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   2008| July-December  | Volume 11 | Issue 2  
    Online since July 5, 2008

 
 
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ORIGINAL ARTICLES
Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery
Yatin Mehta, Dheeraj Arora, Krishna K Sharma, Yugal Mishra, Harpreet Wasir, Naresh Trehan
July-December 2008, 11(2):91-96
DOI:10.4103/0971-9784.41576  PMID:18603748
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.
  35 7,890 1,004
REVIEW ARTICLE
Neuromuscular blockade in cardiac surgery: An update for clinicians
Thomas M Hemmerling, Gianluca Russo, David Bracco
July-December 2008, 11(2):80-90
DOI:10.4103/0971-9784.41575  PMID:18603747
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.
  15 14,544 2,597
ORIGINAL ARTICLES
Bispectral index-guided anaesthesia for off-pump coronary artery bypass grafting
Kanchi Muralidhar, Sanjay Banakal, Keshav Murthy, Rajneesh Garg, G Radhika Rani, R Dinesh
July-December 2008, 11(2):105-110
DOI:10.4103/0971-9784.41578  PMID:18603750
Bispectral index (BIS) monitoring may assist reduction in utilisation of anaesthetic agents during general surgical procedures. This study was designed to test whether the use of BIS monitoring reduces the anaesthetic requirements during off-pump coronary artery bypass grafting (CABG). This prospective - clinical trial was conducted on 40 adult patients undergoing elective off-pump CABG. Patients received either isoflurane or propofol anaesthesia. BIS monitoring, which guided the dose of anaesthetic, was carried out in 50 percent of the patients. The amount of anaesthetic agent (isoflurane or propofol) administered from the start of anaesthesia to the end of surgical procedure was calculated and were compared in four groups of patients - namely Group A (I-no BIS) received isoflurane; end tidal concentration was maintained at 1-1.2% in a low flow technique throughout the procedure, Group B (I-BIS) received isoflurane in a low flow technique; inspired concentration was dictated by BIS value maintained at 50; Group C (P-no BIS) received propofol at a dose range of 4-8 mg/kg/hr and in Group D(P-BIS) the propofol infusion rate was dictated by BIS value maintained at 50. The quantity of isoflurane was significantly less for Group B (I-BIS) as compared with Group A (I-no BIS) (37 4 vs. 24 4 ml; p<0.05) and similarly the amount of propofol infused was significantly less in Group D (P-BIS) as compared with Group C (P-no BIS) (176 9 vs. 120 6 ml; p<0.05). BIS guided anaesthesia reduces the anaesthetic agent required for the performance of off-pump CABG. This can be extrapolated in terms of saving agent and reduced cardiac depression during off-pump CABG.
  10 4,473 661
INTERESTING IMAGES
Pericardial cyst
Thomas Koshy, Prabhat Kumar Sinha, Satyajeet Misra, Madathipat Unnikrishnan
July-December 2008, 11(2):129-130
DOI:10.4103/0971-9784.41584  PMID:18603756
  6 3,535 369
CASE REPORTS
Anaesthetic management of a patient with complete tracheal rupture following blunt chest trauma
Saikat Sengupta, Anjol Saikia, Suresh Ramasubban, Shaikat Gupta, Sudipta Maitra, Amitava Rudra, Gaurab Maitra
July-December 2008, 11(2):123-126
DOI:10.4103/0971-9784.41582  PMID:18603754
Complete tracheal resection is extremely rare after blunt chest trauma. A high degree of suspicion is essential to identify these cases and early intervention is associated with better outcome. We report a patient with complete tracheal resection, in whom the airway was secured whilst the patient remained awake, breathing spontaneously under fibreoptic bronchoscopic guidance. As a precautionary measure, we had kept cardiopulmonary bypass set up in readiness. Anaesthetic management needed to be modified during repair of the trachea, by using total intravenous anaesthesia with propofol and rocuronium infusion and insertion of a separate endotracheal tube into the distal portion of the trachea whilst reconstruction of the trachea took place. The usual inhalational technique could not be used. The anaesthesiologist managing such a case should be aware of the difficulties during securing the airway and during repair of the trachea. Proper planning and keeping back-up plans ready helps in successful management of these patients.
