Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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  Citation statistics : Table of Contents
   2008| January-June  | Volume 11 | Issue 1  
    Online since January 7, 2008

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Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery
Bharathi H Scott, Frank C Seifert, Roger Grimson
January-June 2008, 11(1):15-19
DOI:10.4103/0971-9784.38444  PMID:18182754
The purpose of the present investigation was to examine the impact of blood transfusion on resource utilisation, morbidity and mortality in patients undergoing coronary artery bypass graft (CABG) surgery at a major university hospital. The resources we examined are time to extubation, intensive care unit length of stay (ICULOS) and postoperative length of stay (PLOS). We further examined the impact of number of units of packed red blood cells (PRBCs) transfused during PLOS. This is a retrospective observational study and includes 1746 consecutive male and female patients undergoing primary CABG (on- and off-pump) at our institution. Of these, 1067 patients received blood transfusions, while 677 did not. The data regarding the demography, blood transfusion, resource utilisation, morbidity and mortality were collected from the records of patients undergoing CABG over a period of three years. The mean time to extubation following surgery was 8.0 h for the transfused group and 4.3 h for the nontransfused group ( P ≤ 0.001). The mean ICULOS for the transfused group was 1.6 d and 1.2 d for the nontransfused group ( P < 0.001). The PLOS was 7.2 d for the transfused group and 4.3 d for no-transfused cohorts ( P ≤ 0.001). In all patients and in patients with no preoperative morbidity, partial correlation coefficients were used to examine the effects of transfusion on mortality, time to extubation, ICULOS and PLOS. Linear regression model was used to assess the effect of number of PRBC units transfused on PLOS. We noted that PLOS increased with the number of PRBCs units transfused. Transfusion is significantly correlated with the increased time to extubation, ICULOS, PLOS and mortality. The transfused patients had significantly more postoperative complications than their nontransfused counterparts ( P ≤ 0.001). The 30-day hospital mortality was 3.1% for the transfused group with no deaths in the nontransfused group ( P ≤ 0.001). We conclude that the CABG patients receiving blood transfusion have significantly longer time for tracheal extubation, ICULOS, PLOS and higher morbidity and 30-day hospital mortality. Blood transfusion was an independent predictor of increased resource utilisation, postoperative morbidity and mortality.
  130 11,832 1,564
Cardiac output monitoring
Lailu Mathews, Kalyan RK Singh
January-June 2008, 11(1):56-68
DOI:10.4103/0971-9784.38455  PMID:18182765
Minimally invasive and non-invasive methods of estimation of cardiac output (CO) were developed to overcome the limitations of invasive nature of pulmonary artery catheterization (PAC) and direct Fick method used for the measurement of stroke volume (SV). The important minimally invasive techniques available are: oesophageal Doppler monitoring (ODM), the derivative Fick method (using partial carbon dioxide (CO 2 ) breathing), transpulmonary thermodilution, lithium indicator dilution, pulse contour and pulse power analysis. Impedance cardiography is probably the only non-invasive technique in true sense. It provides information about haemodynamic status without the risk, cost and skill associated with the other invasive or minimally invasive techniques. It is important to understand what is really being measured and what assumptions and calculations have been incorporated with respect to a monitoring device. Understanding the basic principles of the above techniques as well as their advantages and limitations may be useful. In addition, the clinical validation of new techniques is necessary to convince that these new tools provide reliable measurements. In this review the physics behind the working of ODM, partial CO 2 breathing, transpulmonary thermodilution and lithium dilution techniques are dealt with. The physical and the physiological aspects underlying the pulse contour and pulse power analyses, various pulse contour techniques, their development, advantages and limitations are also covered. The principle of thoracic bioimpedance along with computation of CO from changes in thoracic impedance is explained. The purpose of the review is to help us minimize the dogmatic nature of practice favouring one technique or the other.
