In the April 2008 BJA ...
Glycaemic Clamping The use of high dose insulin infusion in the perioperative period in patients undergoing cardiac surgery has come to be used widely, but by no means universally, as part of the prevention of reperfusion injury. The practice of ‘clamping’ blood glucose concentrations at a normoglycaemic level with high dose insulin to prevent the stress response changes has also found some favour in Acute Coronary Syndrome patients and in cardiac failure. However, insulin has other systemic effects in addition to its hypoglycaemic action. This is explored in this month's BJA in a study (Zuurbier et al, pages 442–450) which has identified marked hypolipidaemic effects when this technique is used in coronary artery surgery patients. The consequences and possible detrimental effects of this are further explored in an accompanying editorial (Evans and Nui, pages 429–433). On a related subject, the potential beneficial effects of normoglycaemia are noted in a study (Huhn et al, pages 465–471) using an animal model of sevoflurane preconditioning, in which hyperglycaemia abolished the reduction in infarct size resulting from preconditioning.Vasopressors and septic shock The use of noradrenaline infusion is one of the mainstays of treatment in patients with septic shock, but noradrenaline requirements often increase with time and, recently, the use of pressor agents, such as vasopressin or terlipressin, has been advocated at this stage. However, the pressors can produce a marked fall in cardiac index and a resultant decrease in oxygen delivery. To counteract these deleterious effects, a study (Morelli et al, pages 494–503) has explored the simultaneous use of the predominantly β1 sympathetic stimulant, dobutamine, with terlipressin. They found that dobutamine did reverse the depressive effects of terlipressin but that high doses were required.
Cardiac output measurement in children The use of the thermodilution method with a pulmonary artery catheter (PAC) to measure cardiac output is well established but is not without risk. In children, particularly those with congenital cardiac disease, the use of a PAC may not be possible and a reliable non-invasive alternative is desirable. The use of electrical conductivity to give a measure of bioimpedance which can be converted to ‘electrical velocimetry’ has been evaluated in adults and found to relate well to thermodilution and Doppler measurements. A study in this issue (Tomaske et al, pages 517–520) has evaluated this technology in a group of children during cardiac catheterization and found it less reliable.
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