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Ștef A, Bodolea C, Bocșan IC, Vesa ȘC, Pop RM, Cainap SS, Achim A, Antal O, Tintiuc N, Buzoianu AD. Investigating Potential Correlations between Calcium Metabolism Biomarkers and Periprocedural Clinical Events in Major Cardiovascular Surgeries: An Exploratory Study. J Clin Med 2024; 13:2242. [PMID: 38673516 PMCID: PMC11051212 DOI: 10.3390/jcm13082242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Background: There is emerging but conflicting evidence regarding the association between calcium biomarkers, more specifically ionized calcium and the prognosis of intensive care unit (ICU) postoperative cardiac patients. Methods: Our study investigated the relationship between ionized calcium, vitamin D, and periprocedural clinical events such as cardiac, neurologic and renal complications, major bleeding, vasoactive-inotropic score (VIS), and length of ICU and hospitalization. Results: Our study included 83 consecutive subjects undergoing elective major cardiac surgery requiring cardiopulmonary bypass. The mean age of the participants was 64.9 ± 8.5 years. The majority of procedures comprised isolated CABG (N = 26, 31.3%), aortic valve procedures (N = 26, 31.3%), and mitral valve procedures (N = 12, 14.5%). A difference in calcium levels across all time points (p < 0.001) was observed, with preoperative calcium being directly associated with intraoperative VIS (r = 0.26, p = 0.016). On day 1, calcium levels were inversely associated with the duration of mechanical ventilation (r = -0.30, p = 0.007) and the length of hospital stay (r = -0.22, p = 0.049). At discharge, calcium was inversely associated with length of hospital stay (r = -0.22, p = 0.044). All calcium levels tended to be lower in those who died during the 1-year follow-up (p = 0.054). Preoperative vitamin D levels were significantly higher in those who experienced AKI during hospitalization (median 17.5, IQR 14.5-17.7, versus median 15.3, IQR 15.6-20.5, p = 0.048) Conclusion: Fluctuations in calcium levels and vitamin D may be associated with the clinical course of patients undergoing cardiac surgery. In our study, hypocalcemic patients exhibited a greater severity of illness, as evidenced by elevated VIS scores, and experienced prolonged mechanical ventilation time and hospital stays. Additional larger-scale studies are required to gain a deeper understanding of their impact on cardiac performance and the process of weaning from cardiopulmonary bypass, as well as to distinguish between causal and associative relationships.
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Affiliation(s)
- Adrian Ștef
- Clinical Department of Anesthesia and Intensive Care, Heart Institute “Niculae Stancioiu”, “Iuliu Hatieganu” University of Medicine and Pharmacy, Motilor 19-21, 400001 Cluj-Napoca, Romania
- Anesthesia and Intensive Care 2 Discipline, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania
- Cardiology Department, Heart Institute “Niculae Stancioiu”, “Iuliu Hatieganu” University of Medicine and Pharmacy, Motilor 19-21, 400001 Cluj-Napoca, Romania
| | - Constantin Bodolea
- Anesthesia and Intensive Care 2 Discipline, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania
| | - Ioana Corina Bocșan
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania; (I.C.B.); (R.M.P.)
| | - Ștefan Cristian Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania; (I.C.B.); (R.M.P.)
| | - Raluca Maria Pop
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania; (I.C.B.); (R.M.P.)
| | - Simona Sorana Cainap
- Department of Mother and Child, 2nd Pediatric Discipline, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania
| | - Alexandru Achim
- Cardiology Department, Heart Institute “Niculae Stancioiu”, “Iuliu Hatieganu” University of Medicine and Pharmacy, Motilor 19-21, 400001 Cluj-Napoca, Romania
| | - Oana Antal
- Anesthesia and Intensive Care 2 Discipline, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania
| | - Nadina Tintiuc
- Clinical Department of Anesthesia and Intensive Care, Heart Institute “Niculae Stancioiu”, “Iuliu Hatieganu” University of Medicine and Pharmacy, Motilor 19-21, 400001 Cluj-Napoca, Romania
| | - Anca Dana Buzoianu
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Victor Babes Nr 8 Street, 400012 Cluj-Napoca, Romania; (I.C.B.); (R.M.P.)