  83 29,113 5,656
Early goal-directed therapy in moderate to high-risk cardiac surgery patients
Poonam Malhotra Kapoor, Madhava Kakani, Ujjwal Chowdhury, Minati Choudhury, R Lakshmy, Usha Kiran
January-June 2008, 11(1):27-34
DOI:10.4103/0971-9784.38446  PMID:18182756
Early goal-directed therapy is a term used to describe the guidance of intravenous fluid and vasopressor/inotropic therapy by using cardiac output or similar parameters in the immediate post-cardiopulmonary bypass in cardiac surgery patients. Early recognition and therapy during this period may result in better outcome. In keeping with this aim in the cardiac surgery patients, we conducted the present study. The study included 30 patients of both sexes, with EuroSCORE ≥3 undergoing coronary artery bypass surgery under cardiopulmonary bypass. The patients were randomly divided into two groups, namely, control and early goal-directed therapy (EGDT) groups. All the subjects received standardized care; arterial pressure was monitored through radial artery, central venous pressure through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour and frequent arterial blood gas analysis. In addition, cardiac index monitoring using FloTrac™ and continuous central venous oxygen saturation using PreSep™ was used in patients in the EGTD group. Our aim was to maintain the cardiac index at 2.5-4.2 l/min/m 2 , stroke volume index 30-65 ml/beat/m 2 , systemic vascular resistance index 1500-2500 dynes/s/cm 5 /m 2 , oxygen delivery index 450-600 ml/min/m 2 , continuous central venous oximetry more than 70%, stroke volume variation less than 10%; in addition to the control group parameters such as central venous pressure 6-8 mmHg, mean arterial pressure 90-105 mmHg, normal arterial blood gas analysis values, pulse oximetry, hematocrit value above 30% and urine output more than 1 ml/kg/h. The aims were achieved by altering the administration of intravenous fluids and doses of inotropic or vasodilator agents. Three patients were excluded from the study and the data of 27 patients analyzed. The extra volume used (330 ± 160 v/s 80 ± 80 ml, P = 0.043) number of adjustments of inotropic agents (3.4 ± 1.5 v/s 0.4 ± 0.7, P = 0.026) in the EGDT group were significant. The average duration of ventilation (13.8 ± 3.2 v/s 20.7 ± 7.1 h), days of use of inotropic agents (1.6 ± 0.9 v/s 3.8 ± 1.6 d), ICU stay (2.6 ± 0.9 v/s 4.9 ± 1.8 d) and hospital stay (5.6 ± 1.2 v/s 8.9 ± 2.1 d) were less in the EGDT group, compared to those in the control group. This study is inconclusive with regard to the beneficial aspects of the early goal-directed therapy in cardiac surgery patients, although a few benefits were observed.
  78 15,775 2,270
Current status of bosentan for treatment of pulmonary hypertension
Shahzad G Raja, Gilles D Dreyfus
January-June 2008, 11(1):6-14
DOI:10.4103/0971-9784.38443  PMID:18182753
Pulmonary arterial hypertension (PAH) is a debilitating disease associated with significant morbidity and a high mortality if left untreated. Over the past 5 years, there have been significant advances with regard to the understanding of the pathogenesis, diagnosis and classification of PAH. The availability of newer drugs has resulted in a radical change in the management of this disease with significant improvement in both the quality of life and mortality. One of the recent drugs is an orally active dual endothelin receptor antagonist, bosentan; this drug has shown to improve the exercise capacity and survival in patients with PAH. This review article discusses the pharmacology of bosentan and summarises the current available evidence for the safety and efficacy of bosentan for the treatment of PAH.