  5 4,829 662
LETTERS TO EDITOR
Percutaneous tracheostomy: A comparison of PercuTwist and multi-dilatators techniques
Handan Birbicer, Nurcan Doruk, Davud Yapici, Sebnem Atici, Ali Aydin Altunkan, Serdar Epozdemir, Ugur Oral
July-December 2008, 11(2):131-131
DOI:10.4103/0971-9784.41585  PMID:18603757
  5 2,864 357
ORIGINAL ARTICLES
Treatment of ethanol-induced acute pulmonary hypertension and right ventricular dysfunction in pigs, by sildenafil analogue (UK343-664) or nitroglycerin
Avner Sidi, Bhiken Naik, Felipe Urdaneta, Jochen D Muehlschlegel, David S Kirby, Emilio B Lobato
July-December 2008, 11(2):97-104
DOI:10.4103/0971-9784.41577  PMID:18603749
In patients at risk for sudden ethanol (ETOH) intravascular absorption, prompt treatment of pulmonary hypertension (PHTN) will minimise the risk of cardiovascular decompensation. We investigated the haemodynamic effects of intravenous ETOH and the pulmonary vasodilatory effects of a sildenafil analogue (UK343-664) and nitroglycerin (NTG) during ETOH-induced PHTN in pigs. We studied pulmonary and systemic haemodynamics, and right ventricular rate or time derivate of pressure rise during ventricular contraction ( =dP/dT), as an index of contractility, in 23 pigs. ETOH was infused at a rate of 50 mg/kg/min, titrated to achieve a twofold increase in mean pulmonary arterial pressure (MPAP), and then discontinued. The animals were randomised to receive an infusion of 2 ml/kg ( n = 7) normal saline, a 500-μg/kg bolus of UK343-664 ( n = 8), or NTG 1 μg/kg ( n = 8); each was given over 60 seconds. Following ETOH infusion, dP/dT decreased central venous pressure (CVP), and MPAP increased significantly, resulting in significantly increased pulmonary vascular resistance (PVR). Within 2 minutes after treatment with either drug, CVP, heart rate (HR), and the systemic vascular resistance-to-pulmonary vascular resistance (SVR/PVR) ratio returned to baseline. However, at that time, only in the UK343-664 group, MPAP and dP/dT partially recovered and were different from the respective values at PHTN stage. NTG and UK343-664 decreased PVR within 2 minutes, from 1241579 and 1224494 dyne cm/sec 5 , which were threefold-to-fourfold increased baseline values, to 672308 and 538203 dyne cm/sec 5 respectively. However, only in the UK343-664 group, changes from baseline PVR values after treatment were significant compared to the maximal change during target PHTN. Neither drug caused a significant change in SVR. In this model of ETOH-induced PHTN, both UK343-664 and NTG were effective pulmonary vasodilators with a high degree of selectivity. However, the changes from baseline values of PVR, and the partial recovery of systemic pressure and RV contractility compared to the maximal change during target PHTN, were significant only in the sildenafil analogue group.
  5 5,218 369
LETTERS TO EDITOR
Bosentan for the treatment of portopulmonary hypertension
Deepak K Tempe, Vishnu Datt, Divesh Datta
July-December 2008, 11(2):139-140
DOI:10.4103/0971-9784.41595  PMID:18603763
  4 2,424 450
INTERESTING IMAGES
An unusual complication following mitral valve surgery and use of intra-operative transoesophageal echocardiography
Chinnamuthu Murugesan, Sanjaykumar Banakal, Kanchi Muralidhar
July-December 2008, 11(2):127-128
DOI:10.4103/0971-9784.41583  PMID:18603755
  3 2,881 307
LETTERS TO EDITOR
Blood transfusion is associated with increased resource utilisation, morbidity, and mortality in cardiac surgery
Rajiv Juneja, Yatin Mehta
July-December 2008, 11(2):136-137
DOI:10.4103/0971-9784.41591  PMID:18603761
  3 1,661 247
EDITORIALS
Ultrasound education in anaesthesia: Turning the tables on convention
Colin Royse
July-December 2008, 11(2):77-79
DOI:10.4103/0971-9784.41574  PMID:18603746
  2 2,903 389
CASE REPORTS
Pericardial cyst due to tuberculosis in an adolescent
BG Venkatesh, Samir Girotra, Krishna S Iyer, Manisha Chakrabarti, Poonam Khurana, Ashok Sen
July-December 2008, 11(2):116-118
DOI:10.4103/0971-9784.41580  PMID:18603752
Patient with a mediastinal mass may be diagnosed incidentally or following evaluation for the symptoms due to compressive effects on the adjoining structures. Pericardial cysts account to 6% of mediastinal masses. Echocardiography, computerised tomography and magnetic resonance imaging aid in accurate diagnosis and localization of these cysts. Anaesthesia for patients with these cysts may occasionally turn out to be catastrophic during induction or in postoperative period. Surgery is the preferred choice of treatment in these patients.
  1 3,202 303
LETTERS TO EDITOR
Is blood transfusion an independent predictor of increased resource utilisation and postoperative morbidity?
Mukul C Kapoor
July-December 2008, 11(2):135-136
DOI:10.4103/0971-9784.41589  PMID:18603760
  1 1,561 191
Transoesophageal echocardiography during surgery for atrial septal defect with partial anomalous pulmonary venous connection
Shrinivas Gadhinglajkar, Rupa Sreedhar
July-December 2008, 11(2):140-141
DOI:10.4103/0971-9784.41597  PMID:18603764
  1 1,768 254
BOOK REVIEW
Core topics in Cardiothoracic Critical Care, 1 st edition
Yatin Mehta
July-December 2008, 11(2):148-148
  - 1,355 211
CASE REPORTS
Perioperative issues due to long-standing lung collapse during repair of a large ascending aortic aneurysm
Praveen Kumar Neema, Praveen Kerala Varma, Sethuraman Manikandan, Ramesh Chandra Rathod
July-December 2008, 11(2):119-122
DOI:10.4103/0971-9784.41581  PMID:18603753
Acute lung collapse during open-heart surgery may potentially lead to problems such as inadequate gas exchange, increased pulmonary vascular resistance, increased afterload to the right ventricle, and difficulty in weaning from cardiopulmonary bypass (CPB). Therefore, expansion of the lungs is ensured prior to separation from CPB. We report the inability to manually expand a chronically collapsed lung during the repair of ascending aortic aneurysm. The collapsed lung did not pose difficulty in separation from CPB and in blood gas management during the perioperative period. We discuss perioperative management issues in such situations.
