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.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

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.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

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.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

Volatile anaesthetic agents have direct protective properties against ischemic myocardial damage. The implementation of these properties during clinical anaesthesia can provide an additional tool in the treatment or prevention, or both, of ischemic cardiac dysfunction in the perioperative period. A recent meta-analysis showed that desflurane and sevoflurane reduce postoperative mortality and incidence of myocardial infarction following cardiac surgery, with significant advantages in terms of postoperative cardiac troponin release, need for inotrope support, time on mechanical ventilation, intensive care unit and overall hospital stay. Multicentre, randomised clinical trials had previously demonstrated that the use of desflurane can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalisation following coronary artery bypass graft surgery either with and without cardiopulmonary bypass. The American College of Cardiology/American Heart Association Guidelines recommend volatile anaesthetic agents during non-cardiac surgery for the maintenance of general anaesthesia in patients at risk for myocardial infarction. Nonetheless, e vidence in non-coronary surgical settings is contradictory and will be reviewed in this paper together with the mechanisms of cardiac protection by volatile agents.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]  [PubMed]

We prospectively compared four techniques of cardiac output measurement: bolus thermodilution cardiac output (TDCO), continuous cardiac output (CCO), pulse contour cardiac output (PiCCO™), and Flowtrac^™ (FCCO), simultaneously in fifteen patients undergoing off-pump coronary artery bypass grafting (OPCAB). All the patients received pulmonary artery catheter (capable of measuring both bolus thermodilution cardiac output and CCO), PiCCO^™ arterial cannula in the left and FCCO in the right femoral artery. Cardiac indices (CI) were obtained every fifteen minutes by using all the four techniques. TDCO was treated as 'control' and the rest were treated as 'test' values. Interchangeability of techniques with TDCO was assessed by Bland and Altman plotting and mountain plot. Four hundred and thirty eight sets of data were obtained from fifteen patients. The values of cardiac output varied between 1 to 6.9 L/min. We found that the values of all the techniques were interchangeable. At certain times, the values of CI measured by both PiCCO and FCCO appeared erratic. The values of CI measured simultaneously appeared in the following descending order of accuracy; TDCO>CCO>FCCO>PiCCO ( the % times TDCO correlated with CCO, FCCO, PiCCO was 93, 86 and 80 respectively). The bias and precision (in L/ min) for CCO were 0.03, 0.06, PiCCO 0.13, 0.1 and flowtrac^™ 0.15, 0.04 respectively suggesting interchangeability. We conclude that the cardiac output measured by CCO technique and the pulse contour as measured by PiCCO and FCCO were interchangeable with TDCO more than 80% of the times.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

Minimally invasive surgery with robotic assistance should elicit minimal pain. Regional analgesic techniques have shown excellent analgesia after thoracotomy. Thus the aim of this study was to compare thoracic epidural analgesia (TEA) technique with paravertebral block (PVB) technique in these patients with regard to quality of analgesia, complications, and haemodynamic and respiratory parameters. This was a prospective randomised study involving 36 patients undergoing elective robotic-assisted coronary artery bypass grafting (CABG). TEA or PVB were administered in these patients. The results revealed no significant differences with regard to demographics, haemodynamics, and arterial blood gases. Pulmonary functions were better maintained in PVB group postoperatively; however, this was statistically insignificant. The quality of analgesia was also comparable in both the groups. We conclude that PVB is a safe and effective technique for postoperative analgesia after robotic-assisted CABG and is comparable to TEA with regard to quality of analgesia.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

During induction of general anesthesia hypertension and tachycardia caused by tracheal intubation may lead to cardiac ischemia and arrhythmias. In this prospective, randomized study, dexmedetomidine has been used to attenuate the hemodynamic response to endotracheal intubation with low dose fentanyl and etomidate in patients undergoing myocardial revascularization receiving beta blocker treatment. Thirty patients undergoing myocardial revascularization received in a double blind manner, either a saline placebo or a dexmedetomidine infusion (1 µg/kg) before the anesthesia induction. Heart rate (HR) and blood pressure (BP) were monitored at baseline, after placebo or dexmedetomidine infusion, after induction of general anesthesia, one, three and five minutes after endotracheal intubation. In the dexmedetomidine (DEX) group systolic (SAP), diastolic (DAP) and mean arterial pressures (MAP) were lower at all times in comparison to baseline values; in the placebo (PLA) group SAP, DAP and MAP decreased after the induction of general anesthesia and five minutes after the intubation compared to baseline values. This decrease was not significantly different between the groups. After the induction of general anesthesia, the drop in HR was higher in DEX group compared to PLA group. One minute after endotracheal intubation, HR significantly increased in PLA group while, it decreased in the DEX group. The incidence of tachycardia, hypotension and bradycardia was not different between the groups. The incidence of hypertension requiring treatment was significantly greater in the PLA group. It is concluded that dexmedetomidine can safely be used to attenuate the hemodynamic response to endotracheal intubation in patients undergoing myocardial revascularization receiving beta blockers.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