  18 13,452 2,072
Tako-Tsubo syndrome in an anaesthetised patient undergoing arthroscopic knee surgery
Feyzi Artukoglu, Andrew Owen, Thomas M Hemmerling
January-June 2008, 11(1):38-41
DOI:10.4103/0971-9784.38448  PMID:18182758
We present a case of stress-induced myocardial stunning, also known as tako-Tsubo syndrome, in an anaesthetised patient undergoing arthroscopic replacement of the cruciate ligament. The patient's (44 y male, ASA class II) had a history of hypertension with no other known disease. He underwent a femoral nerve block with 20 ml of 0.5% ropivacaine before receiving a balanced general anaesthesia (propofol induction, sevoflurane maintenance, 10 µg/kg sufentanil). Ten min after the beginning of surgery during endoscopic intra-articular manipulation, the patient suffered from bradycardia and hypotension; following the administration of ephedrine and atropine, he developed tachycardia, hypertension and ST segment depression. Subsequently, his systemic blood pressure dropped necessitating inotropic drug support and - later - intraaortic balloon counterpulsation; a TEE revealed no evidence of hypovolemia, anterior and antero-septal hypokinesia with an ejection fraction of 25%. Surgery was finished whilst stabilising the patient haemodynamically. Postoperative cardiac enzymes showed little elevation, an emergency coronary angiogram apical akinesia with typical ballooning and basal hyperkinesias, compatible with Tako-tsubo syndrome. The patient's postoperative course was uneventful. We theorize that stress caused by sudden surgical pain stimulus (introduction of the endoscope into the articulation), superficial anaesthesia and insufficient analgesia created a stressful event which probably might have caused a catecholamine surge as basis of Tako-tsubo syndrome.
  16 6,527 722
Resistance in gram-negative bacilli in a cardiac intensive care unit in India: Risk factors and outcome
Mandakini Pawar, Yatin Mehta, Apoorva Purohit, Naresh Trehan, Rosenthal Victor Daniel
January-June 2008, 11(1):20-26
DOI:10.4103/0971-9784.38445  PMID:18182755
The objective of this study was to compare the risk factors and outcome of patients with preexisting resistant gram-negative bacilli (GNB) with those who develop sensitive GNB in the cardiac intensive care unit (ICU). Of the 3161 patients ( n = 3,161) admitted to the ICU during the study period, 130 (4.11%) developed health care-associated infections (HAIs) with GNB and were included in the cohort study. Pseudomonas aeruginosa (37.8%) was the most common organism isolated followed by Klebsiella species (24.2%), E. coli (22.0%), Enterobacter species (6.1%), Stenotrophomonas maltophilia (5.7%), Acinetobacter species (1.3%), Serratia marcescens (0.8%), Weeksella virosa (0.4%) and Burkholderia cepacia (0.4%). Univariate analysis revealed that the following variables were significantly associated with the antibiotic-resistant GNB: females ( P = 0.018), re-exploration ( P = 0.004), valve surgery ( P = 0.003), duration of central venous catheter ( P < 0.001), duration of mechanical ventilation ( P < 0.001), duration of intra-aortic balloon counter-pulsation ( P = 0.018), duration of urinary catheter ( P < 0.001), total number of antibiotic exposures prior to the development of resistance ( P < 0.001), duration of antibiotic use prior to the development of resistance ( P = 0.014), acute physiology and age chronic health evaluation score (APACHE II), receipt of anti-pseudomonal penicillins (piperacillin-tazobactam) ( P = 0.002) and carbapenems ( P < 0.001). On multivariate analysis, valve surgery (adjusted OR = 2.033; 95% CI = 1.052-3.928; P = 0.035), duration of mechanical ventilation (adjusted OR = 1.265; 95% CI = 1.055-1.517; P = 0.011) and total number of antibiotic exposure prior to the development of resistance (adjusted OR = 1.381; 95% CI = 1.030-1.853; P = 0.031) were identified as independent risk factors for HAIs in resistant GNB. The mortality rate in patients with resistant GNB was significantly higher than those with sensitive GNB (13.9% vs. 1.8%; P = 0.03). HAI with resistant GNB, in ICU following cardiac surgery, are independently associated with the following variables: valve surgeries, duration of mechanical ventilation and prior exposure to antibiotics. The mortality rate is significantly higher among patients with resistant GNB.
