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   Table of Contents - Current issue
Coverpage
April-June 2019
Volume 22 | Issue 2
Page Nos. 111-238

Online since Tuesday, April 9, 2019

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EDITORIAL  

Argon: The Future Organ Protectant? p. 111
Suresh G Nair
DOI:10.4103/aca.ACA_180_18  PMID:30971590
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REVIEW ARTICLES Top

Propofol for sedation for direct current cardioversion Highly accessed article p. 113
Bruna Galvão de Wafae, Rose Mary Ferreira da Silva, Henrique Horta Veloso
DOI:10.4103/aca.ACA_72_18  PMID:30971591
Direct current cardioversion is a low-risk and standard procedure to restore normal sinus rhythm in patients with tachyarrhythmias. It requires sedation to facilitate the procedure, as it is painful and distressful. The preferred anesthetic drug must be short acting, producing conscious sedation, to enable rapid recovery after the procedure. In this sense, this narrative review focuses on the critical analysis of recent randomized studies and presents about the safety and effectiveness of propofol, comparing it with other established sedatives, mainly etomidate and midazolam. The research was performed on MEDLINE database with Propofol and Cardioversion keywords. In most cases, propofol comes to be the best option, with a quick recovery time and low rates of side effects. Different studies have demonstrated no inferiority when comparing to other drugs and, when these adverse events happened, they were easily and quickly handled. Exceptions in this scenario are those patients, particularly the elderly, with baseline important structural heart disease, in which etomidate with fentanyl has been pointed to lead to better hemodynamic stability.
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A complete review of preclinical and clinical uses of the noble gas argon: Evidence of safety and protection p. 122
Francesca Nespoli, Simone Redaelli, Laura Ruggeri, Francesca Fumagalli, Davide Olivari, Giuseppe Ristagno
DOI:10.4103/aca.ACA_111_18  PMID:30971592
The noble gas argon (Ar) is a “biologically” active element and has been extensively studied preclinically for its organ protection properties. This work reviews all preclinical studies employing Ar and describes the clinical uses reported in literature, analyzing 55 pertinent articles found by means of a search on PubMed and Embase. Ventilation with Ar has been tested in different models of acute disease at concentrations ranging from 20% to 80% and for durations between a few minutes up to days. Overall, lesser cell death, smaller infarct size, and better functional recovery after ischemia have been repeatedly observed. Modulation of the molecular pathways involved in cell survival, with resulting anti-apoptotic and pro-survival effects, appeared as the determinant mechanism by which Ar fulfills its protective role. These beneficial effects have been reported regardless of onset and duration of Ar exposure, especially after cardiac arrest. In addition, ventilation with Ar was safe both in animals and humans. Thus, preclinical and clinical data support future clinical studies on the role of inhalatory Ar as an organ protector.
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ORIGINAL ARTICLES Top

Terlipressin versus norepinephrine to prevent milrinone-induced systemic vascular hypotension in cardiac surgery patient with pulmonary hypertension Highly accessed article p. 136
Mai Mohsen Abdelazziz, Hadil Magdi Abdelhamid
DOI:10.4103/aca.ACA_83_18  PMID:30971593
Introduction: Milrinone at inotropic doses requires the addition of a vasoconstrictive drug. We hypothesized that terlipressin use could selectively recover the systemic vascular hypotension induced by milrinone without increasing the pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (MPAP) as norepinephrine in cardiac surgery patients. Patients and Methods: Patients with pulmonary hypertension were enrolled in this study. At the start of rewarming a milrinone 25 μg/kg bolus over 10 min followed by infusion at the rate of 0.25 μg/kg/min. Just after the loading dose of milrinone, the patients were randomized to receive norepinephrine infusion at a dose of 0.1 μg/kg/min (norepinephrine group) or terlipressin infusion at a dose of 2 μg/kg/h (terlipressin group). Heart rate, mean arterial blood pressure (MAP), central venous pressure, MPAP, systemic vascular resistance (SVR), PVR, cardiac output were measured after induction of anesthesia, after loading dose of milrinone, during skin closure, and in the intensive care unit till 24 h. Results: Milrinone decreased MAP (from 79.56 ± 4.5 to 55.21 ± 2.1 and from 78.46 ± 3.3 to 54.11 ± 1.1) and decreased the MPAP (from 59.5 ± 3.5 to 25.4 ± 2.6 and from 61.3 ± 5.2 to 25.1 ± 2.3) in both groups. After norepinephrine, there was an increase in the MAP which is comparable to terlipressin group (P > 0.05). Terlipressin group shows a significant lower MPAP than norepinephrine group (24.5 ± 1.4 at skin closure vs. 43.3 ± 2.1, than 20.3 ± 2.1 at 24 h vs. 39.8 ± 3.8 postoperatively). There is a comparable increase in the SVR in both group, PVR showed a significant increase in the norepinephrine group compared to the terlipressin group (240.5 ± 23 vs. 140.6 ± 13 at skin closure than 190.3 ± 32 vs. 120.3 ± 10 at 24 h postoperatively). Conclusion: The use of terlipressin after milrinone will reverse systemic hypotension with lesser effect on the pulmonary artery pressure.
