetylcholine↗
PubMed1991

Circulatory effects of verapamil during normovolemic hemodilution in anesthetized rats.

Patients who have undergone perioperative normovolemic hemodilution may require calcium channel blockers for the treatment of myocardial ischemia and/or supraventricular tachyarrhythmias. The purpose of this rodent study was to examine the effect of intravenous verapamil on the hyperdynamic circulatory response to acute normovolemic hemodilution (hematocrit 20%). Anesthetized animals were randomly divided into four groups equal in number: (1) controls (no hemodilution, no drug); (2) hemodilution only; (3) verapamil only; and (4) hemodilution followed by verapamil. Cardiac output was recorded using an electromagnetic flow probe. Pre- and afterload tests were performed, the former consisting of rapid infusion of blood adjusted for hematocrit, the latter consisting of an aortic clamp technique. Animals in group 2 had significantly (P less than 0.05) greater percent increases in cardiac index, stroke volume index, and dP/dt, and greater percent decreases in mean arterial pressure, systemic vascular resistance, and oxygen delivery than did control animals (group 1). Infusion of verapamil after hemodilution (group 4) did not interfere with the compensatory increases in cardiac index and stroke volume index seen in group 2, nor did it reduce the peak stroke volume index in response to preload stress, although it did reduce resting dP/dt, mean arterial pressure and systemic vascular resistance, and peak cardiac index and "left ventricular developed pressure" after preload and afterload stress, respectively. We conclude that reduced ventricular function after verapamil administration does not interfere with the compensatory increase in stroke volume index after normovolemic hemodilution.

Animals↗
PubMed1990

Portal-like microcirculation in rat sympathetic ganglia.

The fine structure of intraganglionic blood vessels of rat superior cervical sympathetic ganglia is studied with the light microscope and with both conventional and ultrastructural histochemical methods. Two sets of small capillaries together with larger sinusoidal ones are identified. One set of capillaries is associated with the clustered (type II) small catecholamine-containing (CC) cells and exhibits features suggestive of fluid transport function (multiple wide fenestrae and active pinocytosis). The second set of capillaries is in direct relation to the sympathetic neurons (SN) and shows characteristics suggestive of absorptive function (microvilli and pinocytotic vesicles). The larger sinusoidal capillaries are observed in the vicinity of type II CC cells, extend parallel to the long axes of the perikarya of the neurons and occasionally form loops around them. The latter are assumed to be larger blood spaces connecting the two capillary sets and serve to slow the circulation around the neurons. A pattern of portal-like intraganglionic microcirculation through which type II CC cells participate in modulating the SN is postulated. Type II CC cells secrete a catecholamine modulator which, driven by concentration gradient, gains access to the circulation through the fenestrated capillaries. The sinusoidal capillaries serve to perfuse the SN with a slow stream of blood rich in the catecholamine modulator. The latter can be filtered through the microvilli and pinocytotic vesicles of the second set of capillaries to induce slow inhibitory postsynaptic potential on the SN.

Animals↗
PubMed1989

Propranolol-induced changes in the catecholamine-containing cells and vesicles of SHR sympathetic ganglia.

The ultrastructural effects of long-term propranolol administration on the catecholamine-containing (CC) cells of cervical sympathetic ganglia were studied in spontaneously hypertensive rats. After 2 months of propranolol administration, there were hydrops of mitochondria, together with swelling and vesiculation of Golgi complex and rough endoplasmic reticulum. Such swollen organelles seemed to coalesce with each other, resulting in transformation of major parts of the cytoplasm into large membrane bound saccules. In that group of animals, the number of CC vesicles showed a significant decrease (P less than 0.025) compared to the control. Moreover, such vesicles looked more electron dense, with decreased electron-lucent haloes compared to the control. Blood pressure recording via rat tail cuff showed a significant drop (P less than 0.0001) of the mean systolic blood pressure in the treated animals. One month after stopping propranolol administration, resorption of the cytoplasmic saccules occurred, but the cytoplasm looked lighter and lost its granular appearance. The mitochondria regained their normal shape, though they appeared fewer in number. The CC vesicles were significantly reduced in number (P less than 0.001) and were less electron dense compared to the control. The possible implications of these findings on the mechanism of action of propranolol as an antihypertensive agent are discussed.

Animals↗
PubMed1989

Hypertension in the surgical patient: management of blood pressure and anesthesia.

Although hypertension has always been a high risk factor during anesthesia and surgery, risk can be reduced by preoperative control of blood pressure, evaluation of the patient to determine risk factors that can exacerbate blood pressure rises, and continuation of preoperative antihypertensive therapy. Patient hemodynamics must be monitored to manage blood pressure fluctuations and signs of ischemia as early as possible. Selection of anesthetic and adjuvant agents must be tailored to the patients, the agents must be administered carefully and in a timely fashion, and the anesthesiologist must be aware of the relevant variables. Increased knowledge of the pathophysiology of hypertension, antihypertensive therapy, and the development of new anesthetics and muscle relaxants with minimum hemodynamic effects has helped minimize complications related to perioperative hypertension.

