Abstract

Background: 

This study evaluates the efficacy of perioperative pregabalin in reducing acute and chronic postoperative pain and opioid consumption in patients undergoing off-pump coronary artery bypass grafting (OPCABG).

Material and Methods: 

A total of 150 patients, aged 30–70 years underwent elective OPCABG and were randomized into two groups of 75. Patients in Group P received 150 mg of pregabalin 2 h before induction of anesthesia and were given pregabalin 75 mg every 12 h for two postoperative days. Patients in Group C received a placebo at similar time intervals. Recorded outcome variables were the Visual Analog Scale (VAS) at rest and during deep breathing from the postoperative period until 3 months after hospital discharge. The time to extubation, hemodynamic parameters, and episodes of breakthrough pain till 48 h were also noted.

Results: 

VAS during rest and on deep breathing were significantly less in group P compared with group C from extubation up to 48 h postoperative. The difference in VAS at rest between both the groups was also significant at 1 month (0.32 ± 0.46 vs. 0.56 ± 0.49, P = 0.003) but was insignificant at 3 months (0.10 ± 0.31 vs. 0.13 ± 0.34, P = 0.618). The sedation score was comparable in both groups.

Conclusion: 

Perioperative pregabalin reduces the pain scores at rest and on deep breathing in patients undergoing elective OPCABG up to 72 h postsurgery. Furthermore, the significance was still showing at 1-month postsurgery but diminished at 3-month postsurgery.

Abstract

Objective: Role of serum procalcitonin (PCT) in critically ill patients is well defined for identification of bacterial infection

but it’s role in prediction of survival is not well established. We studied plasma kinetics of PCT, over the first three critical

care days to validate its role in prediction of survival of patients with sepsis according to plasma level.

Methods: A prospective observational study was conducted in CCU (KGMU). Total 53 consecutive patients either sex

were recruited. Patients with systemic inflammatory response syndrome (SIRS) were recruited. PCT was measured on

1st and 3rd days. We studied 50 days survival using Kaplan-Meier analysis and diagnostic accuracy of PCT using ROC

analysis.

Results: In our study, PCT was statistically significantly higher in non-survivor patients compared to survivor patients

(p<0.05). ROC curve was made with PCT based on culture at both time intervals. On the basis of ROC curve, we

determined a cut-off value as 12.21 ng/ml of PCT on day 3 to predict sepsis with high sensitivity (93.7%) and specificity

(71.4%). Area under curve (AUC) was also higher observed at day 3 (AUC=0.864, p<0.001) compared to day 1

(AUC=0.658, p<0.05). According to Kaplan-Meier curve, risk of mortality was by 83% (HR 0.17(95% 0.07-0.44)) lower in

low sepsis category group (≤12.21 ng/ml) compared to high sepsis category group (>12.21 ng/ml).

Conclusion: According to our study results, we conclude that serum PCT has good clinical diagnostic and prognostic

values in prediction of survival in patients with sepsis. Kinetic studies of PCT can improve sensitivity and accuracy when

evaluating the prognosis of patients with sepsis as well as survival rate.

Key words: sepsis, systemic inflammatory response syndrome, procalcitonin, survival, outcome, diagnostic accuracy

Background & Aims: Amiodarone is a purposive medicine useful in restoring sinus rhythm (SR) after cardiac surgery. The aim of the study was to evaluate the effect of prophylactic intraoperative single-dose intravenous amiodarone and to convert atrial fibrillation (AF) into normal sinus rhythm (NSR) in the patients undergoing valve replacement surgery.
Materials & Methods: In this prospective and interventional study, 180 patients of ASA III (American Society of Anesthesiologist) classification between the ages of 18-60 years, posted for Rheumatic Mitral Valve Replacement were allocated randomly to two equal groups (Group-1 and Group-2). Their hemodynamics parameters, Pre and post pulse rate, ECG findings and incidence of AF and VT/VF and ICU, Hospital stay were noted. Data was analysed with SPSS v26 using chi-square test. A two-tailed P value of 0.05 or less was regarded as statistically significant.
Results: In our study, we found that there was suggestive significance between both groups as regard to mean pulse rate changes after 5 and 10 minutes of induction (P value >0.05). At the end of surgery, there was developing atrial fibrillation in few patients and sinus rhythm in more (P value >0.05). Postoperative arrhythmias in the first 24 hrs, AF was seen in 9(10%) patients in the Group 1 compare to Group 2 49 (54.4%) (P <0.001). In both groups as regard to Mechanical ventilation & ICU stay was of suggestive significance in amiodarone group (P value <0.0001).
Conclusion: The incidence of post-operative AF among high-risk patients was significantly reduced by a prophylactic amiodarone treatment resulting in a shorter time of intensive care unit and hospital stay.

