Annals of Cardiac Anaesthesia : 2012 - 15(1)

Scientific publications from India - On the right trajectory?

Murali Chakravarthy — Thu,5 Jan 2012

Murali Chakravarthy

Annals of Cardiac Anaesthesia 2012 15(1):1-3

Are tranexamic acid and ε-aminocaproic acid adequate substitutes for aprotinin?

Deepak K Tempe — Thu,5 Jan 2012

Deepak K Tempe, Suruchi Hasija

Annals of Cardiac Anaesthesia 2012 15(1):4-5

Risk factors associated with postoperative seizures in patients undergoing cardiac surgery who received tranexamic acid: A case-control study

Felix R Montes — Thu,5 Jan 2012

Felix R Montes, Daniel F Pardo, Marisol Carreño, Catalina Arciniegas, Rodolfo J Dennis, Juan P Umaña

Annals of Cardiac Anaesthesia 2012 15(1):6-12

Antifibrinolytic agents are used during cardiac surgery to minimize bleeding and reduce exposure to blood products. Several reports suggest that tranexamic acid (TA) can induce seizure activity in the postoperative period. To examine factors associated with postoperative seizures in patients undergoing cardiac surgery who received TA. University-affiliated hospital. Case-control study. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) between January 2008 and December 2009 were identified. During this time, all patients undergoing heart surgery with CPB received TA. Cases were defined as patients who developed seizures that required initiation of anticonvulsive therapy within 48 h of surgery. Exclusion criteria included subjects with preexisting epilepsy and patients in whom the convulsive episode was secondary to a new ischemic lesion on brain imaging. Controls who did not develop seizures were randomly selected from the initial cohort. From an initial cohort of 903 patients, we identified 32 patients with postoperative seizures. Four patients were excluded. Twenty-eight cases and 112 controls were analyzed. Cases were more likely to have a history of renal impairment and higher preoperative creatinine values compared with controls (1.39 ± 1.1 vs. 0.98 ± 0.02 mg/dL, P = 0.02). Significant differences in the intensive care unit, postoperative and total lengths of stay were observed. An association between high preoperative creatinine value and postoperative seizure was identified. TA may be associated with the development of postoperative seizures in patients with renal dysfunction. Doses of TA should be reduced or even avoided in this population.

Urinary neutrophil gelatinase-associated lipocalin as an early predictor of prolonged intensive care unit stay after cardiac surgery

Elena Bignami — Thu,5 Jan 2012

Elena Bignami, Elena Frati, Ferruccio Ceriotti, Rita Daverio, Simona Silvetti, Giovanni Landoni, Giovanni Marino, Alberto Zangrillo

Annals of Cardiac Anaesthesia 2012 15(1):13-17

Neutrophil gelatinase-associated lipocalin (NGAL) is a protein of lipocalin family highly expressed in various pathologic states and is an early biomarker of acute kidney injury in cardiac surgery. We performed an observational study to evaluate the role of NGAL in predicting postoperative intensive care stay in high-risk patients undergoing cardiac surgery. We enrolled 27 consecutive patients who underwent high-risk cardiac surgery with cardiopulmonary bypass. Urinary NGAL (uNGAL) was measured before surgery, at intensive care unit (ICU) arrival and 24 h later. Univariate and multivariate predictors of ICU stay were performed. uNGAL was 18.0 (8.7-28.1) ng/mL at baseline, 10.7 (4.35-36.0) ng/mL at ICU arrival and 29.6 (9.65-29.5) 24 h later. The predictors of prolonged ICU stay at the multivariate analysis were body mass index (BMI), uNGAL 24 h after surgery, and aortic cross-clamp time. The predictors of high uNGAL levels 24 h after at a multivariate analysis were preoperative uNGAL and logistic European System for Cardiac Operative Risk Evaluation. At a multivariate analysis the only independent predictors of prolonged ICU stay were BMI, uNGAL 24 h after surgery and aortic cross-clamp time.

