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  • 1.
    Bahlmann, Hans
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Hahn, Robert
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Södertälje Hosp, Sweden.
    Nilsson, Lena
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Pleth variability index or stroke volume optimization during open abdominal surgery: a randomized controlled trial2018In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 18, article id 115Article in journal (Refereed)
    Abstract [en]

    Background: The impact of Goal Directed Fluid Therapy (GDFT) based on the non-invasive Pleth Variability Index (PVI) on clinical outcome after abdominal surgery has only sparingly been explored. The purpose of this study was to compare the effect of intraoperative GDFT guided by PVI to a control group using esophageal Doppler on the incidence of complications and length of hospital stay after major abdominal surgery. We hypothesized that there would be no difference between the groups. Methods: This was a randomized controlled trial in a Swedish university hospital between November 2011 and January 2015; 150 patients scheduled for open abdominal surgery lasting 2 h or more were included. Exclusion criteria included hepatic resection or severe cardiac arrhythmia. The patients were randomized 1: 1 to either the intervention group or the control group. The intervention group received intraoperative GDFT by administering fluid boluses of 3 ml/kg tetrastarch aiming at a PVI value below 10%, while GDFT in the control group aimed for optimization of stroke volume as assessed with esophageal Doppler. Blinded observers assessed complications until postoperative day 30 using pre-defined definitions, as well as length of hospital stay. Results: One hundred and-fifty patients were randomized and 146 patients were available for the final data analysis. Median duration of surgery was 3 h. A total of 64 complications occurred in the PVI group (N = 74) and 70 in the Doppler group (N = 72) (p = 0.93). Median (IQR) length of stay was 8.0 (8.0) days in the PVI group and 8.0 (9.5) in the Doppler group (P = 0.57). Conclusions: No difference in clinical outcome, as defined by number of postoperative complications, and length of hospital stay, was found when goal directed fluid therapy was applied using PVI as an alternative to esophageal Doppler. PVI appears to be an acceptable alternative to esophageal Doppler for goal directed fluid therapy during major open abdominal surgery.

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  • 2.
    Bergenzaun, Lill
    et al.
    Lund Univ, Sweden.
    Ohlin, Hans
    Lund Univ, Sweden.
    Gudmundsson, Petri
    Malmo Univ, Sweden.
    During, Joachim
    Lund Univ, Sweden.
    Willenheimer, Ronnie
    Lund Univ, Sweden.
    Chew, Michelle S.
    Lund Univ, Sweden.
    High-sensitive cardiac Troponin T is superior to echocardiography in predicting 1-year mortality in patients with SIRS and shock in intensive care2012In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 12, article id 25Article in journal (Refereed)
    Abstract [en]

    Background: Left ventricular (LV) dysfunction is well documented in the critically ill. We assessed 1-year mortality in relation to cardiac biomarkers and LV function parameters by echocardiography in patients with shock. Methods: A prospective, observational, cohort study of 49 patients. B-natriuretic peptide (BNP), high-sensitive troponin T (hsTNT) and transthoracic echocardiography (TTE) were assessed within 12 h of study inclusion. LV systolic function was measured by ejection fraction (LVEF), mean atrioventricular plane displacement (AVPDm), peak systolic tissue Doppler velocity imaging (TDIs) and velocity time integral in the LV outflow tract (LVOT VTI). LV diastolic function was evaluated by transmitral pulsed Doppler (E, A, E/A, E-deceleration time), tissue Doppler indices (e, a, E/e) and left atrial volume (La volume). APACHE II (Acute Physiology and Chronic Health Evaluation) and SOFA (Sequential Organ Failure Assessment) scores were calculated. Results: hsTNT was significantly higher in non-survivors than in survivors (60 [17.0-99.5] vs 168 [89.8-358] ng/l, p = 0.003). Other univariate predictors of mortality were APACHE II (p = 0.009), E/e (p = 0.023), SOFA (p = 0.024) and age (p = 0.031). Survivors and non-survivors did not differ regarding BNP (p = 0.26) or any LV systolic function parameter (LVEF p = 0.87, AVPDm p = 0.087, TDIs p = 0.93, LVOT VTI p = 0.18). Multivariable logistic regression analysis identified hsTNT (p = 0.010) as the only independent predictor of 1-year mortality; adjusted odds ratio 2.0 (95% CI 1.2-3.5). Conclusions: hsTNT was the only independent predictor of 1-year mortality in patients with shock. Neither BNP nor echocardiographic parameters had an independent prognostic value. Further studies are needed to establish the clinical significance of elevated hsTNT in patients in shock.