The aim of this prospective, randomized, and double-blinded study was to compare the effects of desflurane, sevoflurane, propofol on both atrial and ventricular wall function by measurement of QT dispersion (QTd), corrected QT dispersion (QTcd), and P dispersion (Pd) on electrocardiogram (ECG). Forty-six patients from the American Society of Anesthesiologists class I−II undergoing noncardiac surgery, were enrolled in this study. Patients were randomly allocated to receive desflurane, sevoflurane or propofol anesthesia. ECG recordings were taken before and after 5 minutes of drug administration. Induction with desflurane significantly increased the QTd compared to baseline (38 ± 2 ms vs. 62 ± 6 ms, P < 0.05). Sevoflurane and propofol anesthesia was not associated with any changes in QTd. QTcd was increased with desflurane induction and decreased with sevoflurane and propofol induction, but this decrease was only significant in the propofol group (67 ± 5 ms vs. 45 ± 3 ms, P < 0.05). Pd was significantly increased after induction with desflurane (34 ± 3 vs. 63 ± 6 ms, P < 0.05). There was a significant increase in QTd and Pd in desflurane group, but this increment did not cause any dangerous arrhythmias. QTcd significantly decreased in propofol group. We believe that further investigations are required for using desflurane as safe as sevoflurane and propofol in noncardiac surgery patients who have high cardiac arrhythmia and ischemia risk.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

Extracorporeal membrane oxygenation (ECMO) is an adaptation of conventional cardiopulmonary bypass techniques to provide cardiopulmonary support. ECMO provides physiologic cardiopulmonary support to aid reversible aspects of the disease process and to allow recovery. ECMO does not provide treatment of the underlying disease. The indications for ECMO support have expanded from acute respiratory failure to acute cardiac failure refractory to conventional treatments from wide patient subsets involving neonates to adults. Vascular access for ECMO support is either percutaneous through a single-site, dual-lumen bicaval cannula or transthoracic via separate cannulas. The modes of support are either veno-venous or veno-arterial ECMO. In this article, the physiologic aspects of ECMO support are outlined.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]  [PubMed]

Williams syndrome is a complex syndrome characterized by developmental abnormalities, craniofacial dysmorphic features, and cardiac anomalies. Sudden death has been described as a very common complication associated with anesthesia, surgery, and procedures in this population. Anatomical abnormalities associated with the heart pre-dispose these individuals to sudden death. In addition to a sudden and rapid downhill course, lack of response to resuscitation is another significant feature seen in these patients. The authors report a five-year-old male with Williams syndrome, hypothyroidism, and attention deficit hyperactivity disorder. He suffered an anaphylactic reaction during CT imaging with contrast. Resuscitation was unsuccessful. Previous reports regarding the anesthetic management of patients with Williams are reviewed and the potential for sudden death or peri-procedure related cardiac arrest discussed in this report. The authors also review reasons for refractoriness to defined resuscitation guidelines in this patient population.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