The effects of preemptive pregabalin on attenuation of stress response to endotracheal intubation and opioid- sparing effect in patients undergoing off-pump coronary artery bypass grafting

Ayya Syama Sundar — Thu,5 Jan 2012

Ayya Syama Sundar, Rajeshkumar Kodali, Sajith Sulaiman, Harish Ravullapalli, Ranjith Karthekeyan, Mahesh Vakamudi

Annals of Cardiac Anaesthesia 2012 15(1):18-25

The clinical study was designed to evaluate and compare single preoperative dose of pregabalin to a placebo regarding hemodynamic responses to laryngoscopy and endotracheal intubation, to assess perioperative fentanyl requirement and any side-effects. It was a randomized, double-blind, placebo-controlled, parallel assignment, efficacy study. The study was done at a tertiary university hospital. This study was a comparison between two groups of 30 adult patients scheduled for elective off pump coronary artery bypass surgery. In the control group, the patients were given placebo capsules, and in the pregabalin group, the patients were given pregabalin 150 mg capsule orally 1 h before surgery. The patients were compared for hemodynamic changes before the start of the surgery, after induction, 1, 3, and 5 min after intubation. Additionally, fentanyl requirement during surgery and the first postoperative day was also compared. The present study shows that a single oral dose of 150 mg pregabalin given 1 h before surgery attenuated the pressor response to tracheal intubation in adults, but the drug did not show any effect on perioperative opioid consumption and was devoid of side-effects in the given dose.

Utility of Sonoclot analysis and tranexamic acid in tetralogy of Fallot patients undergoing intracardiac repair

Vikram Aggarwal — Thu,5 Jan 2012

Vikram Aggarwal, Poonam Malhotra Kapoor, Minati Choudhury, Usha Kiran, Ujjwal Chowdhury

Annals of Cardiac Anaesthesia 2012 15(1):26-31

Sonoclot analysis is a point of care test to monitor the coagulation process, presenting a comprehensive evaluation of the clot formation and retraction as well as platelet function. This randomized double-blinded study was designed to investigate the utility of Sonoclot analysis in monitoring the coagulation profile as also the antifibrinolytic effects of tranexamic acid administered in patients with tetralogy of Fallot undergoing intracardiac repair. Eighty of a total 94 patients were randomly divided into two groups of 40 each. In the study group, TA was administered thrice at a dosage of 10 mg/kg, i.e. before CPB, on CPB and after CPB, whereas in the control group, placebo was administered at the same time intervals. Sonoclot analysis and D-dimer measurement were performed at baseline and following heparin neutralisation. An additional variable, DR 15 (diminishing rate of clot strength at 15 min postmaximal clot strength), was calculated from the Sonoclot graph and was compared with d-dimer levels as a measure of fibrinolysis. The three Sonoclot variables, i.e. activated clotting time, clot rate and platelet function, were deranged at baseline in all the patients. Post-CPB, the change in these variables was not significant. ACT, clot rate and platelet function showed no significant (P > 0.05) difference in both the groups at both the time intervals. DR 15 and d-dimer values were comparable at baseline in both the groups. However, a significant (P < 0.05) difference was seen in these variables in the control group as compared with the TA group following heparin neutralisation. To conclude, Sonoclot analysis is a useful, point of care method for the monitoring of coagulation and fibrinolysis in patients with tetralogy of Fallot undergoing intracardiac repair.