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  • 3.
    Elewa, Ahmed M.
    et al.
    Suez Canal Univ, Egypt.
    Faisal, Mohammed
    Suez Canal Univ, Egypt; Sahlgrens Univ Hosp, Sweden.
    Sjöberg, Folke
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, ANOPIVA US.
    Abuelnaga, Mohamed E.
    Suez Canal Univ, Egypt.
    Comparison between erector spinae plane block and paravertebral block regarding postoperative analgesic consumption following breast surgery: a randomized controlled study2022In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 22, no 1, article id 189Article in journal (Refereed)
    Abstract [en]

    Background: Pain control following breast surgery is of utmost importance in order to reduce the chance of chronic pain development, and facilitate early rehabilitation. The erector spinae plane block (ESPB) is a recently developed regional anaesthesia procedure successfully used for different types of surgical procedures including thoracic and abdominal surgeries. Methods: A double-blind, randomized, controlled trial was conducted on 90 patients who were scheduled for modified radical mastectomy (MRM). Patients were randomly categorized into groups I (women who underwent ESPB), II (women who underwent paravertebral block (PVB), and III (women who underwent general anaesthesia). Results: The ESPB (4.9 +/- 1.2 mg) and PVB (5.8 +/- 1.3 mg) groups had significantly lower total morphine consumption than the control group had (16.4 +/- 3.1 mg; p < 0.001). Notably, patients in the ESPB group had insignificantly lower morphine consumption than those in the PVB group had (p= 0.076). Moreover, patients in the ESPB and PVB groups had a significantly longer time to first required anaesthesia than those in the control group (7.9 +/- 1.2 versus 7.5 +/- 0.9 versus 2 +/- 1.2 h, respectively; p<0.001).The postoperative visual analog scale scores were lower in the ESPB and PVB groups than in the control group on the first 24 h after the procedure (p< 0.001). Conclusion: ESPB and PVB provide effective postoperative analgesia for women undergoing MRM. The ESPB appears to be as effective as the PVB.

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  • 4.
    Elewa, Ahmed M.
    et al.
    Suez Canal Univ, Egypt.
    Faisal, Mohammed
    Sahlgrens Univ Hosp, Sweden.
    Sjöberg, Folke
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Abuelnaga, Mohamed E.
    Suez Canal Univ, Egypt.
    Erector spinae plane block versus paravertebral block in analgesic outcomes following breast surgery2023In: BMC Anesthesiology, E-ISSN 1471-2253, Vol. 23, no 1, article id 19Article in journal (Other academic)
    Abstract [en]

    This article represents the response to the inquiries adopted by Dr. Raghuraman M Sethuraman, M.D., regarding our recently published study which compared the erector spinae plane block (ESPB) versus paravertebral block (PVB) regarding postoperative analgesic consumption following breast surgeries (Elewa et al, BMC Anesthesiol 22: 1-9, 2022). We would like to introduce our appreciation and gratitude to the author for his interest in our work, despite being inaccurate in some of his comments.

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  • 5.
    Hahn, Robert G
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Research Unit, Södertälje Hospital, Södertälje, Sweden.
    Ljunggren, Stefan
    Research Unit, Södertälje Hospital, Södertälje, Sweden.
    Preoperative insulin resistance reduces complications after hip replacement surgery in non-diabetic patients.2013In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 13, no 1, p. 39-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Insulin resistance negatively affects the outcome of surgery in patients with type 2 diabetes. This association is often believed to be present in other patient populations as well, but studies are lacking on the influence of preoperative insulin resistance on the clinical course of surgery in non-diabetic patients.