 

Keywords: Atrial Fibrillation, Amiodarone, Normal Sinus Rhythm, Valve Surgery

Abstract

Background: Hypotension is the most common complication of spinal anesthesia with high intrathecal spread of local anaesthetic drug especially during caesarean section. Hip Shoulder width Ratio (HSWR) is one of the factors which affects spread of spinal anaesthesia.

Materials and Methods: 85 ASA II participants with singleton term pregnancy undergoing elective caesarean section received 12mg hyperbaric bupivacaine intrathecally with 26G Quincke’s spinal needle in L3-4 intervertebral subarachnoid space via midline approach. Post spinal anaesthesia haemodynamic parameters were monitored every 5 minutes for the first 20 minutes and at the end of surgery. Sensory level was assessed by a pinprick test every 5 minutes till 20 minutes and post-surgery. Hypotension was defined as 20% fall from baseline systolic blood pressure at 15 minutes post spinal anaesthesia.

Result: We found significant positive correlation between high shoulder width ratio and highest sensory level achieved (p - 0.0005) using mutiple regression analysis and pearson's correlataion. With every unit increased in high shoulder width ratio spinal level significantly increased by 5 units. Hip shoulder width ration and age were significantly correlatwd with incidence of hypotension.

Conclusion: Hip-shoulder Width Ratio has a positive effect on cephalad spread of spinal anaesthesia and thus incidence of hypotension. By knowing the Hip-shoulder Width Ratio, it can help anaesthesiologists to predict the spread of spinal anaesthesia and titrate the dose of 0.5% hyperbaric bupivacaine.

Abstract

Background: 

Patients undergoing elective off-pump coronary artery bypass grafting (CABG) are at risk of hemodynamic instability, ischemia, arrhythmia, and dysfunction. These events need to be managed by pharmacological supports or relieving of mechanical obstruction (octopus) of the heart to maintain the hemodynamic stability. There is a paucity of data on the effect of left ventricular (LV) dysfunction on left atrial appendage (LAA) emptying velocity. We evaluated the relationship between LV function and LAA emptying velocity and requirement of inotropic support perioperatively.

Materials and Methods: 

In this prospective open-label all-comer study, fifty patients undergoing elective off-pump CABG under general anesthesia, we measured LAA emptying velocity by pulsed wave Doppler and evaluated if it could predict the need for inotropes perioperatively. It is a case series of 50 patients without a comparator arm. We measured pulsed wave Doppler across the mitral valve leaflet and early mitral inflow velocity (Evel) and late mitral inflow velocity, tissue Doppler at the lateral annulus of the mitral valve (e’) and also calculated the ratio of Evel and e’. Need for inotrope in the intraoperative and postoperative period was captured perioperatively. Vasoactive-inotropic score (VIS) was calculated for all the patients.

Results: 

The VIS was significant (P < 0.0001, with odds ratio of 131.6 and confidence interval of 95% (0.9–1). However, there was no significant correlation between ejection fraction (EF) and VIS (P = 0.87). In patients with the need of inotropes, LAA emptying velocity was significantly increased in the postgrafting period as compared to the pregrafting period (75.64 cm/s vs. 57.9 cm/s, P < 0.001).

Conclusion: 

The assessment of LAA emptying velocity value was a useful predictor of the need of inotropic support during off-pump surgery, especially during Obtuse marginal and Ramus grafting. This study paves the need of larger case–control studies to validate the findings.

Abstract

Aims and Objectives: 

The incidence of postoperative liver dysfunction is high in patients undergoing double-valve replacement – mitral and aortic valve replacement (DVR). This study aims to evaluate N-acetylcysteine’s free radical scavenging property (NAC) to prevent postoperative liver dysfunction in these patients, thus affecting overall clinical outcomes.

Methods: 

A single-center, prospective, randomized, double-blinded interventional study of 60 patients divided into two groups of 30 each. Group N received prophylactic intravenous NAC, and Group C received volume-matched 5% dextrose. Data comprised demographics, liver function tests (LFT), renal function tests (RFT), vasoactive-inotropic scores (VIS) score, and C-reactive protein (CRP) at various time intervals. Postoperative parameters such as ventilation duration, length of stay in ICU (LOS-ICU), length of hospital stay (LOHS), atrial fibrillation (AF), acute kidney injury (AKI) requiring hemodialysis, and mortality were noted. Statistical analysis was performed with the Student’s t-test and Chi-square test (SPSS 22 software).

Results: 

All postoperative LFT parameters (total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), and alkaline phosphatase (ALP)) were significantly lower (P < 0.05) at 24, 48, and 72 hours in Group N compared to Group C. RFT and VIS scores were lower in Group N; however, were not statistically significant except for Serum Creatinine at 48 hours (P = 0.0478). Ventilation duration (P = 0.0465) and LOS-ICU (P = 0.0431) were significantly lower in Group N. Other outcomes like AF, LOHS, and mortality were lower in Group N but were not statistically significant.