The effect of low-dose intravenous ketamine on continuous intercostal analgesia following thoracotomy

Alexandre Yazigi — Thu,5 Jan 2012

Alexandre Yazigi, Hicham Abou-Zeid, Tamara Srouji, Samia Madi-Jebara, Fadia Haddad, Khalil Jabbour

Annals of Cardiac Anaesthesia 2012 15(1):32-38

Ketamine, a noncompetitive N-methyl-d-aspartate antagonist, provides analgesia and prevents chronic pain following thoracotomy. The study was aimed to assess the effect of intravenous low-dose ketamine on continuous intercostal nerve block analgesia following thoracotomy. The study was a prospective, randomized, double-blinded, and placebo-controlled clinical study, performed in a single university hospital. Sixty patients, undergoing elective lobectomy through an open posterolateral thoracotomy, were included. For postoperative pain, all patients received a continuous intercostal nerve block with bupivacaine plus intravenous paracetamol and ketoprofen. In addition, patients were randomized to have intravenous ketamine (0.1 mg/kg as a preincisional bolus followed by a continuous infusion of 0.05 mg/kg/h) in group 1 or intravenous placebo in group 2. Patients reporting a visual analog scale pain score at rest ≥40 mm received intravenous morphine sulfate as rescue analgesia. The following parameters were assessed every 6 hours for 3 postoperative days: Visual analog scale pain scores at rest and during coughing, requirement of rescue analgesia with morphine, Ramsay sedation scores and psychomimetic adverse effects. Both the groups were statistically comparable regarding visual analog scale pain scores at rest (P=0.75) and during coughing (P=0.70), number of morphine deliveries (P=0.17), cumulative dose of rescue morphine (P=0.2), sedation scores (P=0.4), and psychomimetic adverse effects (P=0.09). Intravenous low-dose ketamine, when combined with continuous intercostal nerve block, did not decrease acute pain scores and supplemental morphine consumption following thoracotomy.

The effects of dexmedetomidine on attenuation of stress response to endotracheal intubation in patients undergoing elective off-pump coronary artery bypass grafting

Sajith Sulaiman — Thu,5 Jan 2012

Sajith Sulaiman, Ranjith Baskar Karthekeyan, Mahesh Vakamudi, Ayya Syama Sundar, Harish Ravullapalli, Ravikumar Gandham

Annals of Cardiac Anaesthesia 2012 15(1):39-43

This study was designed to study the efficacy of intravenous dexmedetomidine for attenuation of cardiovascular responses to laryngoscopy and endotracheal intubation in patients with coronary artery disease. Sixty adult patients scheduled for elective off-pump coronary artery bypass surgery were randomly allocated to receive dexmedetomidine (0.5 mcg/kg) or normal saline 15 min before intubation. Patients were compared for hemodynamic changes (heart rate, arterial blood pressure and pulmonary artery pressure) at baseline, 5 min after drug infusion, before intubation and 1, 3 and 5 min after intubation. The dexmedetomidine group had a better control of hemodynamics during laryngoscopy and endotracheal intubation. Dexmedetomidine at a dose of 0.5 mcg/kg as 10-min infusion was administered prior to induction of general anaesthesia attenuates the sympathetic response to laryngoscopy and intubation in patients undergoing myocardial revascularization. The authors suggest its administration even in patients receiving beta blockers.

Anaesthetic management of peripartum cardiomyopathy using "epidural volume extension" technique: A case series

Akhilesh Kumar Tiwari — Thu,5 Jan 2012

Akhilesh Kumar Tiwari, Jitendra Agrawal, Swapnil Tayal, Madhur Chadha, Anuja Singla, Grace Valson, Gaurav Singh Tomar

Annals of Cardiac Anaesthesia 2012 15(1):44-46

Peripartum cardiomyopathy is a rare cause of dilated cardiomyopathy in parturients, occurring in approximately one in 1000 deliveries, manifesting during the last few months or the first 5 months of the postpartum period. It can result in severe ventricular dysfunction during late puerperium. The major concern while managing these patients is to optimize fluid administration and avoid myocardial depression, while maintaining stable intraoperative hemodynamics. We present a case series of five parturients that were posted for elective cesarean section and managed successfully by the epidural volume extension technique.