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Comparison of full outline of unresponsiveness score and Glasgow Coma Scale in Medical Intensive Care Unit p. 143
Jamileh Ramazani, Mohammad Hosseini
DOI:10.4103/aca.ACA_25_18  PMID:30971594
Context: The Glasgow Coma Scale (GCS) is the most commonly used scale, and Full Outline of Unresponsiveness (FOUR) score is new validated coma scale as an alternative to GCS in the evaluation of the level of consciousness. Aim: The aim of the current study was to evaluate FOUR score and GCS ability in predicting the outcomes (Survivors, nonsurvivors) in Medical Intensive Care Unit (MICU). Setting and Design: This was an observational and prospective study of 300 consecutive patients admitted to the MICU during a 14 months' period. Materials and Methods: FOUR score, GCS score, and demographic characteristics of all patients were recorded in the first admission 24 h. Statistical Analysis Used: A receiver operator characteristic (ROC) curve, Hosmer–Lemeshow test, and Logistic regression were used in the statistical analysis (95% confidence interval). Results: Data analysis showed a significant statistical difference in FOUR score and GCS score between survivors and nonsurvivors (P < 0.0001, P < 0.0001; respectively). The discrimination power was good for both FOUR score and GCS (area under ROC curve: 87.3% (standard error [SE]: 2.1%), 82.6% [SE: 2.3%]; respectively). The acceptable calibration was seen just for FOUR score (χ2 = 8.059, P = 0.428). Conclusions: Both FOUR score and GCS are valuable scales for predicting outcomes in patients are admitted to the MICU; however, the FOUR score showed better discrimination and calibration than GCS, so it is superior to GCS in predicting outcomes in this patients population.
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COMMENTARY Top

In search of a better measuring scale of consciousness p. 149
Jayantee Kalita, Usha K Misra
DOI:10.4103/aca.ACA_193_18  PMID:30971595
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ORIGINAL ARTICLES Top

The effect of perioperative magnesium sulfate on blood sugar in patients with diabetes mellitus undergoing cardiac surgery: A double-blinded randomized study p. 151
Rabie Soliman, Hussein Nofal
DOI:10.4103/aca.ACA_32_18  PMID:30971596
Objective: The aim of the present study was to evaluate the perioperative effect of magnesium infusion on blood sugar level in patients with diabetes mellitus undergoing cardiac surgery. Design: This was a double-blind randomized study. Setting: The study was conducted at cardiac center. Patients: The study included 122 adult patients. Intervention: Group M – The patients received a continuous infusion of magnesium sulfate (without a loading dose) at 15 mg/kg/h. The infusion rate was started 20 min before induction maintained during surgery and the first postoperative 24 h. The medication was prepared by adding 5 g magnesium sulfate in 50 ml syringe. Group C – The patients received equal amount of normal saline. Measurements: The monitors included heart rate, mean arterial blood pressure, central venous pressure, urine output, blood levels of magnesium, sugar, and potassium. Results: The blood sugar level and the required insulin significantly decreased with Group M than Group C (P < 0.05). There were minimal changes in the potassium level in Group M, but potassium decreased in patients of Group C (P < 0.05). The amount of urine output was too much higher in Group M than Group C (P < 0.05). The pharmacological and mechanical support significantly decreased with Group M than Group C (P < 0.05). The hospital and Intensive Care Unit length of stay significantly decreased with Group M than Group C (P < 0.05). Conclusion: The magnesium sulfate produced a better-controlled effect on the blood sugar level. It decreased the requirement of insulin infusion and minimized the changes in the blood level of potassium.