Conclusion: 

Our study showed that prophylactic administration of NAC in patients undergoing DVR is associated with a reduction in the incidence of postoperative liver dysfunction with a positive impact on postoperative outcomes.

Abstract

Background: 

Patients undergoing elective off-pump coronary artery bypass grafting (CABG) are at risk of hemodynamic instability, ischemia, arrhythmia, and dysfunction. These events need to be managed by pharmacological supports or relieving of mechanical obstruction (octopus) of the heart to maintain the hemodynamic stability. There is a paucity of data on the effect of left ventricular (LV) dysfunction on left atrial appendage (LAA) emptying velocity. We evaluated the relationship between LV function and LAA emptying velocity and requirement of inotropic support perioperatively.

Materials and Methods: 

In this prospective open-label all-comer study, fifty patients undergoing elective off-pump CABG under general anesthesia, we measured LAA emptying velocity by pulsed wave Doppler and evaluated if it could predict the need for inotropes perioperatively. It is a case series of 50 patients without a comparator arm. We measured pulsed wave Doppler across the mitral valve leaflet and early mitral inflow velocity (Evel) and late mitral inflow velocity, tissue Doppler at the lateral annulus of the mitral valve (e’) and also calculated the ratio of Evel and e’. Need for inotrope in the intraoperative and postoperative period was captured perioperatively. Vasoactive-inotropic score (VIS) was calculated for all the patients.

Results: 

The VIS was significant (P < 0.0001, with odds ratio of 131.6 and confidence interval of 95% (0.9–1). However, there was no significant correlation between ejection fraction (EF) and VIS (P = 0.87). In patients with the need of inotropes, LAA emptying velocity was significantly increased in the postgrafting period as compared to the pregrafting period (75.64 cm/s vs. 57.9 cm/s, P < 0.001).

Conclusion: 

The assessment of LAA emptying velocity value was a useful predictor of the need of inotropic support during off-pump surgery, especially during Obtuse marginal and Ramus grafting. This study paves the need of larger case–control studies to validate the findings.

Background: 

Clearance of tissue carbon dioxide by circulation is measured by venous to arterial carbon dioxide partial pressure difference (AVCO₂) and is correlated with cardiac output (CO) in critically ill adult patients. This study aimed to correlate AVCO₂ with other CO indices like arteriovenous oxygen saturation difference (AVO₂), central venous oxygen saturation (ScVO₂), and serum lactate in pediatric patients undergoing intracardiac repair (ICR) for tetralogy of Fallot (TOF).

Methods: 

We conducted a prospective observational study in 50 patients, of age 5 months to 5 years, undergoing ICR for TOF and analyzed AVO₂, AVCO₂, ScVO₂, and lactate from arterial and venous blood gas pairs obtained at different time intervals from admission to pediatric intensive care unit (PICU) (T₀), at 6 h (T₁), 12 h (T₂), 24 h (T₃), and 48 h (T₄) postoperatively. Bivariate correlations were analyzed using Pearson for parametric variables.

Results: 

Admission AVCO₂ was not correlated with AVO₂ (R² = 0.166, P = 0.246), ScVO₂ (R² = -2.2, P = 0.124), and lactate (R² = -0.07, P = 0.624). At T₁, AVCO₂ was correlated with AVO₂ (R² = 0.283, P = 0.0464) but not with ScVO₂ (R² = - 0.25, P = 0.079) and lactate (R² = -0.07, P = 0.623). At T₂, T₃ and T₄, AVCO₂ was correlated with AVO₂ (R² = 0.338,0.440 & 0.318, P = 0.0162, 0.0013, and 0.024), ScVO₂ (R² = - 0.344, - 0.488, and -0.366; P = 0.0143, <0.0001, and 0.017), and lactate (R² = 0.305, 0.467 and 0.607; P = 0.0314, 0.00062 and <0.0001). AVCO₂ was negatively correlated with ScVO₂. No correlation observed between admission AVCO₂ and mechanical ventilation duration. Two nonsurvivors had higher value of admission AVCO₂ compared to survivors.

Conclusion: 

AVCO₂ is correlated with other CO surrogates like AVO₂, ScVO₂, and lactate in pediatric patients undergoing ICR for TOF.