    METHODS: Sixty non-diabetic patients with a mean age of 68 years underwent a 75-min intravenous glucose tolerance test (IVGTT) one day before and after elective hip replacement surgery. Patients were regarded to be either insulin resistant (< median insulin sensitivity) or not (> median insulin sensitivity). Hypotensive events occurring in the postoperative care unit and complications in the orthopedic ward were recorded. Fatigue and well-being were assessed via questionnaires.

    RESULTS: A total of 52 patients were included in the final analysis. Insulin resistance before surgery was associated with a lower risk of arterial hypotension in the postoperative care unit (systolic pressure < 80 mmHg; P < 0.05) and with fewer complications in the orthopedic ward (mean 1.9 versus 1.2 per operation, P < 0.01), particularly with respect to nausea/vomiting (P < 0.04) and arterial hypotension (P < 0.05). Fewer of these patients had more than one complication (23% versus 58%, P < 0.001), while no statistical link between preoperative insulin resistance and fatigue or well-being was evident. Insulin resistance, when measured one day postoperatively, did not correlate with the number of complications.

    CONCLUSIONS: Preoperative insulin resistance offers some benefit in the postoperative period and early convalescence in non-diabetic patients who undergo hip replacement surgery.

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  • 6.
    Hahn, Robert G.
    et al.
    Sodertalje Hosp, Sweden; Karolinska Inst, Sweden.
    Wuethrich, Patrick Y.
    Univ Bern, Switzerland.
    Zdolsek, Joachim
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Clinical Chemistry and Pharmacology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, ANOPIVA US.
    Can perioperative hemodilution be monitored with non-invasive measurement of blood hemoglobin?2021In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 21, no 1, article id 138Article in journal (Refereed)
    Abstract [en]

    Background Trends in non-invasive measurements of blood hemoglobin (Hb) may be useful for identifying the need for transfusion in the perioperative period. Methods Crystalloid fluid (5-20 mL/kg) was administered intravenously or by mouth to 30 volunteers and 33 surgical patients in five non-randomized clinical studies where Hb was measured on 915 occasions by non-invasive (Radical-7 (TM)) and invasive methodology. The hemodilution curves were compared by volume kinetic analysis and linear regression, with the slope and scattering of the data as key outcome measures. Results The slope was 1.0, indicating unity between the two modes of measuring Hb when crystalloid fluid was infused in volunteers; however, only 40-45% of the variability in the non-invasive Hb could be explained by the invasive Hb. Patients undergoing major surgery, who showed the most pronounced hemodilution (median 24 g/L); non-invasive Hb explained 72% of the variability but indicated only half the magnitude of the invasive Hb changes (slope 0.48, P &lt; 0.001 versus the volunteers). Simulations based on volume kinetic parameters from the volunteers showed 25% less plasma volume expansion after infusion when based on non-invasive as compared to invasive Hb, while no difference was found during infusion. Conclusions In volunteers the non-invasive Hb had good accuracy (low bias) but poor precision. In surgical patients the non-invasive Hb had good precision but systematically underestimated the hemodilution. Despite severe limitations, the non-invasive technology can be used to follow Hb trends during surgery if supported by occasional invasive measurements to assure acceptable quality of the hemodilution curve.

  • 7.
    Hindocha, Nishma
    et al.
    Zealand Univ Hosp, Denmark.
    Manhem, Filip
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Clinical and Experimental Medicine. Region Östergötland, Public Dental Health Care, Public General Dental Health Care.
    Bäckryd, Emmanuel
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Bågesund, Mats
    Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Public Dental Health Care, Center for Orthodontics/Pedodontics Norrköping.
    Ice versus lidocaine 5% gel for topical anaesthesia of oral mucosa: a randomized cross-over study2019In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 19, no 1, article id 227Article in journal (Refereed)
    Abstract [en]

    Background

    Topical anaesthesia is important to optimize pain control during dental injection. Our aim was to describe a new simple method for topical anaesthesia of oral mucosa and to compare the effectiveness of ice and lidocaine 5% gel for topical anaesthesia of oral mucosa.

    Methods

    A total of 40 patients aged 10.7–19.5 years were included. The side and method of application were both randomized. Heart rate was recorded, and discomfort and pain were evaluated with a visual analogue scale (VAS). A paired t-test was used to compare mean values, a chi2 test was used to compare proportions, and a Pearson correlation test was used to examine correlations between variables.