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Lomivorotov VV, Leonova EA, Belletti A, Shmyrev VA, Landoni G. Calcium Administration During Weaning From Cardiopulmonary Bypass: A Narrative Literature Review. J Cardiothorac Vasc Anesth 2019; 34:235-244. [PMID: 31350149 DOI: 10.1053/j.jvca.2019.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/07/2019] [Accepted: 06/10/2019] [Indexed: 02/08/2023]
Abstract
The search for safe and effective patient management strategies during weaning from cardiopulmonary bypass is ongoing; intravenous calcium is occasionally used as a first-line drug. The physiologic role of calcium suggests that it can support the function of the cardiovascular system during this critical period. Patients may be mildly hypocalcemic after cardiopulmonary bypass; however, this degree of hypocalcemia does not significantly impair the cardiovascular system. The transient beneficial effects of calcium administration (increase in arterial blood pressure, systemic vascular resistance, cardiac index, stroke volume, and coronary perfusion pressure) might be helpful in cases of moderate contractility reduction or vasoplegia. Nonetheless, effects on clinically relevant endpoints are unknown, and possible systemic side effects, such as transient reduction in internal mammary artery graft flow, attenuation of the effects of β-sympathomimetics, "stone heart" phenomenon, and pancreatic cellular injury, may limit the use of calcium salts. Further studies are needed to expand the understanding of the effects of calcium administration on patient outcomes.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - Elizaveta A Leonova
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vladimir A Shmyrev
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Abstract
Because of improved social and medical standards in the western world, the average age of the population continues to increase. This altering demographic profile has its impact on the surgical population, resulting in a dramatic increase in the number of patients with exten sive cardiovascular disease, presenting for either car diac or noncardiac surgery. As a result, the incidence of perioperative acute congestive heart failure (CHF) is a major clinical problem at the present time. For the pharmacologic management of acute CHF, the β-adreno ceptor agonists continue to be the mainstay of therapy, due to their short duration of action and hemodynamic controlability by continuous intravenous infusion. Mono therapy with the phosphodiesterase type III (PDE) inhibi tors appears to be the treatment of choice in selected patients with high systemic vascular resistance or re sidual β-adrenoceptor blockade. Combination therapy especially deserves attention, because this approach allows the enhancement of contractile force, possibly without the side effects associated with the administra tion of high concentrations of one agent alone. New developments including ultrashort-acting PDE inhibi tors, calcium-dependent calcium sensitizers, and cal cium promotors are anxiously awaited.
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Affiliation(s)
- Margreeth B. Vroom
- Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
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DiVincenti L, Westcott R, Lee C. Sheep (Ovis aries) as a model for cardiovascular surgery and management before, during, and after cardiopulmonary bypass. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE 2015; 35:131-2. [PMID: 25255065 DOI: 10.1002/clc.21952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 11/22/2011] [Indexed: 12/20/2022]
Abstract
Because of its similarity to humans in important respects, sheep (Ovis aries) are a common animal model for translational research in cardiovascular surgery. However, some unique aspects of sheep anatomy and physiology present challenges to its use in these complicated experiments. In this review, we discuss relevant anatomy and physiology of sheep and discuss management before, during, and after procedures requiring cardiopulmonary bypass to provide a concise source of information for veterinarians, technicians, and researchers developing and implementing protocols with this model.
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Affiliation(s)
- Louis DiVincenti
- Department of Comparative Medicine, University of Rochester Medical Center, Rochester, New York, USA.