Anesthesia↗
PubMed1987

Cardiovascular effects of non-depolarizing neuromuscular blockers in patients with aortic valve disease.

To compare haemodynamic responses associated with equipotent doses of neuromuscular blockers and high-dose fentanyl (50 micrograms.kg-1), 40 patients with aortic valve stenosis (AS) and 20 patients with aortic insufficiency (AI) were randomized to four study groups to receive the following: (1) pancuronium 0.12 mg.kg-1, (2) vecuronium 0.12 mg.kg-1, (3) atracurium 0.4 mg.kg-1, or (4) pancuronium-metocurine mixture (0.4 mg + 1.6 mg/ml): 1 ml/10 kg). Neuromuscular blockers were injected at the same time with the fentanyl; haemodynamics were recorded with the patients awake (baseline), at two minutes post-induction, and at two and five minutes after intubation. In patients with AS, pancuronium increased heart rate more than vecuronium or atracurium; heart rates were also higher with the pancuronium-metocurine mixture than with vecuronium. Although there were no ECG signs of ischaemia, one patient given pancuronium developed severe hypotension associated with tachycardia. Reductions in SVR after atracurium allowed small but significant (p less than 0.01) decreases in MAP which were well tolerated; one patient, however, did develop severe hypotension. Intubation resulted in significant (p less than 0.01) increases in MAP in the pancuronium-metocurine mixture group. Vecuronium permitted the most stable overall haemodynamic course at all measurement times. In contrast, patients with AI showed stable haemodynamics after vecuronium, pancuronium and the pancuronium-metocurine mixture; one patient became tachycardic following vecuronium. Atracurium caused unexplained elevations in diastolic and mean arterial pressures which were significant when compared to vecuronium (p less than 0.01). These results in increases in PCWP; mean PA pressures and CVP were also increased. These effects of atracurium inpatients with Al need further evaluation.

Aged↗
PubMed1987

Hemodilution affects the pressor response to norepinephrine.

A hindlimb preparation of 19 male rats was used to determine the responses to norepinephrine (NE) at different levels of hemodilution at a constant flow, at increased flow and maintained pressure, and after reversal of hemodilution. An initial series demonstrated that the preparation remained stable with unchanged blood pressure, plasma electrolytes, and blood gases; and had reproducible responses to NE throughout the experiment. Two levels of isovolumic hemodilution were achieved by blood/hetastarch exchanges equivalent to 1.5% and 3.0% body weight, which reduced hematocrit to 30.8 +/- 2% and 18.7 +/- 1.5%, respectively. Hemodilution reduced the perfusion pressure from 73.6 mmHg to 58.6 and 55.7 mmHg following 1.5% and 3.0% hemodilution, respectively. A dose-response relationship to NE (0.1, 0.3, 1.0 micrograms/kg) was obtained. The responses to NE were markedly reduced following both 1.5% and 3.0% hemodilution. Retransfusion of packed red blood cells increased the hematocrit from 21.1 +/- 2.2% during hemodilution to 41.2 +/- 2.1% (P less than .01). Concomitantly, perfusion pressure increased from 46.2 +/- 3.6 to 68.3 +/- 6.5 mmHg (P less than .001), close to prehemodilution levels (65.3 +/- 5.3 mmHg). Restoration of hematocrit levels restored responses to NE. In a third series, hemodilution was continued, but the blood flow was increased from 4.0 to 8.3 +/- 0.9 mL/min, and perfusion pressure returned to baseline values. This also restored the pressor responsiveness to NE to near normal.

Animals↗
PubMed1986

Cardiovascular effects of non-depolarizing neuromuscular blockers in patients with coronary artery disease.

To compare haemodynamic responses associated with equipotent doses of muscle relaxants and high dose fentanyl (50 micrograms X kg-1), 40 non-hypertensive patients who were receiving beta adrenergic and calcium channel blocker therapy and undergoing coronary bypass surgery were randomized to four study groups receiving the following: (1) atracurium: 0.4 mg X kg-1, (2) pancuronium: 0.12 mg X kg-1, (3) vecuronium: 0.12 mg X kg-1, or (4) pancuronium-metocurine mixture: (0.4 mg + 1.6 mg X ml-1):1 ml/10 kg. Neuromuscular blockers were injected with fetanyl at induction. Haemodynamics were recorded with the patients awake (baseline), at two minutes post-induction, and at two and five minutes after intubation. Pancuronium was the only drug associated with significant increases in HR; no other significant changes occurred within each group when compared to their respective baseline haemodynamics. HR increased more after induction with pancuronium when compared to atracurium (23 vs. 4 per cent, p less than 0.05) and to vecuronium (23 vs. 2 per cent, p less than 0.05), and when compared to vecuronium after intubation (29 vs. 7 per cent, p less than 0.05). The pancuronium-metocurine mixture caused tachycardia which was less than, though not significantly different than with pancuronium; however, HR returned to baseline by five minutes with the mixture, but remained elevated with pancuronium (3 vs. 18 per cent, p less than 0.05). SVR fell more on induction with atracurium when compared to vecuronium (-18 vs. 1 per cent, p less than 0.05). These changes in HR or SVR were not accompanied by ECG signs of ischaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia↗