The Effect of Continuous Low Dose Methylprednisolone Infusion on Inflammatory Parameters in Patients Undergoing Coronary Artery Bypass Graft Surgery: a Randomized-Controlled Clinical Trial
-
Abbas Ghiasi
,
Akbar Shafiee
,
Abbas Salehi Omran
,
Neda Ghaffari-Marandi
,
Mahmood Shirzad
,
Khosro Barkhordari
Abstract
This trial was performed to determine if a continuous low-dose infusion of methylprednisolone is as effective as its bolus of high-dose in reducing inflammatory response. The study was single-center, double-blinded randomized clinical trial and performed in a surgical intensive care unit of an academic hospital. In this study, 72 consecutive patients undergoing elective coronary artery bypass grafting (CABG) were assigned to receive either a methylprednisolone loading dose (1mg/kg) followed by continuous infusion (2mg/Kg/24 hours for 1 day) (low-dose regime) or a single dose of methylprednisolone (15 mg/kg) before cardiopulmonary bypass (high dose regime). Serum concentrations of IL-6 and C- reactive protein (CRP) were measured preoperatively and 6, 24 and 48 hours after surgery, and serum creatinine was measured before the operation and 24, 48 and 72 hours postoperatively. The measurements were then compared between the groups to evaluate the efficacy of each regimen. The basic characteristics and measurements were not different between the study groups. There was no significant difference in IL-6 and CRP elevation (P=0.52 and P=0.46, respectively). Early outcomes such as the length of stay in the intensive care unit, intubation time, changes in serum creatinine and blood glucose levels, inotropic support, insulin requirements, and rate of infection were also similar in both groups. A continuous low dose infusion of methylprednisolone was as effective as a single high dose methylprednisolone in reducing the inflammatory response after CABG with extracorporeal circulation with no significant difference in the postoperative measurements and outcomes.
Whitlock RP, Chan S, Devereaux PJ, et al. Clinical benefit of steroid use in patients undergoing cardiopulmonary bypass: a meta-analysis of randomized trials. Eur Heart J 2008;29(21):2592-600.
El Azab SR, Rosseell PMJ, de Lange JJ, et al. Dexamethasone decreases the pro- to anti-inflammatory cytokine ratio during cardiac surgery. Brit J Anaesth 2002;88(4):496-501.
Suleiman MS, Zacharowski K, Angelini GD. Inflammatory response and cardioprotection during openheart surgery: the importance of anaesthetics. Brit J Pharmacol 2008;153(1):21-33.
Warren OJ, Smith AJ, Alexiou C, et al. The Inflammatory Response to Cardiopulmonary Bypass: Part 1-Mechanisms of Pathogenesis. J Cardiothor Vasc An 2009;23(2):223-31.
Hedman A, Larsson PT, Alam M, et al. CRP, IL-6 and endothelin-1 levels in patients undergoing coronary artery bypass grafting. Do preoperative inflammatory parameters predict early graft occlusion and late cardiovascular events? Int J Cardiol 2007;120(1):108-14.
Mitchell JD, Grocott HP, Phillips-Bute B, et al. Cytokine secretion after cardiac surgery and its relationship to postoperative fever. Cytokine 2007;38(1):37-42.
Barkhordari K, Karimi A, Shafiee A, et al. Effect of pentoxifylline on preventing acute kidney injury after cardiac surgery by measuring urinary neutrophil gelatinase - associated lipocalin. J Cardiothorac Surg 2011;6(1):8.
Fitch JCK, Rollins S, Matis L, et al. Pharmacology and biological efficacy of a recombinant, humanized, singlechain antibody C5 complement inhibitor in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass. Circulation 1999;100(25):2499-506.
Welters ID, Feurer MK, Preiss V, et al. Continuous S-(+)- ketamine administration during elective coronary arterybypass graft surgery attenuates pro-inflammatory cytokine response during and after cardiopulmonary bypass. Br J Anaesth. 2011;106(2):172-9.
Chaney MA. Corticosteroids and cardiopulmonary bypass: a review of clinical investigations. Chest 2002;121(3):921-31.
Ho KM, Tan JA. Benefits and risks of corticosteroid prophylaxis in adult cardiac surgery: a dose-response meta-analysis. Circulation 2009;119(14):1853-66.
McBride WT, Allen S, Gormley SMC, et al. Methylprednisolone favourably alters plasma and urinary cytokine homeostasis and subclinical renal injury at cardiac surgery. Cytokine 2004;27(2-3):81-9.
Meduri GU, Golden E, Freire AX, et al. Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial. Chest 2007;131(4):954-63.