Perioperative Thoracic epidural analgesia (TEA) is an important part of a multimodal approach to improve analgesia and patient outcome after cardiac and thoracic surgery. This is particularly important for obese patients undergoing off pump coronary artery bypass surgery (OPCAB). We conducted a randomized clinical trial at tertiary care cardiac institute to compare the effect of TEA and conventional opioid based analgesia on perioperative lung functions and pain scores in obese patients undergoing OPCAB. Sixty obese patients with body mass index >30 kg/m ² for elective OPCAB were randomized into two groups (n=30 each). Patients in both the groups received general anesthesia but in group 1, TEA was also administered. We performed spirometry as preoperative assessment and at six hours, 24 hours, second, third, fourth and fifth day after extubation, along with arterial blood gases analysis. Visual analogue scale at rest and on coughing was recorded to assess the degree of analgesia. The other parameters observed were: time to endotracheal extubation, oxygen withdrawal time and intensive care unit length of stay. On statistical analysis there was a significant difference in Vital Capacity at six hours, 24 hours, second and third day postextubation. Forced vital capacity and forced expiratory volume in one second followed the same pattern for first four postoperative days and peak expiratory flow rate remained statistically high till second postoperative day. ABG values and PaO ₂ /FiO ₂ ratio were statistically higher in the study group up to five days. Visual analogue scale at rest and on coughing was significantly lower till fourth and third postoperative day respectively. Tracheal extubation time, oxygen withdrawal time and ICU stay were significantly less in group 1. The use of TEA resulted in better analgesia, early tracheal extubation and shorter ICU stay and should be considered for obese patients undergoing OPCAB.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

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.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]  [PubMed]

Perioperative and postoperative morbidity and mortality associated with cardiac surgery affect both the outcome and quality of life. Markers such as troponin effectively predict short-term outcome. In a prospective cohort study in a University Hospital we assessed the role of cardiac biomarkers, also as predictors of long-term outcome and life quality after cardiac surgery with a three-year follow-up after conventional heart surgery. Patients were interviewed via phone calls with a structured questionnaire examining general health, functional status, activities of daily living, perception of life quality and need for hospital readmission. Descriptive statistics and multivariate analysis were performed. Out of 252 consecutive patients, 8 (3.2%) died at the three years follow up: 7 for cardiac complications and 1 for cancer. Thirty-six patients (13.5%) had hospital readmission for cardiac causes (mostly for atrial fibrillation or other arrhythmias (9.3%), but none needed cardiac surgical reintervention; 21 patients (7.9%) were hospitalised for non-cardiac causes. No limitation in function activities of daily living was reported by most patients (94%), 92% perceived their general health as excellent, very good or good and none considered it insufficient; 80% were NYHA I, 17% NYHA II, 3% NYHA III and none NYHA IV. Multivariate analysis indicated preoperative treatment with digitalis or nitrates, and postoperative cardiac biomarkers release was independently associated to death. Elevated cardiac biomarker release and length of hospital stay were the only postoperative independent predictors of death in this study.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]  [PubMed]

C-reactive protein is a powerful independent predictor of cardiovascular events in patients with coronary artery disease. The relation between C-reactive protein (CRP) concentration and in-hospital outcome, after coronary artery bypass grafting (CABG), has not yet been established. The study aims to evaluate the predictive value of pre-operative CRP for in-hospital cardiovascular events after CABG surgery. High-sensitivity CRP (hs-CRP) levels were measured pre-operatively on the day of surgery in 66 patients scheduled for elective on pump CABG surgery. Post-operative cardiovascular events such as death from cardiovascular causes, ischemic stroke, myocardial damage, myocardial infarction and low output heart failure were recorded. During the first 30 days after surgery, 54 patients were free from observed events and 14 developed the following cardiovascular events: 10 (15%) had myocardial damage, four (6%) had low output heart failure and two (3%) suffered stroke. No patients died during the follow-up period. Serum concentration of hs-CRP ≥ 3.3 mg/l (cut-off point obtained by ROC analysis) was related to higher risk of post-operative cardiovascular events (36% vs 6%, P = 0.01), myocardial damage (24% vs 6%, P = 0.04) and low output heart failure (12% vs 0%, P = 0.04). Multivariate logistic regression analysis showed that hs-CRP ≥ 3.3 mg/l ( P = 0.002, O.R.: 19.3 (95% confidence interval (CI) 2.9-128.0)), intra-operative transfusion of red blood cells ( P = 0.04, O.R.: 9.9 (95% C.I. 1.1-85.5)) and absence of diuretics in daily antihypertensive treatment ( P = 0.02, O.R.: 15.1 (95% C.I. 1.4-160.6) were independent predictors of combined cardiovascular event. Patients having hs-CRP value greater or equal to 3.3 mg/l pre-operatively have an increased risk of post-operative cardiovascular events after on pump coronary artery bypass grafting surgery.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

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.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