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The effect of cerebral oximeter use on the shunt placement concerning carotid endarterectomy surgery p. 158
Dilek Ceyhan, Cengiz Ovali
DOI:10.4103/aca.ACA_57_18  PMID:30971597
Background: During carotid arterial endarterectomy (CAE) surgery, an intraluminal shunt is used to prevent hypoperfusion, which can be caused by a cross-clamping cerebral ischemia. However, routine shunt use is not recommended. Various cerebral monitoring techniques are used to determine the need for shunt placement. In this study, retrospective analysis of data on the efficacy of cerebral oximetry in the decision of shunt use during elective CAE surveys was planned. Materials and Methods: We collected data on 68 patients operated under general anesthesia between December 2016 and December 2017. Patients were evaluated for near infrared spectrometry (NIRS) and stump pressure values and whether shunt was placed or not. Results: Eight (11.7%) patients were shunting. NIRS value after cross-clamping was lower in patients with shunt. Stump pressure values were below 40 mmHg. Conclusions: Cerebral monitoring in elective CAE operations has great importance in determining the necessity of using intraluminal shunt to reduce the complications that may occur.
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Hyperkalemia in ambulant postcardiac surgery patients during combined therapy with angiotensin-converting enzyme inhibitor, spironolactone, and diet rich in potassium: A report of two cases and review of literature p. 162
Aanchal Dixit, Gauranga Majumdar, Prabhat Tewari
DOI:10.4103/aca.ACA_65_18  PMID:30971598
Introduction: Potassium is the most abundant cation in intracellular compartment. A deficiency or excess of its serum concentration can be deleterious to the one suffering from a cardiac ailment. Post cardiac surgery patients are often on multiple drugs like angiotensin receptor blockers (ARBs), angiotensin converting enzyme inhibitors (ACEI), diuretics including potassium sparing diuretics which are known to predispose for hyperkalemia. We report two postoperative cases who developed life threatening hyperkalemia despite normal renal function due to a combination of factors like treatment with ACEI, potassium sparing diuretics, high dietary intake of potassium and we also discuss renal handling of potassium in this review of literature. Methodology: We present a case series of two cases of cardiac surgery, who presented in the emergency department with hyperkalemia, managed conservatively and detailed history revealed that patient were also on very high nutritional potassium. Result: Both the patients responded to conservative management and there was no recurrence of such episodes once the dose of diuretics was adjusted and diet modification advised. Conclusion: In India, many patients are from a low socioeconomic background and often resort to cheap and filling food items like bananas. This dietary factor should be kept in mind while prescribing patients with these medications and adequate counseling regarding diet should be done.