| | - Robin Westcott
- Division of Laboratory Animal Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Candice Lee
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Influence of chromosome 22q11.2 microdeletion on postoperative calcium level after cardiac-correction surgery. Pediatr Cardiol 2011; 32:904-9. [PMID: 21678063 DOI: 10.1007/s00246-011-0012-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 05/28/2011] [Indexed: 10/18/2022]
Abstract
One of the most common constitutional chromosomal abnormalities, 22q11.2 microdeletion (del22q11.2) syndrome has diverse medical complications, such as congenital heart defect, hypocalcaemia, and immune deficiency, which require coordinated multidisciplinary care. Until now, the natural history of hypocalcaemia in chromosome del22q11.2 syndrome had been only partly documented, but there has been limited recognition of the importance of calcium status during the postoperative period when altered calcium status may be associated with serious complications. The goals of our study were (1) to delineate the clinical characteristics of serum calcium in patients with del22q11.2 during the postoperative period and (2) to make recommendations for the investigation and management of del22q11.2 patients after cardiac correction. This study included 22 children diagnosed with del22q11.2 syndrome and 110 children without del22q11.2 syndrome from Nanjing Children's Hospital. Clinical examinations and blood ionized calcium testing were reviewed retrospectively. A comparative study of postoperative calcium levels and complications of del22q11.2 patients with nondeletion patients was performed. Association between postoperative hypocalcaemia and adverse incidents after cardiac correction was also examined. Postoperative hypocalcaemia was observed among 86.4% of del22q11.2 patients and among only 47.3% of nondeletion subjects. The difference was statistically significant (P = 0.0017). Patients with del22q11.2 syndrome also had a much sharper decrease in serum calcium levels during the first 6 h after surgery than nondeletion patients. Postoperative clinical analysis showed that del22q11.2 patients with hypocalcaemia experience more postoperative complications (18 of 19) and greater mortality (5 of 19) after cardiac correction than del22q11.2 patients without normal calcium levels and nondeletion patients. Del22q11.2 children have high susceptibility of hypocalcaemia during the postoperative period, and this low calcium status after cardiac correction may be associated with significant risk of postoperative complications and mortality in patients with del22q11.2.
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Ashraf A, Mick G, Atchison J, Petrey B, Abdullatif H, McCormick K. Prevalence of hypovitaminosis D in early infantile hypocalcemia. J Pediatr Endocrinol Metab 2006; 19:1025-31. [PMID: 16995588 DOI: 10.1515/jpem.2006.19.8.1025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To further define the pathogenesis of infantile hypocalcemia, the prevailing vitamin D status, and treatment outcomes. METHODS AND RESULTS Of the 23 infants admitted with infantile hypocalcemia, 21 had biochemical evidence of hypocalcemia and hyperphosphatemia and the other two had isolated hypocalcemia. The majority of these infants had relatively low serum intact parathyroid hormone responses against the backdrop of hypocalcemia. Thirteen (56.5%) of these infants had low 25-hydroxyvitamin D (25-OHD) levels, of whom 69% were Hispanic and 23% were African American. Infantile serum vitamin D status reflected that of the mother in all the 16 instances in which it was measured. Treatment with calcitriol hastened recovery from hypocalcemia in our series. CONCLUSIONS Relative hypoparathyroidism is the etiology in the majority of cases of late onset and early infantile hypocalcemia. We identified vitamin D deficiency in a significant percentage of infants with hypocalcemia, especially Hispanics and African Americans. Maternal 25-OHD concentrations should be ascertained if the infant has low 25-OHD levels.
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Affiliation(s)
- Ambika Ashraf
- Department of Pediatrics/Division of Pediatric Endocrinology and Metabolism, The Children's Hospital, University ofAlabama at Birmingham, 35233, USA.
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Carlstedt F, Lind L, Joachimsson PO, Rastad J, Wide L, Ljunghall S. Circulating ionized calcium and parathyroid hormone levels following coronary artery by-pass surgery. Scand J Clin Lab Invest 1999; 59:47-53. [PMID: 10206097 DOI: 10.1080/00365519950185995] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
In critically ill patients, hypocalcaemia is a common finding. Also variable derangements in the normally tight Ca2+-mediated control of the parathyroid hormone (PTH) secretion have been found. Utilizing coronary artery by-pass grafting (CABG) as a standardized model of severe trauma, 18 patients underwent determinations of blood levels of calcium, magnesium (Mg), ionized calcium (Ca2+), serum levels of intact PTH, procalcitonin (PCT) and the proinflammatory cytokines tumour necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6). Samples were collected before, directly after, the morning after and 5 days after surgery. A significant, but minor, decrease in blood Ca2+ levels (mean 0.04 mmol/L, p<0.05) was seen shortly after CABG, not accompanied by any significant change of serum PTH levels. This alteration of the Ca2+ control of the steady-state PTH levels contrasted with the maintenance of the PTH secretory response to a sequential citrate and calcium infusion (CiCa clamp), which was normal in two patients evaluated in the morning following surgery. Serum Mg levels were transiently increased after operation (+0.25 mmol/L, p<0.001) and correlated to the TNF-alpha (r=0.62, p <0.01) and PCT (r=0.67, p < 0.006) levels in the morning after surgery. Serum levels of IL-6 and TNF-alpha were significantly (p < 0.0001) increased immediately after surgery, while the peak in serum PCT levels (p < 0.001) occurred in the morning after CABG. Serum PTH levels correlated positively with IL-6 (r=0.68, p<0.008) 5 days after surgery. In conclusion, CABG caused a decrease in ionized calcium levels without a rise in steady-state PTH levels, but rapid changes in Ca2+ during CiCa clamping revealed a normal PTH secretory response. These findings might relate to elevated serum Mg levels, while a direct action of TNF-alpha or IL-6 on the PTH release seem less possible.