Earthing defect: A cause for unstable hemodynamics

R Barani Selvan — Thu,5 Jan 2012

R Barani Selvan, Parnandi Bhaskar Rao, TR Ramachandran, David George Veliath

Annals of Cardiac Anaesthesia 2012 15(1):47-49

Interference of monitored electrocardiogram (ECG) is a common event in intensive care units and operation theaters. Artifacts in the ECG tracing can resemble serious arrhythmia, thus leading to unnecessary usage of antiarrhythmics or electrical defibrillation. In addition, ECG artifacts may lead to serious hemodynamic consequences secondary to intra-aortic balloon pump (IABP) trigger failure. We report a rare event of IABP failure due to ECG artifact, which appeared on placement of the transthoracic echocardiography probe over the chest. Subsequent evaluation revealed potential current leakage from echocardiography machine secondary to earthing defect in the machine.

Perioperative challenges in a patient of severe G6PD deficiency undergoing open heart surgery

Vivek Chowdhry — Thu,5 Jan 2012

Vivek Chowdhry, Samarjit Bisoyi, Banabihari Mishra

Annals of Cardiac Anaesthesia 2012 15(1):50-53

We describe a successful perioperative management of a case of 38-year-old male, presented with chronic jaundice with severe mitral stenosis and moderate tricuspid regurgitation; upon evaluation, he was found to have severe glucose-6-phosphate dehydrogenase (G6PD) deficiency. Usually, patients deficient in G6PD exhibit increased hemolysis andtherefore increased need for blood transfusion after cardiac surgery as well as impaired oxygenation in the postoperative period leading to prolonged ventilation. On reperfusion after a period of ischemia, the antioxidant system recruits all of its components in an attempt to neutralize the overwhelming oxidative stress of free radicals, as the free radical scavenging system is deficient in these patients, the chances of free-radical-induced injury is more. Our patient underwent mitral valve replacement and tricuspid annuloplasty under cardiopulmonary bypass with necessary precautions to reduce the formation of free radicals. Treatment was targeted toward theprevention of free radical injuryin the G6PD-deficient patient. He had an uneventful intraoperative and postoperative course.

Anaesthetic management of transcatheter aortic valve implantation

Annalisa Franco — Thu,5 Jan 2012

Annalisa Franco, Chiara Gerli, Laura Ruggeri, Fabrizio Monaco

Annals of Cardiac Anaesthesia 2012 15(1):54-63

Transcatheter aortic valve implantation (TAVI) is an emergent technique for high-risk patients with aortic stenosis. TAVI poses significant challenges about its management because of the procedure itself and the population who undergo the implantation. Two devices are currently available and marketed in Europe and several other technologies are being developed. The retrograde transfemoral approach is the most popular procedure; nevertheless, it may not be feasible in patients with signiﬁcant aortic or ileo-femoral arterial disease. Alternatives include a transaxillary approach, transapical approach, open surgical access to the retroperitoneal iliac artery and the ascending aorta. A complementary approach using both devices and alternative routes tailored to the anatomy and the comorbidities of the single patient is a main component for the successful implementation of a TAVI program. Anaesthetic strategies vary in different centers. Local anaesthesia or general anaesthesia are both valid alternatives and can be applied according to the patient's characteristics and procedural instances. General anaesthesia offers many advantages, mainly regarding the possibility of an early diagnosis and treatment of possible complications through the use of transesophageal echocardiography. However, after the initial experiences, many groups began to employ, routinely, sedation plus local anaesthesia for TAVI, and their procedural and periprocedural success demonstrates that it is feasible. TAVI is burdened with potential important complications: vascular injuries, arrhythmias, renal impairment, neurological complications, cardiac tamponade, prosthesis malpositioning and embolization and left main coronary artery occlusion. The aim of this work is to review the anaesthetic management of TAVI based on the available literature.