Mirhosseini SJ, Forouzannia SK, Sayegh AH, et al. Effect of prophylactic low dose of methylprednisolone on postoperative new atrial fibrillation and early complications in patients with severe LV dysfunction undergoing elective off-pump coronary artery bypass surgery. Acta Med Iran 2011;49(5):288-92.
Whitlock RP, Rubens FD, Young E, et al. Pro: Steroids should be used for cardiopulmonary bypass. J Cardiothor Vasc An 2005;19(2):250-4.
Cappabianca G, Rotunno C, de Luca Tupputi Schinosa L, et al. Protective effects of steroids in cardiac surgery: A meta-analysis of randomized, double-blind trials. J Cardiothor Vasc Anesth 2011;25(1):156-65.
Dieleman JM, van Paassen J, van Dijk D, et al. Prophylactic corticosteroids for cardiopulmonary bypass in adults. Cochrane Database Syst Rev 2011;5:CD005566.
Augoustides JGT. The Inflammatory Response to Cardiac Surgery With Cardiopulmonary Bypass: Should Steroid Prophylaxis Be Routine? J Cardiothor Vasc Anesth 2012;26(5):952-8.
Zeni F, Freeman B, Natanson C. Anti-inflammatory therapies to treat sepsis and septic shock: a reassessment. CritCare Med 1997;25(7):1095-100.
Coetzer M, Coetzee A, Rossouw G. The effect of methylprednisolone, given prior to cardiopulmonary bypass, on indices of gas exchange. S Afr Med J 1996;86:C188-C92.
Kilger E, Weis F, Briegel J, et al. Stress doses of hydrocortisone reduce severe systemic inflammatory response syndrome and improve early outcome in a risk group of patients after cardiac surgery. Crit Care Med 2003;31(4):1068-74.
Liakopoulos OJ, Schmitto JD, Kazmaier S, et al. Cardiopulmonary and systemic effects of methylprednisolone in patients undergoing cardiac surgery. Ann Thorac Surg 2007;84(1):110-9.
Murphy GS, Sherwani SS, Szokol JW, et al. Small-dose dexamethasone improves quality of recovery scores after elective cardiac surgery: a randomized, double-blind, placebo-controlled study. J Cardiothor Vasc Anesth 2011;25(6):950-60.
Gould MK, Ruoss SJ, Rizk NW, et al. Indices of hypoxemia in patients with acute respiratory distress syndrome: reliability, validity, and clinical usefulness. Crit Care Med 1997;25(1):6-8.
Weiss YG, Merin G, Koganov E, et al. Postcardiopulmonary bypass hypoxemia: a prospective study on incidence, risk factors, and clinical significance. J Cardiothor Vasc Anesth 2000;14(5):506-13.
Taggart DP, El-Fiky M, Carter R, et al. Respiratory dysfunction after uncomplicated cardiopulmonary bypass. Ann Thorac Surg 1993;56(5):1123-8.
Karbing DS, Kjærgaard S, Smith BW, et al. Variation in the PaO2/FiO2 ratio with FiO2: mathematical and experimental description, and clinical relevance. Crit Care 2007;11(6):R118.
Bourbon A, Vionnet M, Leprince P, et al. The effect of methylprednisolone treatment on the cardiopulmonary bypass-induced systemic inflammatory response. Eur J Cardiothorac Surg 2004;26(5):932-8.
Whitlock R, Young E, Noora J, et al. Pulse low dose steroids attenuate post-cardiopulmonary bypass SIRS; SIRS I. J Surg Res 2006;132(2):188-94.
Meduri GU, Marik PE, Chrousos GP, et al. Steroid treatment in ARDS: a critical appraisal of the ARDS network trial and the recent literature. Intensiv Care Med 2008;34(1):61-9.
Seam N, Meduri GU, Wang H, et al. Effects of methylprednisolone infusion on markers of inflammation, coagulation, and angiogenesis in early acute respiratory distress syndrome. Crit Care Med 2012;40(2):495-501.
de Mendonça-Filho H, Pereira KC, Fontes M, Vet al. Circulating inflammatory mediators and organ dysfunction after cardiovascular surgery with cardiopulmonary bypass: a prospective observational study. Crit Care 2006;10(2):R46.
Ashraf S, Tian Y, Zacharrias S, et al. Effects of cardiopulmonary bypass on neonatal and paediatric inflammatory profiles. Eur J Cardiothorac Surg 1997;12(6):862-8.
Morariu AM, Loef BG, Aarts LPHJ, et al. Dexamethasone: Benefit and Prejudice for Patients Undergoing On-Pump Coronary Artery Bypass Grafting. Chest 2005;128(4):2677-87.
| Files | ||
| Issue | Vol 53, No 2 (2015) | |
| Section | Articles | |
| Keywords | ||
| Coronary artery bypasses grafting Cytokines Methylprednisolone Post-operative | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