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Affiliation(s)
- F Carlstedt
- Department of Internal Medicine, University Hospital of Uppsala, Sweden
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Prielipp R, Butterworth J. Con: calcium is not routinely indicated during separation from cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1997; 11:908-12. [PMID: 9412897 DOI: 10.1016/s1053-0770(97)90133-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Severe hypocalcemia is uncommon in adult cardiac surgery patients; the nearly ubiquitous mild hypocalcemia does not impair myocardial performance. Clinicians should recognize that in certain circumstances, calcium may interact negatively with catecholamines such as epinephrine or dobutamine. Lastly, evidence suggests that calcium influx during ischemia-reperfusion contributes to myocardial dysfunction after CPB. Therefore, there appears to be no justification for the practice of routinely administering large doses of calcium salts to adult cardiac surgery patients after CPB.
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Affiliation(s)
- R Prielipp
- Department of Anesthesiology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC 27157-1009, USA
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Affiliation(s)
- J A DiNardo
- Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, USA
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Nielsen PK, Rasmussen AK, Butters R, Feldt-Rasmussen U, Bendtzen K, Diaz R, Brown EM, Olgaard K. Inhibition of PTH secretion by interleukin-1 beta in bovine parathyroid glands in vitro is associated with an up-regulation of the calcium-sensing receptor mRNA. Biochem Biophys Res Commun 1997; 238:880-5. [PMID: 9325185 DOI: 10.1006/bbrc.1997.7207] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The principal regulator of parathyroid hormone (PTH) secretion is ionized calcium, but other factors are also known to modulate PTH secretion, such as vitamin D, estrogen, and recently inorganic phosphate. Interleukin-1 (IL-1) possesses a wide variety of biological activities and is produced by leukocytes as well as by various other cells including cells from endocrine tissues and might play a role as a paracrine factor in the control of PTH secretion. We investigated the effect in vitro of IL-1 beta on PTH release, PTHmRNA and the mRNA for the extracellular calcium-sensing receptor (CaR) levels in preparations of bovine parathyroid cells. PTH secretion from cultured parathyroid tissue slices was significantly inhibited in a medium containing IL-1 beta at a concentration of 2000 pg/ml (PTH in % of control: 63.5 +/- 5.3), n=10 (p<0.01). The inhibitory effect of IL-1 beta was not found in preparations of dispersed cells. The inhibitory effect of IL-1 beta could be counteracted by the IL-1 receptor antagonist (IL-1ra), indicating that the inhibitory effect was mediated through the specific IL-1 receptor on the parathyroid cells. IL-1 beta (2000 pg/ml) up-regulated CaRmRNA levels to 180% of control, whereas no change in PTHmRNA was found. IL-1ra abolished the upregulating effect of IL-1 beta on the CaRmRNA. This study demonstrates a direct effect in vitro of IL-1 beta on PTH secretion from bovine parathyroid glands, an effect which may be mediated at least in part through the specific IL-1 receptor causing an upregulation of the calcium-sensing receptor mRNA. IL-1 might therefore play a role as a auto- and/or paracrine factor in the regulation of the PTH secretion.