The present study compares the cardiac output (CO) estimated by a new, non-invsive continuous Doppler device (Ultrasonic cardiac output monitor-USCOM) with that by bolus thermodilution technique (TD). Thirty post off-pump coronary artery bypass graft surgery patients were studied in this prospective non­randomozed study. Right heart CO estimation by USCOM and TD was performed and measured in quadruplet. A total of 120 paired observations were made. The mean CO was 4.63 and 4.76 L/min as estimated by TD and USCOM respectively. For TD and USCOM, the CO had a mean bias (tendency of one technique to differ from other) of -0.13 L/min and limits of agreement (mean bias±2SD) at -0.86 and 0.59 L/min. The study reveals very good agreement between the values of CO estimated by USCOM and TD.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

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.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

This review outlines the basic pharmacodynamic and pharmacokinetic properties of sugammadex for the cardiac anesthesiologist. It describes the different clinical scenarios when sugammadex can be used during cardiac surgery and gives clinical recommendations. Sugammadex is a unique reversal drug that binds a chemical complex with rocuronium and vecuronium, by which the neuromuscular blockade is quickly reversed. It is free of any clinical side-effects and doses of 2 mg/kg or more reliably reverse neuromuscular blockade within 5-15 min, depending on the depth of the neuromuscular blockade. Doses below 2 mg/kg should be avoided at any time because of the inherent risk of recurarization. Sugammadex should not replace good clinical practice - titration of neuromuscular blocking drugs to clinical needs and objective monitoring of neuromuscular blockade in the operating room or intensive care unit. Neuromuscular transmission should be determined in all patients before sugammadex is considered and 5 min after its administration to ensure that extubation is performed with normal neuromuscular transmission.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]  [PubMed]

[FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

The benefits of thoracic epidural analgesia in patients undergoing coronary artery bypass grafting are well documented. However, the literature available on the role of high thoracic epidural analgesia (HTEA) in patients with chronic obstructive pulmonary disease undergoing off-pump coronary artery bypass graft (OPCAB) surgery is scarce. We conducted a randomized clinical trial to establish whether HTEA is beneficial in patients with chronic obstructive pulmonary disease undergoing elective OPCAB surgery. After institutional ethics board approval and informed consent, 62 chronic obstructive pulmonary disease patients undergoing elective OPCAB were randomly grouped into two (n = 31 each). Both groups received general anesthesia (GA), but in the HTEA group patients, TEA was also administered. Standardized surgical and anesthetic techniques were used for both the groups. Pulmonary function tests were performed pre-operatively, 6 h and 24 h post-extubation and on days 2, 3, 4 and 5 along with arterial blood gas analysis (ABG) analysis. Time for extubation (h) and time for oxygen withdrawal (h) were recorded. Pain score was assessed by the 10-cm visual analogue scale. All hemodynamic/oxygenation parameters were noted. Any complications related to the TEA were also recorded. Patients in the HTEA group were extubated earlier (10.8 h vs. 13.5 h, P < 0.01) and their oxygen withdrawal time was also significantly lower (26.26 h vs. 29.87 h, P < 0.01). The VAS score, both at rest and on coughing, was significantly lower in the HTEA group at all times, post-operatively (P < 0.01). The forced vital capacity improved significantly at 6 h post-operatively in the HTEA group (P = 0.026) and remained significantly higher thereafter. A similar trend was observed in forced expiratory volume in the first second on day 2 in the HTEA group (P = 0.024). We did not observe any significant side-effects/mortality in either group. In chronic obstructive pulmonary disease patients undergoing elective OPCAB surgery, HTEA is a good adjunct to GA for early extubation, faster recovery of pulmonary function and better analgesia.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]  [PubMed]

There have been great advancements in cardiac surgery over the last two decades; the widespread use of off-pump aortocoronary bypass surgery, minimally invasive cardiac surgery, and robotic surgery have also changed the face of cardiac anaesthesia. The concept of "Fast-track anaesthesia" demands the use of nondepolarising neuromuscular blocking drugs with short duration of action, combining the ability to provide (if necessary) sufficiently profound neuromuscular blockade during surgery and immediate re-establishment of normal neuromuscular transmission at the end of surgery. Postoperative residual muscle paralysis is one of the major hurdles for immediate or early extubation after cardiac surgery. Nondepolarising neuromuscular blocking drugs for cardiac surgery should therefore be easy to titrate, of rapid onset and short duration of action with a pathway of elimination independent from hepatic or renal dysfunction, and should equally not affect haemodynamic stability. The difference between repetitive bolus application and continuous infusion is outlined in this review, with the pharmacodynamic and pharmacokinetic characteristics of vecuronium, pancuronium, rocuronium, and cisatracurium. Kinemyography and acceleromyography are the most important currently used neuromuscular monitoring methods. Whereas monitoring at the adductor pollicis muscle is appropriate at the end of surgery, monitoring of the corrugator supercilii muscle better reflects neuromuscular blockade at more central, profound muscles, such as the diaphragm, larynx, or thoraco-abdominal muscles. In conclusion, cisatracurium or rocuronium is recommended for neuromuscular blockade in modern cardiac surgery.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