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Perioperative anesthesia management for pulmonary endarterectomy: Adopting an established European Protocol for the Asian Population p. 169
Yufan Chen, Zihui Tan, Shitalkumar S Shah, Kenny W T Loh
DOI:10.4103/aca.ACA_63_18  PMID:30971599
Background: Anesthesia for pulmonary endarterectomy (PEA) has always been one of the challenges of anesthesia. As one of the leading cardiothoracic institutions in Southeast Asia, our hospital has vast interest in this subject. A local multidisciplinary team was deployed to an expert center in the United Kingdom (UK), and the experience was then integrated to the care of our patients. We present a case series of ten patients undergoing anesthesia for PEA, a first for our institution, and discuss techniques as well as potential complications. Methods: Patients with chronic thromboembolic pulmonary hypertension were reviewed by a multidisciplinary team, and those who were suitable for surgical intervention subsequently underwent PEA. A total of ten patients were identified and operated on. The perioperative management and conduction of anesthesia for all patients followed a protocol adapted from the expert center in the UK, with revisions to cater to our Asian population. Results: In the ten patients operated on, eight of them were successfully extubated on the first postoperative day. Apart from one incident of prolonged ventilator usage due to reperfusion lung injury and pneumonia, there were no major respiratory or hemodynamic complications. Certainly, six of the ten patients developed subdural hemorrhage after the commencement of enoxaparin, although none of them sustained any permanent neurological deficits. Conclusion: We have demonstrated that with careful planning and a well-outlined protocol, anesthesia for PEA in an Asian population can be achieved with favorable outcomes. Further fine-tuning of the protocol is still required based on local expertise.
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A comparative study of safety and efficacy of ultrasound-guided infra-clavicular axillary vein cannulation versus ultrasound-guided internal jugular vein cannulation in adult cardiac surgical patients p. 177
Prajakta D Shinde, Amish Jasapara, Kishan Bansode, Rohit Bunage, Anvay Mulay, Vijay L Shetty
DOI:10.4103/aca.ACA_24_18  PMID:30971600
Background: Ultrasound (US)-guided internal jugular vein (IJV) cannulation is a widely accepted standard procedure. The axillary vein (AV) in comparison to the subclavian vein is easily visualized, but its cannulation is not extensively studied in cardiac patients. Aims: This study is an attempt to study the efficacy of real-time US-guided axillary venous cannulation as a safe alternative for the time-tested US-guided IJV cannulation. Design: This is a prospective randomized controlled study. Materials and Methods: A total of 100 adult patients scheduled for cardiac surgery were divided equally in Group A-US-guided IJV cannulation, and Group B-US-guided axillary venous cannulation. Under local anesthesia and real-time US guidance the IJV or AV was secured. The access time, guidewire time, and procedure time were noted. Furthermore, the number of needle attempts, malposition, change of site, and complications were noted. Results: The data were analyzed for 49 patients in Group A and 48 patients in the Group B due to exclusions. The access time and the guidewire time were comparable in both groups. The first attempt needle puncture was successful for the IJV group in 98% of patients in comparison to 95% of patients in Group B. Guidewire was passed in the first attempt in 94% in Group A and 89% in the Group B. Except for arterial puncture in one case in group A, the complications were insignificant in both groups. Conclusion: The study shows that the US-guided AV cannulation may serve as an effective alternative to the IJV cannulation in cardiac surgery.
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Female Gender is not a Risk Factor for Early Mortality after Coronary Artery Bypass Grafting p. 187
Akhil Gurram, Neethu Krishna, Anu Vasudevan, Luis Alberto Baquero, Aveek Jayant, Praveen Kerala Varma
DOI:10.4103/aca.ACA_27_18  PMID:30971601
Background: The female gender is considered as a risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). Aim: In this analysis, we assessed the impact of female gender on early outcome after CABG. Study Design: This is a retrospective analysis of data from our center situated in South India. Statistical Analysis: Patients were categorized according to gender and potential differences in pre-operative and post-operative factors were explored. Significant risk factors were then built in a multivariate model to account for differences in predicting gender influence on surgical outcome. Methods: 773 consecutive patients underwent first time CABG between January 2015 and December 2016. 96.77% of cases were performed using off-pump technique. 132 (17.07%) patients were females. These patients formed the study group. Results: The in-house/ 30-day mortality in females was similar to that of males (3.03% vs. 3.12%, p value 0.957). Mediastinitis developed more commonly in females (5.35% vs. 1.30%; p value 0.004) compared to males. There were more re-admissions to hospital for female patients (21.37% in females vs. 10.14% in males, p value <0.001). In multivariate analysis using logistic regression; there was a significant association between age (OR 1.08), chronic obstructive airway disease (OR 4.315), and use of therapeutic antibiotics (OR 6.299), IABP usage (OR 11.18) and renal failure requiring dialysis (OR 28.939) with mortality. Conclusions: Early mortality in females was similar to that of males. Females were associated with higher rate of wound infection and readmission to hospital.