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Affiliation(s)
- P K Nielsen
- Department of Nephrology and Endocrinology, Rigshospitalet, University of Copenhagen, Denmark
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Koch SM, Mehlhorn U, Baggstrom E, Donovan D, Allen SJ. Hypercalcitoninemia and inappropriate calciuria in the acute trauma patient. J Crit Care 1996; 11:117-21. [PMID: 8891962 DOI: 10.1016/s0883-9441(96)90007-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE This study was undertaken to determine the role of calcium-regulatory hormones (calcitonin [CT], parathyroid hormone [PTH], and vitamin D analogs) during the first 48 hours after acute trauma. METHODS Eleven acutely traumatized patients admitted to the shock-trauma intensive care unit (STICU) in a tertiary care teaching hospital were enrolled. Eleven same-day elective surgery patients served as the control group. Levels of ionized calcium (Ca2+), total calcium, magnesium, phosphate, CT, PTH, vitamin D analogs, electrolyte supplementation, and renal electrolyte loss were recorded during the first 48 hours after admission to the STICU. Control-group measurements consisted of Ca2+ and CT. RESULTS At admission, 91% of the patients had ionized hypocalcemia (1.04 +/- 0.10 mmol/L). Ca2+ levels increased significantly over time (1.13 +/- 0.08 at 24 hours; 1.16 +/- 0.07 at 48 hours) but remained below the control-group value (1.28 +/- 0.05; P < .05) despite supplementation. Ninety-one percent of the patients had increased CT values at admission, 91% at 24 hours, and 78% at 48 hours. Median CT values in the trauma patients were higher throughout the study than in the control group (P < .05). Urinary calcium loss in the trauma patients was within the normal range. PTH and vitamin D analog values were within the normal range throughout the study. Multiple regression analysis did not show any significant correlation between electrolytes and hormone or protein concentrations. CONCLUSIONS Acute trauma patients have ionized hypocalcemia associated with inappropriate urinary calcium loss, increased CT levels, and normal PTH and vitamin D analog values. We believe the degree of calciuria we observed was inappropriate in the context of ionized hypocalcemia. The cause of these increased CT levels is unclear. Our results suggest that Ca(2+)-regulatory mechanisms may be disrupted in the acute trauma patient.
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Affiliation(s)
- S M Koch
- Department of Anesthesiology, University of Texas Medical School, Houston, USA
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Ragosta KG, Bergstrom WH, Briggs DG, Brandt B. Protamine and acute depletion of magnesium limit bone response to parathyroid hormone. Anesth Analg 1996; 82:29-32. [PMID: 8712421 DOI: 10.1097/00000539-199601000-00006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The effect of protamine on calcium homeostasis was studied in nine pediatric patients undergoing cardiopulmonary bypass. Total serum calcium decreased from 8.44 mg/dL to 7.49 mg/dL (P < 0.05) after protamine. Ionized calcium decreased from 1.39 to 1.31 mmol/L (P < 0.05). A bioassay determined the etiology of this response. Bone disks were placed in sera, protamine, parathyroid hormone, parathyroid hormone antibody, or magnesium-depleted solutions, then were incubated in solutions with known calcium content. The change in the media's calcium concentration reflects the bone's response to the initial stimulus. Calcium change is expressed as Experimental delta/Control delta (E/C). Normal bone responds to parathyroid hormone, E/C = 0.59 (P < 0.001). Protamine-treated bone loses this response, E/C = 0.9 (P = not significant [NS]). A parathyroid-hormone-induced osteoblast messenger was found. Protamine-treated bone continued to respond to this messenger, E/C = 0.42 (P < 0.001). Bone showed reversible loss of response to parathyroid hormone after incubation in magnesium-free solution, E/C = 0.93 (P = NS). With reincubation in magnesium, E/C = 0.69 (P < 0.01). Since protamine blocks parathyroid receptors, and magnesium depletion limits the bone's response to parathyroid hormone, this may explain the persistent hypocalcemia seen in some patients undergoing cardiopulmonary bypass.