ST segment depression following pulmonary artery banding

Rakhi K Retnamma — Thu,5 Jan 2012

Rakhi K Retnamma, Suresh G Nair, GS Sunil, R Benedict

Annals of Cardiac Anaesthesia 2012 15(1):64-66

Incidental transarterial placement of a dialysis catheter into the femoral vein

Gerald Huschak — Thu,5 Jan 2012

Gerald Huschak, Felix Pfeifer, Ludger Mende, Florian Dazinger, Udo X Kaisers, Sven Laudi

Annals of Cardiac Anaesthesia 2012 15(1):67-68

Extracorporeal Membrane Oxygenation - an Anaesthesiologist's perspective - Part II: Clinical and Technical consideration

Sandeep Chauhan — Thu,5 Jan 2012

Sandeep Chauhan, S Subin

Annals of Cardiac Anaesthesia 2012 15(1):69-82

Although the concept of extracorporeal membrane oxygenation (ECMO) has remained unchanged, component technology has evolved considerably over the past three decades. Presently the clinical conditions requiring ECMO support have been updated with input from the outcome data of patient registries. Modern circuit configuration has become less cumbersome, safer, and more efficient. Technological advances now allow prolonged support with fewer complications compared to the past eras and facilitate transition to a single bedside caregiver model, similar to hemofiltration or ventricular-assist devices. The clinical considerations and indicators for placing the patient on ECMO, the various circuit configurations, clinical and technical issues, and management aspects are considered in this article.

Coronary artery bypass grafting and dengue fever

Viroj Wiwanitkit — Thu,5 Jan 2012

Viroj Wiwanitkit

Annals of Cardiac Anaesthesia 2012 15(1):83-83

Off-pump cardiac surgery (OPCAB) in a patient with recent leech therapy

Ravindra Sawhney — Thu,5 Jan 2012

Ravindra Sawhney, Rajiv Juneja, Rajinder Singh Rawat, Yatin Mehta, Naresh Trehan

Annals of Cardiac Anaesthesia 2012 15(1):83-85

Artifactual electrocardiographic ST segment depression: Less likely due to electrocautery

Santosh Patel — Thu,5 Jan 2012

Santosh Patel

Annals of Cardiac Anaesthesia 2012 15(1):85-86

TRALI: A volley of caution

Dilip Gude — Thu,5 Jan 2012

Dilip Gude

Annals of Cardiac Anaesthesia 2012 15(1):86-87

Lumbar epidural analgesia in pain management of Nuss procedures: Paediatric case

Handan Birbicer — Thu,5 Jan 2012

Handan Birbicer, Nurcan Doruk, Yücel Uguz, Türkan Altun

Annals of Cardiac Anaesthesia 2012 15(1):87-88

Irreversible loss of vision in a paediatric patient due to occipital infarction after cardiopulmonary bypass

Vishnu Datt — Thu,5 Jan 2012

Vishnu Datt, Sanjula Virmani, Indira Malik, Saket Agarwal, Chander S Joshi, Aastha Dhingra, Rahul Dutta, Akhalesh S Tomar

Annals of Cardiac Anaesthesia 2012 15(1):88-90

Decompression of superior vena cava during Bidirectional Glenn Shunt: A simple but risky technique

Praveen Kumar Neema — Thu,5 Jan 2012

Praveen Kumar Neema, Sethuraman Manikandan, Subrata K Singha, Ramesh Chandra Rathod

Annals of Cardiac Anaesthesia 2012 15(1):90-92

Authors' reply

Venugopal Kulkarni — Thu,5 Jan 2012

Venugopal Kulkarni, Ravikiran Mudunuri, Krishnaprasad Mulavisala, R Jagannath Byalal

Annals of Cardiac Anaesthesia 2012 15(1):92-92

Prophylactic percutaneous minitracheostomy after omentoplasty for sternal wound infection

Dheeraj Arora — Thu,5 Jan 2012

Dheeraj Arora, Yatin Mehta

Annals of Cardiac Anaesthesia 2012 15(1):92-93