  - 4,332 232
EDITORIALS
Teaching cardiac anaesthesia
Kanchi Muralidhar
July-December 2008, 11(2):75-76
DOI:10.4103/0971-9784.41573  PMID:18603745
  - 5,536 641
LETTERS TO EDITOR
Authors' reply
Shahzad G Raja
July-December 2008, 11(2):140-140
DOI:10.4103/0971-9784.41596  
  - 960 118
Transoesophageal echocardiography during Senning's operation
Shrinivas Gadhinglajkar, Rupa Sreedhar
July-December 2008, 11(2):141-142
DOI:10.4103/0971-9784.41598  PMID:18603765
  - 1,758 176
Utility of transoesophageal echocardiography during surgery on left atrial myxoma
Shrinivas Gadhinglajkar, Rupa Sreedhar
July-December 2008, 11(2):142-143
DOI:10.4103/0971-9784.41599  PMID:18603766
  - 1,380 227
Role of alpha adrenergic antagonism in a child with a bidirectional Glenn shunt undergoing cleft palate repair
Madan Mohan Maddali, Valakatte Seetharam Vinayakumar, Chona Thomas
July-December 2008, 11(2):132-134
DOI:10.4103/0971-9784.41586  PMID:18603758
  - 2,196 252
Blood transfusion in cardiac surgery
Ramachandran Gopinath
July-December 2008, 11(2):134-135
DOI:10.4103/0971-9784.41587  PMID:18603759
  - 1,940 365
Authors' reply
Bharathi H Scott
July-December 2008, 11(2):135-135
DOI:10.4103/0971-9784.41588  
  - 1,219 126
Authors' reply
Bharathi H Scott
July-December 2008, 11(2):136-136
DOI:10.4103/0971-9784.41590  
  - 820 112
Authors' reply
Bharathi H Scott
July-December 2008, 11(2):137-138
DOI:10.4103/0971-9784.41592  
  - 987 134
Hidden hazards of Bosentan therapy in pulmonary hypertension
Swati Sethi, Rajesh Sethi, Conrad Wareham
July-December 2008, 11(2):138-138
DOI:10.4103/0971-9784.41593  PMID:18603762
  - 2,096 285
Authors' reply
Shahzad G Raja, Gilles D Dreyfus
July-December 2008, 11(2):138-139
DOI:10.4103/0971-9784.41594  
  - 988 112
MEDICOLEGAL CASE
Legal consequences of not performing requisite pre-anaesthesia test

July-December 2008, 11(2):144-147
Suggested Precautions
  1. Perform sensitive test before giving anaesthesia and specifically record the said fact in pre-operative notes.
  2. Necessary precautions prescribed and followed in medicine must be strictly followed and duly recorded.
  - 1,693 191
ORIGINAL ARTICLES
Transvenous, intracardial cardioversion for the treatment of postoperative atrial fibrillation
Robert D Fitzgerald, Stefan Fritsch, Wojciech Wislocki, Wolfgang Oczenski, Ferdinand R Waldenberger, Sylvia Schwarz
July-December 2008, 11(2):111-115
DOI:10.4103/0971-9784.39558  PMID:18603751
Atrial fibrillation (AF) following cardiac surgery is an important factor contributing to postoperative morbidity. Transvenous, intracardial cardioversion (TIC) has been shown to be effective in the treatment of chronic AF, but is an invasive and cost-intensive procedure. However, TIC would definitely be a beneficial approach if recurrence of AF following TIC is low and pharmacological treatment could be avoided. Thus, we hypothesised that TIC would be superior to conventional treatment with amiodarone with respect to the conversion rate and recurrence of AF. We compared TIC and conventional amiodarone therapy in a prospective, randomised and controlled trial in patients who developed AF following cardiac surgery. Twenty-three patients developed AF out of a total of 76 patients who gave written informed consent. Eighteen of these AF patients could be randomised into two equally sized groups to receive either an ALERT TM pulmonary artery catheter and TIC, or a standard pulmonary artery catheter and treatment with amiodarone. Haemodynamic parameters were registered before intervention to exclude pulmonary hypertension or fluid overload. Rates of cardioversion were compared by a Likelyhood ratio test. Out of the nine ALERT patients, AF in five cases converted to sinus rhythm (SR) with a median of two shocks (6 J). After 24 hours however, only two patients remained in sinus rhythm. On the other hand, six of the nine patients treated with amiodarone were still in SR after 24 hours. Whereas no difference was detectable in the conversion rate, persistence of SR following TIC was low. Thus, TIC without antiarrhythmic treatment is not recommendable for the treatment of postoperative AF.
  - 3,295 300