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Affiliation(s)
- K G Ragosta
- Department of Pediatrics, State University of New York, Syracuse 13210, USA
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Ragosta KG, Bergstrom WH, Briggs DG, Brandt B. Protamine and Acute Depletion of Magnesium Limit Bone Response to Parathyroid Hormone. Anesth Analg 1996. [DOI: 10.1213/00000539-199601000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Smeulers NJ, Wierda JM, van den Broek L, Gallandat Huet RC, Hennis PJ. Effects of hypothermic cardiopulmonary bypass on the pharmacodynamics and pharmacokinetics of rocuronium. J Cardiothorac Vasc Anesth 1995; 9:700-5. [PMID: 8664462 DOI: 10.1016/s1053-0770(05)80232-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To study the influence of hypothermic cardiopulmonary bypass (CPB) on the pharmacodynamics and pharmacokinetics of rocuronium. DESIGN Prospective, descriptive study. SETTING Operating room at a university hospital. PARTICIPANTS Ten ASA class III and IV patients, ranging in age from 35 to 75 years, scheduled for elective coronary artery bypass grafting. INTERVENTIONS Neuromuscular transmission was monitored mechanomyographically. The time course of action of maintenance doses and plasma concentration-response relationships were determined before, during, and after CPB. The plasma concentration decay and renal elimination were studied simultaneously. Plasma and urine concentration of rocuronium were determined by high-performance liquid chromatography. MEASUREMENTS AND MAIN RESULTS Hypothermic CPB prolonged the duration of action of maintenance doses and coincided with a lower plasma concentration at a twitch response of 5% of control. The duration of action of maintenance doses returned to prehypothermic CPB level after rewarming to a nasopharyngeal temperature of 37 degrees C. The plasma concentration-response relationship did not return to precooling control value, probably owing to persisting peripheral hypothermia. Both the renal elimination of rocuronium and the plasma concentration decay after the last maintenance dose under normothermic conditions resembled values obtained in patients not undergoing hypothermic CPB. CONCLUSIONS Hypothermic CPB prolongs the duration of action of maintenance doses and alters the plasma concentration-response relationship of rocuronium. These changes may be the result of, on the one hand, an increased sensitivity of the neuromuscular transmission and/or decreased muscle contractility and, on the other hand, the result of a reduced plasma clearance during hypothermia.
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Affiliation(s)
- N J Smeulers
- Research Group for Experimental Anesthesiology and Clinical Pharmacology, University Hospital, Groningen, Netherlands
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Jankowski S, Vincent JL. Calcium administration for cardiovascular support in critically ill patients: when is it indicated? J Intensive Care Med 1995; 10:91-100. [PMID: 10172421 DOI: 10.1177/088506669501000205] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Calcium has a fundamental role in the maintenance of myocardial function and vascular tone. The ionized form of calcium is the most important physiologically, and this form needs to be measured to assess physiologically active calcium levels. Ionized hypocalcemia can occur as a result of various pathophysiological disturbances, and it is seen frequently in critically ill patients. Several investigators have observed a poorer prognosis in those patients with ionized hypocalcemia. It is unclear whether calcium supplementation is beneficial in these patients. It may improve cardiovascular performance, but, in contrast, it may contribute to cellular damage (especially during hypoxia following cardiopulmonary resuscitation). In sepsis, there may be an increased cellular influx of calcium, which may be deleterious to cellular function; indeed, calcium entry blockers in this situation may be protective. We review the role of calcium as an inotropic agent, its interaction with other inotropic agents, and its use during blood transfusion and during cardiopulmonary resuscitation.
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Affiliation(s)
- S Jankowski
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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Abstract
Although a wide variety of positive inotropic agents have been administered to cardiac surgery patients, few of them have been carefully studied in controlled clinical trials, in surgical patient populations. The limited data available suggest that one of the more widely used agents, calcium, may lack efficacy and possibly inhibit the actions of catecholamines. Dopamine, dobutamine, and dopexamine are highly effective agents, but more prone to produce tachycardia than epinephrine. Amrinone is an effective agent by itself, but is especially useful in combination with a beta-adrenergic agonist for patients with severe left-ventricular dysfunction.