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Comparison of grading of aortic stenosis between transthoracic and transesophageal echocardiography in adult patients undergoing elective aortic valve replacement surgeries: A prospective observational study p. 194
S Nanditha, Vishwas Malik, Suruchi Hasija, Poonam Malhotra, V Sreenivas, Sandeep Chauhan
DOI:10.4103/aca.ACA_4_18  PMID:30971602
Introduction: Intraoperative trans-esophageal echocardiography (TEE) has been found to underestimate severity of aortic stenosis (AS) compared to trans-thoracic echo (TTE). We conducted a prospective study comparing pre induction TTE and intra operative TEE grading of AS in patients posted for aortic valve replacement surgeries. Methods: Sixty patients with isolated AS who were undergoing aortic valve replacement were enrolled in our study. Baseline TTE was done and after induction of anesthesia, TEE was done. Mean gradient across aortic valve, peak jet velocity, aortic valve area (AVA) by continuity equation and dimensionless index (DI) were assessed in both. Results: Mean gradient decreased from 56.4 in TTE to 39.8 mm Hg in TEE leading to underestimation of AS in 74.5% of patients (P < 0.0). Mean of peak jet velocity also decreased from 500 in TTE to 386cm/s in TEE (P < 0.01). In 76 % of patients this led to reduction of AS grade from severe to moderate. Mean AVA was 0.67 cm2 in TTE and 0.69 cm2 in TEE. Though there was 0.02 cm2 increase, it was not statistically significant (P = 0.07). All the patients remained as severe AS in TEE. DI mean was 0.19 in both TTE and TEE (P = 0.14).It led to underestimation of severity in 6% of patients in TEE. Conclusion: Our study shows that AVA measurement by continuity equation and DI are reliable in grading aortic stenosis while performing intraoperative TEE. Mean gradient and jet velocity can be significantly reduced.
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BRIEF COMMUNICATION Top

The utilization spectrum of cardiac output monitoring devices among anesthesiology programs across Veterans Health Administration in the United States p. 199
Jahan Porhomayon, Leili Pourafkari, Ata Mahmoodpoor, Nader D Nader
DOI:10.4103/aca.ACA_107_18  PMID:30971603
Background: Electronic monitoring of physiologic variables has gained widespread support over the past decade for critical patients in the intensive care setting. Specifically, anesthesiologists have increased the emphasis and practice of hemodynamic control through monitoring cardiac output (CO). However, these physicians are presented with several options in terms of how they wish to study the trend of this physiologic parameter. Materials and Methods: A survey was distributed to 250 general and subspecialty-trained anesthesiologists. A series of questions were presented in terms of preference of patient monitoring methods requiring yes or no answers. Anesthesiologists were asked about subspecialty training, years since residency graduation, and preferences toward specific hemodynamic monitoring tools. Nonparametric statistical analysis and Chi-squared tests were used to analyze both normal and nonnormally distributed data. Results: CO monitoring devices were implemented by 106 out of 133 anesthesiologists, with 98 of these physicians utilizing CO monitoring for fluid and vasopressors response. Of the physicians implementing a monitoring device, 48 out of 107 physicians preferred pulmonary artery catheter, while pulse contour analysis was preferred by 17 anesthesiologists. An echocardiography unit was available to the department for 90 anesthesiologists, and 77 anesthesiologists were trained to use this technology for monitoring cardiac function. Conclusion: Many anesthesiologists have placed emphasis on the importance of CO monitoring within the intensive care setting. However, physicians are still faced with multiple options in terms of how they wish to specifically monitor this hemodynamic variable. Factors that influence such decisions include the time of physician's residency training along with patient and clinical case characteristics.