    Results

    When ice was used, buccal injection VAS pain was rated lower (p = 0.044), and VAS discomfort was rated higher (p = 0.001), in comparison to when lidocaine 5% gel was used. There was no significant difference in relative heart rate change between ice and lidocaine 5% gel at either needle stick or injection. Lidocaine 5% gel produced a relative heart rate reduction after palatal injection (0.99 ± 0.06) while buccal injection produced an increased relative heart rate (1.02 ± 0.08) (p = 0.010). Unpleasant taste was more frequently reported when lidocaine 5% gel was used (p = 0.025). An application time of 1 min was sufficient for both ice and lidocaine 5% gel to achieve pain reduction from needle stick in buccal mucosa.

    Conclusion

    The cheap and readily available described method using ice for topical anaesthesia of oral mucosa before dental injection is an effective alternative to lidocaine 5% gel.

    Trial registration

    The European Union Drug Regulating Authorities Clinical Trials Database EudraCT201300530531. Date of registration: February 10th, 2014.

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  • 8.
    Li, Yuhong
    et al.
    Zhejiang University, Peoples R China; Shaoxing Peoples Hospital, Sweden.
    He, Rui
    Zhejiang University, Peoples R China.
    Ying, Xiaojiang
    Shaoxing Peoples Hospital, Sweden.
    Hahn, Robert
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Ringer's lactate, but not hydroxyethyl starch, prolongs the food intolerance time after major abdominal surgery; an open-labelled clinical trial2015In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 15Article in journal (Refereed)
    Abstract [en]

    Background: The infusion of large amounts of Ringers lactate prolongs the functional gastrointestinal recovery time and increases the number of complications after open abdominal surgery. We performed an open-labelled clinical trial to determine whether hydroxyethyl starch or Ringers lactate exerts these adverse effects when the surgery is performed by laparoscopy. Methods: Eighty-eight patients scheduled for major abdominal cancer surgery (83% by laparoscopy) received a first-line fluid treatment with 9 ml/kg of either 6% hydroxyethyl starch 130/0.4 (Voluven) or Ringers lactate, just after induction of anaesthesia; this was followed by a second-line infusion with 12 ml/kg of either starch or Ringers lactate over 1 hour. Further therapy was managed at the discretion of the attending anaesthetist. Outcome data consisted of postoperative gastrointestinal recovery time, complications and length of hospital stay. Results: The order of the infusions had no impact on the outcome. Both the administration of greater than= 2 L of Ringers lactate and the development of a surgical complication were associated with a longer time period of paralytic ileus and food intolerance (two-way ANOVA, P less than 0.02), but only surgical complications prolonged the length of hospital stay (P less than 0.001). The independent effect of Ringers lactate and complications of food intolerance time amounted to 2 days each. The infusion of greater than= 1 L of hydroxyethyl starch did not adversely affect gastrointestinal recovery. Conclusions: Ringers lactate, but not hydroxyethyl starch, prolonged the gastrointestinal recovery time in patients undergoing laparoscopic cancer surgery. Surgical complications prolonged the hospital stay.

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  • 9.
    Thomas, Owain
    et al.
    Lund University, Sweden; SUS Lund University Hospital, Sweden.
    Larsson, Anna
    Lund University, Sweden.
    Tynngård, Nahreen
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Immunology and Transfusion Medicine. Region Östergötland, Center for Diagnostics, Department of Clinical Chemistry.
    Schott, Ulf
    Lund University, Sweden; SUS Lund University Hospital, Sweden.
    Thromboelastometry versus free-oscillation rheometry and enoxaparin versus tinzaparin: an in-vitro study comparing two viscoelastic haemostatic tests dose-responses to two low molecular weight heparins at the time of withdrawing epidural catheters from ten patients after major surgery2015In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 15Article in journal (Refereed)
    Abstract [en]

