الفهرس 
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Abstract
Summary
This prospective, double blind, randomized study was conducted in anesthesia and intensive care department in Minia University Hospital for cardiothoracic surgery during the period from may 2015 till January 2016 on a total 60 adult patients aged between 18 to 60 years of either sex with (ASA) physical statues II and III scheduled for elective on pump valvular cardiac surgery.
This study aimed to evaluate and compare the use of propofol or insulin in cold blood cardioplegia for myocardial protection assessed by left papillary muscle biopsy and troponin I.
Patients enrolled into the study were divided into 3 equal groups of 20 patients each :
1- Control group (C group) : received cold blood cardioplegia solution which enriched with 20 mmol potassium chloride 15%, 32 mmol magnesium sulfate, 10 mmol sodium bicarbonate 8.4%, 100 mg lidocaine hydrochloride 2%, 2.4 mmol calcium gluconate 10% and 13 ml glucose 25% for each liter of cold cardioplegia.
2- Propofol group (P group) : received 9 mg propofol 10% added to each one liter of cold blood cardioplegia of the same previous components
3- Insulin group (I group) : received 10 IU of regular insulin for each one liter of cold blood cardioplegia solution of the same previous components.
The three groups were compared with respect to:
• Patients characteristics ( age, sex, height and weight).
• Operative parameters (aortic cross clamping time, total volume of cardioplegia and cardiopulmonary bypass duration) .
• Trans-thoracic ECHO parameters (preoperative left or right ventricular dilatation or hypertrophy, preoperative pulmonary artery pressure, pre and postoperative ejection fraction).
• Haemodynamics ( mean arterial blood pressure and heart rate) before induction, 5, 30, 45, 60, 75, 90, 105 and 120 min after induction and at 1, 6, 12 and 24 hours post operatively
• Arterial blood gas parameters (PH, PaO2, PaCo2, HCO3 and SaO2) after induction, 20 min on CPB and 20 min after CPB intra operatively and at 1, 6, 12, 24 and 48 hours post operatively.
• Changes in the mean of temperature immediately after induction and at 5, 30, 45, 60, 75, 90, 105 and 120 min. intraoperatively.
• Liver functions (ALT and AST) and renal function ( serum creatinine and urea) preoperatively and 24, 48 hours postoperatively.
• Serum glucose level, insulin need, serum potassium and need for potassium supplementation preoperatively, immediately after induction, 20 min on CPB and 20 min after CPB intra operatively and at 1, 6, 12, 24 and 48 hours post operatively.
• Serum blood troponinI (CTnI) level pre and post operatively ( 12 hours after chest closure).
• Histopathological examination of left papillary muscle biopsy.
• ICU data (need for pacing, time of extubation and ICU stay).
• Complications ( dysrhythmia, myocardial infarction, dysglycemia and renal failure) .
• Results of this research didn’t record any significant difference in patients characteristics or operative data. ECHO parameters showed no significant difference between the studied groups apart from preoperative ECHO parameters which showed a significant difference between group C and group I and preoperative pulmonary artery pressure data that showed significant difference between group C and each of group P and group I. Postoperative ECHO showed no significant difference.
• There was no significant difference in systolic and diastolic blood pressure between or inside the studied groups neither pre, intra nor postoperatively. Intergroup comparison revealed significant decrease in mean arterial blood pressure values (MAP) in all studied groups when compared with basal values at 45, 60, 75, 90 min and 105 min. and extended to 120 min. intraoperatively in group (C) only to be followed by significant increase postoperativly at 1 hour in this group then at 6, 12 and 24hrs postoperatively in all studied groups with no significant difference between them .
• The three studied groups were comparable as regard heart rate (HR) with no significant difference between the studied groups however, within group comparison recorded higher values in comparison to basal values in group C and I in many intervals but at 24 hours only in group P postoperatively.
• No significant differences recorded in arterial blood gas parameters at all time intervals.
• Temperature values showed significant decrease inside each group in comparison to basal value immediately after induction and at 5, 30, 45, 60, 75, 90, 105 and 120 min. intraoperatively with no significant difference between the groups.
• Renal functions showed significant increase in postoperative serum creatinine in comparison to the preoperative value in the three groups, while postoperative serum urea showed significant increase only in group C with no significant changes detected in liver functions (ALT and AST).
• The current study recorded that serum glucose had raised significantly 20 min. after CPB and declined significantly 48 hours postoperatively in group C which did not occur in the other two groups. Consequently, higher number of patients were in need for insulin in the control group.
• Regarding serum potassium, a significant difference was recorded between group C and P at 20 min. after CPB and at 6, 24 and 48 hours postoperatively. Inside the group, significant decline occurred at 20 min. on CPB in all groups while postoperatively, significant rise occurred at 24 and 48 hours in group C and at 48 hours only in group I. Higher need for potassium supplementation intraoperatively in group C was recorded followed by group I then group P with significant difference only between groups C and P.
• Troponin I was positively elevated in the second sample to variable degrees in the three studied groups. This increase was maximum in group C with 77.33 folds relative to the preoperative values, group C with 47.7 folds increase and group P was the least degree of rise with 40 folds only.
• Biopsy form left papillary muscle showed higher degree of protection in group P as only one case was recorded with grade four of myocardial injury to be followed by four cases in group I and seven cases in group C.
• ICU parameters were non significant between the studied groups apart from time of extubation which was hastened in group P.
• Control group was the only group that experienced complications with higher number of patients had atrial fibrillation (AF) (8 cases) followed by insulin group (5 cases) and propofol group free of arrythmias.