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CASE REPORTS Top

Acute renal failure due to bilateral renal vein thromboses: A rare complication of heparin-induced thrombocytopenia p. 204
Allan M Klompas, Robert C Albright, Simon Maltais, Onur Demirci
DOI:10.4103/aca.ACA_114_18  PMID:30971604
Heparin-induced thrombocytopenia type II is a rare but devastating complication of heparin exposure. We review a case of a 66-year-old female who underwent aortic valve surgery requiring venoarterial extracorporeal membranous oxygenation (ECMO) support postoperatively. She subsequently developed acute renal failure due to bilateral renal vein thromboses and thrombocytopenia and was found to have platelet factor 4/heparin antibodies and was diagnosed with heparin-induced thrombocytopenia (HIT). She was transitioned to nonheparin anticoagulation and her thrombocytopenia improved. Although a rare complication of anticoagulation, diagnosing HIT in a patient on ECMO requires a high index of suspicion and should be considered.
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Postoperative hyperbilirubinemia and Gilbert's syndrome in patients undergoing cardiac surgery p. 207
Angel L Fernández, Aurora Baluja, Zaid Al-Hamwy, Julian Alvarez
DOI:10.4103/aca.ACA_48_18  PMID:30971605
We report a series of seven patients with Gilbert's syndrome undergoing cardiac surgery. Early and transient increase of total, direct, and indirect bilirubin without other complications was observed. Although this is a benign process, we believe that this disease should be routinely included in the differential diagnosis of postoperative jaundice after cardiopulmonary bypass.
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Cardiac arrest after induction of anesthesia in a 2-month-old infant with undiagnosed Williams syndrome p. 210
Julie D Dunlap, Morton C Green, Aali M Shah, Brandon T Kibby, Deborah F Billmire
DOI:10.4103/aca.ACA_38_18  PMID:30971606
A 2-month-old male infant presented for elective repair of inguinal hernias. His preoperative medical history and physical examination were unremarkable. During induction of anesthesia, the infant sustained an adverse cardiac event. The event was characterized by tachycardia, hypotension, and massive ST-segment elevation. Despite vigorous resuscitation, spontaneous hemodynamic stability could not be achieved and extracorporeal membrane oxygenation was required. A transthoracic echocardiogram revealed severe hypoplasia of the ascending aorta. As effective cardiac function did not recover and there was evidence of diffuse ischemic brain injury, life support was withdrawn. Genetic testing performed postoperatively was definitive for Williams syndrome.
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COMMENTARY Top

Intraoperative sudden cardiac death in pediatric patients - Calamity yet to overcome? p. 213
Ajita Suhrid Annachhatre
DOI:10.4103/aca.ACA_90_18  PMID:30971607
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CASE REPORTS Top

Perioperative management of a patient with double orifice mitral valve with supramitral ring with subaortic membrane with ventricular septal defect and severe pulmonary hypertension: Report of a rare case p. 215
Vishnu Datt, Priyanka Khurana, Saket Aggarwal, Smita Mishra, CN Sujith, Sanjula Virmani
DOI:10.4103/aca.ACA_123_18  PMID:30971608
Double-orifice mitral valve (DOMV) is an unusual congenital anomaly characterized by a mitral valve with a single fibrous annulus with two orifices or rarely two orifices with two separate mitral annuli opening into the left ventricle. We present a first report of a patient with a DOMV with supramitral ring (SMR), subaortic membrane (SAM), a large ventricular septal defect (VSD) with more than 50% aortic override, and severe pulmonary arterial hypertrophy (PAH). This patient underwent excision of the SAM, and SMR, with closure of the VSD together under cardiopulmonary bypass (CPB). However postoperatively, the patient developed an irreversible fatal pulmonary hypertensive crisis (PHC), immediately after transferring the patient to the cardiac intensive care unit from the operating room (OR). The PHC was refractory to intravenous and inhaled milrinone and nitroglycerine and intravenous adrenaline, dobutamine, norepinephrine, vasopressin, patent foramen oval (PFO), and CPB support. The management of DOMV and perioperative pulmonary hypertension is discussed.