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Affiliation(s)
- J Butterworth
- Department of Anesthesia, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC 27157-1009
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Johnston WE, Robertie PG, Butterworth JF, Royster RL, Kon ND. Is calcium or ephedrine superior to placebo for emergence from cardiopulmonary bypass? J Cardiothorac Vasc Anesth 1992; 6:528-34. [PMID: 1421063 DOI: 10.1016/1053-0770(92)90094-n] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To determine whether ephedrine or CaCl2 improves hemodynamics in cardiac surgery patients emerging from cardiopulmonary bypass, three sequential doses of either CaCl2 (200 mg/dose; n = 12), ephedrine (5 mg/dose; n = 12), or placebo (n = 12) were administered in a prospective, randomized, double-blind fashion. Thermodilution volumetric catheters were used to calculate right ventricular (RV) volumes and ejection fraction. The first dose of ephedrine improved RV stroke volume from 57 +/- 3 to 63 +/- 4 mL/beat (P < 0.05) and ejection fraction from 44 +/- 2% to 49 +/- 2% (P < 0.05). Subsequent doses maintained this improvement but without further change. In contrast, placebo and CaCl2 had minimal effects on RV end-systolic volume, stroke volume, and ejection fraction. After the third injection of ephedrine, mean arterial pressure had significantly increased from 78 +/- 2 to 93 +/- 4 mmHg (P < 0.05) in contrast to insignificant increments with placebo and CaCl2. Serum ionized calcium increased by 6% to 8% after each CaCl2 bolus but remained stable in the ephedrine and placebo groups. CaCl2 failed to improve RV performance in mildly hypocalcemic patients during separation from cardiopulmonary bypass. In patients with normal preoperative ventricular function, ephedrine more effectively improved RV performance and arterial blood pressure than placebo or CaCl2, and is a suitable short-acting drug to assist separation from cardiopulmonary bypass.
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Affiliation(s)
- W E Johnston
- Department of Anesthesia, Wake Forest University Medical Center, Winston-Salem, NC 27157-1009
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Robertie PG, Butterworth JF, Prielipp RC, Tucker WY, Zaloga GP. Parathyroid hormone responses to marked hypocalcemia in infants and young children undergoing repair of congenital heart disease. J Am Coll Cardiol 1992; 20:672-7. [PMID: 1512348 DOI: 10.1016/0735-1097(92)90023-g] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The integrity of the parathyroid axis was tested in 18 infants and young children undergoing repair of congenital heart disease with cardiopulmonary bypass. BACKGROUND Infants are believed to have an immature parathyroid hormone response to hypocalcemia. Whereas adults are known to respond appropriately to hypocalcemia during cardiopulmonary bypass, children have not been studied carefully. METHODS Calcium, magnesium, parathyroid hormone, phosphate and total protein were measured in blood samples withdrawn at defined times before, during and after cardiopulmonary bypass. RESULTS At the initiation of cardiopulmonary bypass, ionized calcium decreased markedly in 12 infants less than or equal to 24 months old (mean +/- SEM 1.11 +/- 0.04 to 0.29 +/- 0.05 mM) and decreased significantly in 6 young children greater than 24 months old (1.19 +/- 0.02 to 0.42 +/- 0.12 mM). In response to hypocalcemia, parathyroid hormone concentration increased significantly in both the infants (from 42 +/- 8 to 103 +/- 29 and 85 +/- 22 pg/ml) and the young children (from 39 +/- 8 to 44 +/- 20 and 92 +/- 30 pg/ml). Before separation from cardiopulmonary bypass, increased parathyroid hormone concentration restored ionized calcium concentration to 0.75 +/- 0.03 mM in the infants and to 0.92 +/- 0.07 mM in the young children. There was no significant influence of either age or the use of deep hypothermia and circulatory arrest on either calcium or parathyroid hormone responses. Total magnesium and total protein concentrations decreased on initiation of cardiopulmonary bypass and thereafter remained stable. Phosphate concentrations were unchanged during the study. CONCLUSIONS In infants and young children undergoing cardiac surgery, the parathyroid hormone response to both hypocalcemia and to rising ionized calcium concentrations was at least as great as that of adults. Thus, the calcium-parathyroid-vitamin D axis functions in infants and young children as it does in adults.
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Affiliation(s)
- P G Robertie
- Department of Anesthesia, Wake Forest University Medical Center, Winston-Salem, North Carolina 27157-1009
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