The surgical procedures performed with robtic assitance and the scope for its future assistance is endless. To keep pace with the developing technologies in this field it is imperative for the cardiac anesthesiologists to have aworking knowledge of these systems, recognize potential complications and formulate an anesthetic plan to provide safe patient care. Challenges posed by the use of robotic systems include, long surgical times, problems with one lung anesthesia in presence of coronary artery disease, minimally invasive percutaneous cardiopulmonary bypass management and expertise in Trans-Esophageal Echocardiography. A long list of cardiac surgeries are performed with the use of robotic assistance, and the list is continuously growing as surgical innovation crosses new boundaries. Current research in robotic cardiac surgery like beating heart off pump intracardic repair, prototype epicardial crawling device, robotic fetal techniques etc. are in the stage of animal experimentation, but holds a lot of promise in future

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]  [PubMed]

Chest tube removal in the postcardiac surgical patients is a painful and distressful event. Fentanyl and sufentanil have not been used for pain control during chest tube removal in the postoperative period. We compared efficacy of fentanyl and sufentanil in controlling pain due to chest tube removal. One hundred and forty one adult patients undergoing cardiac surgery were recruited in a prospective, randomized, double blind, placebo controlled study. Patients were randomized to receive either 2 µg/Kg fentanyl IV or 0.2 µg/Kg sufentanil IV or 2 ml isotonic normal saline, 10 min before removing chest tubes. Pain intensity was assessed by measuring visual analog scale pain score 10 minutes before removing chest tubes and 5 min and 20 min after removing chest tubes. Level of sedation, heart rate, arterial pressure, oxygen saturation, and respiratory rate were recorded by a blinded observer at the same time intervals. Mean pain intensity scores 10 minutes before removal of chest tubes in fentanyl, sufentanil and control groups were 23.88±5.2, 25.10±5.39 and 23.64±6.10 respectively. The pain scores 5 minutes after chest tube removal were reduced to 20.11±6.9 (p<0.05) in the fentanyl group and 13.60±6.60 (p<0.05) in the sufentanil group, whereas in control group pain scores increased to 27.97±8.39 (p<0.05). The pain scores in sufentanil group were significantly lower compared with fentanyl or control group. Sedation scores remained low in all groups and patients remained alert and none of the patients showed any adverse effects of opioids. Heart rate, arterial pressure and respiratory rate had least variations in sufentanil group than fentanyl or control group.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

Thirty children undergoing cardiac surgery under cardiopulmonary bypass (CPB) were prospectively studied to assess beneficial effects of modified ultrafiltration (MUF) over and above conventional ultrafiltration (CUF). Transoesophaegeal echocardiography determined ejection fraction (EF), fractional area change (FAC) and posterior wall thickness in end-diastole and end-systole were measured and compared in two groups undergoing CUF (group I) and CUF plus MUF (group II). Haemodynamic data, haematocrit, temperature drift, postoperative chest tube drainage in first 48 hours, ventilation and intensive care unit (ICU) stay were also recorded. Within group data were analysed by general linear trend and intergroup comparisons were made with t-test. EF and FAC decreased at 0 min after CPB in both groups, but both recovered at 10 and 30 min after CPB in group II. Increase in EF and FAC in group II was about 12-15 % and 3-5 % from 0 min respectively. There was also significant improvement in posterior wall thickness and haematocrit (P<0.05) in group II. Patients in group II maintained better systolic blood pressure and heamoglobin after CPB. Chest tube drainage in first 48 hours was significantly less in group II (100 ±18 verses 85 ± 20 ml, P<0.05), but ventilation and ICU stay were not different between the two groups. Combined ultrafiltration has beneficial effect an haemodynamics with improvement in EF and FAC. It improves haematocrit and decreases chest pulse drainage.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]

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.

[ABSTRACT]  [FULL TEXT]  [PDF] [CITATIONS]  [PubMed]