    Background: Monitoring low molecular weight heparins (LMWHs) in the perioperative period is prudent in patients at high risk of coagulative complications, especially when the patient has an epidural catheter requiring withdrawal, which is associated with the risk of spinal haematoma. The aim of this study was to evaluate the in vitro dose-responses of two different LMWHs on two different viscoelastic haemostatic tests, using blood sampled from patients with normal routine coagulation parameters, on the day after major surgery when their epidural catheters were due to be withdrawn. Methods: Enoxaparin or tinzaparin were added in vitro to blood from ten patients who had undergone oesophageal resection, to obtain plasma concentrations of approximately 0, 0.5, 1.0 and 1.5 IU/mL. Coagulation was monitored using thromboelastometry (ROTEM (R)) using the InTEM (R) activating reagent; and free oscillation rheometry (FOR: ReoRox (R)), activated using thromboplastin. Clot initiation was measured using ROTEM-CT, ReoRox-COT1 and ReoRox-COT2. Clot propagation was measured using ROTEM-CFT, ROTEM-Alpha Angle and ReoRox-Slope. Clot stability was measured using ROTEM-MCF and ReoRox-Gmax, and clot lysis was measured using ROTEM-ML and ReoRox-ClotSR. Results: Clot initiation time assessed by thromboelastometry and FOR was prolonged by increasing concentrations of both LMWHs (P &lt; 0.01). Equivalent doses of tinzaparin in international units (anti FXa units) per millilitre prolonged clot initiation more than enoxaparin (P &lt; 0.05). There was significant inter-individual variation - the ranges of CT and COT1 at LMWH-concentrations of 0 and 1.5 IU/mL overlapped. None of the tests reflecting clot formation rate or stability showed a dose-response to either LMWH but clot lysis showed a tentative negative dose-response to the LMWHs. Conclusions: Clot initiation times dose-dependent prolongation by LMWHs in this study agrees with previous research, as does tinzaparins stronger anti-coagulative effect than enoxaparin at equivalent levels of anti-FXa activity. This casts doubt on the validity of using anti-FXa assays alone to guide dosage of LMWHs. The significant inter-individual variation in dose-response suggests that the relationship between dose and effect in the postoperative period is complicated. While both ROTEM and FOR may have some role in postoperative monitoring, more research is needed before any conclusion can be made about their clinical usefulness.

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  • 10.
    Vidlund, Mårten
    et al.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Tajik, Bashir
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Håkansson, Erik
    Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Friberg, Örjan
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Holm, Jonas
    Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Vánky, Farkas
    Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Svedjeholm, Rolf
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Post hoc analysis of the glutamics-trial: intravenous glutamate infusion and use of inotropic drugs after cabg2016In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 16, p. 1-9, article id 16:54Article in journal (Refereed)
    Abstract [en]

    Background: Intravenous glutamate reduced the risk of developing severe circulatory failure after isolated coronary artery bypass graft surgery (CABG) for acute coronary syndrome (ACS) in a double-blind randomised clinical trial (GLUTAMICS-ClinicalTrials. gov Identifier:NCT00489827). Here our aim was to study if glutamate was associated with reduced the use of inotropes.

    Methods: Post-hoc analysis of 824 patients undergoing isolated CABG for ACS in the GLUTAMICS-trial. ICU-records were retrospectively scrutinised including hourly registration of inotropic drug infusion, dosage and total duration during the operation and postoperatively.

    Results: ICU-records were found for 171 out of 177 patients who received inotropes perioperatively. Only one fourth of the patients treated with inotropes fulfilled study criteria for postoperative heart failure at weaning from cardiopulmonary bypass (CPB) or later in the ICU. Inotropes were mainly given preemptively to facilitate weaning from CPB or to treat postoperative circulatory instability (bleeding, hypovolaemia). Except for a significantly lower use of epinephrine there were only trends towards lower need of other inotropes overall in the glutamate group. In patients treated with inotropes (glutamate n = 17; placebo n = 13) who fulfilled study criteria for left ventricular failure at weaning from CPB the average duration of inotropic treatment (34 +/- 20 v 80 +/- 77 h; p = 0.014) and the number of inotropes used (1.35 +/- 0.6 v 1.85 +/- 0.7; p = 0.047) were lower in the glutamate group.

    Conclusions: Intravenous glutamate was associated with a minor influence on inotrope use overall in patients undergoing CABG for ACS whereas a considerable and significant reduction was observed in patients with heart failure at weaning from CPB.

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