  14 7,040 1,140
Cardiac output - Have we found the 'gold standard'?
Murali Chakravarthy
January-June 2008, 11(1):1-2
DOI:10.4103/0971-9784.38441  PMID:18182751
  6 4,821 927
Anomalous connection of superior vena cava to the left atrium masquerading as epilepsy: A case report with review of literature
Sandeep Singh, Muhammed Abid Geelani, Pranav Modi, Yogesh Niwaria, Sudhir Shahi, Amit Banerjee
January-June 2008, 11(1):42-45
DOI:10.4103/0971-9784.38449  PMID:18182759
An 11-year-old girl who presented with recurrent epileptic fits was eventually found to have a superior vena cava draining into the left atrium. There was no atrial septal defect. The patient underwent a successful surgical correction.
  3 4,694 386
Grown-up congenital heart (GUCH) disease: An evolving global challenge
James A DiNardo
January-June 2008, 11(1):3-5
DOI:10.4103/0971-9784.38442  PMID:18182752
  3 4,994 773
Incidental TOE finding - Carpentier mitral annuloplasty ring dehiscence during heart transplantation
Harish Ramakrishna
January-June 2008, 11(1):49-50
DOI:10.4103/0971-9784.38451  PMID:18182761
  3 2,785 256
Use of intraaortic balloon counter pulsation in a patient with tortuous aorta
Murali Chakravarthy, Vivek Jawali
January-June 2008, 11(1):35-37
DOI:10.4103/0971-9784.38447  PMID:18182757
The intraaortic balloon pulsation (IABP) catheter is commonly used to treat left ventricular failure. The abnormality of the descending thoracic and abdominal aorta is considered as a relative contraindication for its insertion. We present here a patient with acute myocardial infarction with a post-infarct ventricular septal defect who presented with left ventricular failure. During coronary angiography, tortuous abdominal aorta was noted and IABP catheter was inserted under fluoroscopic guidance to support the cardiovascular system. This case is reported to encourage discussion on the use of IABP catheters in patients with tortuous aorta and avoidance of events described.
  1 5,697 405
Simultaneous off-pump coronary artery bypass graft surgery and wide glossectomy
Shilpa Bhojraj, Sanjesh Jain, Zainul Hamdulay, Pawan Kumar, Mohammed Ali, Sultan Pradhan
January-June 2008, 11(1):46-48
DOI:10.4103/0971-9784.38450  PMID:18182760
Patients suffering with significant coronary artery disease undergoing elective noncardiac surgery may benefit by revascularisation prior to noncardiac surgery with high or intermediate risks. Alternatively, combined procedures can be performed. We describe the management of an anaesthetic patient suffering with significant coronary artery disease with left ventricular dysfunction and tumour of the tongue causing difficult intubation.
  - 3,089 221
Congenital left atrial appendage aneurysm
Thiruvenkadam Selvaraj, Poonam Malhotra Kapoor, T Murali Krishna, Usha Kiran, Ujjwal Chowdhury, Sandeep Seth
January-June 2008, 11(1):51-52
DOI:10.4103/0971-9784.38452  PMID:18182762
  - 3,284 415
An unusual cause of hypoxaemia in a patient with pneumonia
Tiziana Bove, Giuseppe Crescenzi, Mariagrazia Calabro, Camilla Biselli, Martina Crivellari, Giulia Maj, Giovanni Landoni, Alberto Zangrillo
January-June 2008, 11(1):53-54
DOI:10.4103/0971-9784.38453  PMID:18182763
  - 3,341 256
Arterial inflow cannula obstruction during paediatric cardiac surgery
Sambhunath Das, Madhava Kakani, Usha Kiran, Akshaya Kumar Bisoi, Ritu Airan
January-June 2008, 11(1):54-55
DOI:10.4103/0971-9784.38454  PMID:18182764
  - 2,813 214