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Sternal osteomyelitis by Gordonia Bronchialis in an immunocompetent patient after open heart surgery p. 221
Paurush Ambesh, Aditya Kapoor, Danish H Kazmi, Moustafa Elsheshtawy, Vijay Shetty, Yu S Lin, Stephan Kamholz
DOI:10.4103/aca.ACA_125_18  PMID:30971609
Gordonia is a catalase-positive, aerobic, nocardioform, Gram-positive staining actinomycete that also shows weak acid-fast staining. Several Gordonia species are commonly found in the soil. The bacterium has been isolated from the saliva of domesticated/wild dogs as well. In hospitalized patients, most commonly it is found in the setting of intravascular catheter-related infections. However, recent reports show that it is being increasingly isolated from sternal wounds, skin/neoplastic specimens and from pleural effusions. Gordonia shares many common characteristics with Rhodococcus and Nocardia. Ergo, it is commonly misrecognized as Nocardia or Rhodococcus. Since this pathogen requires comprehensive morphological and biochemical testing, it is often difficult and cumbersome to isolate the species. Broad-range Polymerase Chain Reaction (PCR) and sequencing with genes like 16S rRNA or hsp65 are used to correctly identify the species. Identification is essential for choosing and narrowing the right antimicrobial agent. Herein, we report our experience with a patient who presented with sternal osteomyelitis after infection with this elusive bug.
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Aortic rupture during endovascular repair of a postoperative coarctation pseudoaneurysm in an adult: Emergency lifesaving stent graft implantation p. 225
Theodoros Kratimenos, Vasileios Patris, Nikolaos G Baikoussis, Dimitrios Tomais, Ilias Samiotis, Michalis Argiriou
DOI:10.4103/aca.ACA_36_18  PMID:30971610
We present a case with aortic rupture during an operation of thoracic endovascular aortic repair of an anastomotic pseudoaneurysm. This happened after the use of a low-pressure remodeling balloon inside the covered part of the deployed endografts. It was successfully treated with a second more centrally in the aortic arch-implanted endograft with full coverage of the left subclavian artery orifice. This patient had a history of surgically operated aortic coarctation.
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Unusual case of intraoperative acute cor pulmonale during spine surgery p. 229
Bishav Mohan, Palavi Garg, Ruhani Bali, Rajesh Arya, Rohit Tandon, Abhishek Goyal, Bhupinder Singh, Shibba Takkar Chhabra, Naved Aslam, Gurpreet S Wander
DOI:10.4103/aca.ACA_128_18  PMID:30971611
Perioperative complications of prolonged surgery and prone positioning are well known. Changing the position from prone to supine in an anesthetized patient can result in aspiration and airway obstruction. The drop-in oxygen saturation and hemodynamic changes are warning signs and can cause acute cardiac decompensation leading to diagnostic dilemma. We present a case where the patient had these changes after changing the position after spine surgery in prone position. A quick response from the treating anesthesiologist and active involvement of cardiologist helped in reaching the diagnosis and successful management of aspiration pneumonitis in this patient. We conclude that a quick response in investigations and multimodality approach helps in the management of such perioperative complications.
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LETTERS TO EDITOR Top

Nonopioid Analgesics for Managing Postoperative Pain after Cardiothoracic Surgeries p. 233
Abhijit S Nair
DOI:10.4103/aca.ACA_208_18  PMID:30971612
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In response to: Non opioid analgesics for managing postoperative pain after cardiothoracic surgeries p. 234
Brenda Saboi Lupindula Nachiyunde, Louisa Lam
DOI:10.4103/aca.ACA_16_19  PMID:30971613
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Effect of chloride liberal fluids on renal and metabolic profiles of patients undergoing off-pump CABGs p. 235
Satyen Parida, Pranit Patil, Prasanna Udupi Bidkar, Sakthirajan Panneerselvam, MV S Satyaprakash
DOI:10.4103/aca.ACA_223_18  PMID:30971614
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Discovering substitutes to the conventional lead positions of three-lead electrocardiogram monitoring p. 236
Talib Khan, Shaista Yaqoob Mir, Shaqul Qamar Wani
DOI:10.4103/aca.ACA_89_18  PMID:30971615
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