Introduction: Coronavirus disease 2019 (COVID-19) affected care among surgical patients. Considering the underlying comorbidities, physical status, and intricate perioperative course, the cardiac surgery patient represents a vulnerable cohort. This study describes baseline characteristics, laboratory findings, diagnosis, postoperative course, and their correlation with immediate outcomes in patients undergoing cardiac surgery. Methodology: Patients who underwent cardiac surgery at our institute for 1 year were screened for COVID-19 with the reverse transcription-polymerase chain reaction swab test and then were posted for surgery only after corroborating negative reports, except for emergency cases. Dedicated preoperative areas and COVID-appropriate measures were taken. Data from the electronic patient records of those diagnosed with COVID-19 in the immediate postoperative period were reviewed retrospectively. Continuous normal distributed variables are presented as mean ± standard deviation, alternatively as median ± interquartile range, and categorical variables as percentages. Results: A total of 22 patients were infected in the immediate postoperative period in spite of appropriate screening and had a high mortality of 36.36% (vs. non-COVID 6.27%, P < 0.001). Days from index surgery to diagnosis were 6 (±3.75). The median stay in the intensive care unit and hospital stay was 6 (±2.75) and 10 (±3.2) days, respectively. The moderate and high-risk categories of the European System for Cardiac Operative Risk Evaluation II showed mortality of 33.3% (vs. 2.69% in non-COVID, odds ratio of 18.42) and 71.4% (vs. 11.2% in non-COVID, odds ratio of 19.65). Patients with C-reactive protein >100 mg/lit, D dimer >1000 ng/ml, and neutrophil/lymphocyte ratio >3.5 showed very high mortality. Noninvasive and invasive ventilation in 27.27% and 31.8%, respectively. Two patients acquired acute kidney injury that required hemodialysis. Conclusions: Despite requisite measures, COVID infection still remains a momentous differential to postoperative complications affecting early outcomes. Therefore, more robust preoperative protocols, better strategies for the COVID-free environment, and early clinical suspicion and workup are required to mitigate its effect on this cohort.

Abstract

Background and Aims: 

Cardiovascular (CV) complications of coronavirus disease 2019 (COVID-19) are neither well-defined nor comprehensively characterized. Hence, long-term studies are required to monitor silent but progressive CV complications postrecovery in COVID-19 patients. Our aim of the study was to assess and determine the presence of CV morbidity and mortality in COVID-19 patients.

Materials and Methods: 

A retrospective study was conducted at our institute. All COVID-19-positive patients who were admitted in the intensive care unit during April 3, 2020–May 23, 2021, were recruited for the study. A total of 1460 patients were enrolled and monitored until discharge/death. Patients were evaluated based on demographics, clinical data, and laboratory values and 42 patients among them underwent coronary angiography for an adequate understanding of CV complications.

Results: 

The total reported deaths among the study sample were 453 (31%). Common preexisting clinical conditions among them were hypertension 520 (35.6%), diabetes 211 (14.45%), CV disease 88 (6.02%), and hypothyroidism 61 (4.17%). A total of 149 patients displayed elevated creatine phosphokinase-MB (CPK-MB) levels, while 141 patients displayed elevated hs-TnI levels. The absolute rise of cardiac troponin (hs-TnI) and CPK-MB displayed a technically positive correlation, but a weaker relationship (r: 0.2113, P < 0.01 for correlation). Twenty-two out of 42 patients showed the presence of single/multivessel disease and 31 patients displayed mild-to-severe left ventricular dysfunction.

Conclusions: 

The results of the current study provide evidence for the risk and burden of CV complications among COVID-19 patients. Hence, attention to long-term CV health and disease among COVID-19 survivors is necessary.

Abstract

Learning Objective: 

Hemodynamic monitoring during in-hospital transport of intubated patients is vital; however, no prospective randomized trials have evaluated the hemodynamic consequences of hand versus machine ventilation during transport among pediatric patients’ post-cardiac surgery. The authors hypothesized that manual ventilation after pediatric cardiac surgery would alter hemodynamic and arterial blood gas (ABG) parameters during transport compared to mechanical ventilation.

Design: 

A prospective randomized trial.

Setting: 

Tertiary cardiac care hospital.

Participants: 

Pediatric cardiac surgery patients.

Materials and Methods: 

One hundred intubated pediatric patients were randomized to hand or machine ventilation immediately post-cardiac surgery during transport from the operating room to the pediatric post-operative intensive care unit (PICU). Hemodynamic variables, including end-tidal CO₂ (ETCO₂), oxygen saturation, heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), peak airway pressure (Ppeak), and mean airway pressure (Pmean), were measured at origin, during transport, and at the destination. ABG was measured before and upon arrival in the PICU, and adverse events were recorded. The Chi-square test and independent t-test were used for comparison of categorical and continuous parameters, respectively.

Results and Discussion: 

The mean transport time was comparable between hand-ventilated (5.77 ± 1.46 min) and machine-ventilated (5.96 ± 1.19 min) groups (P = 0.47). ETCO₂ consistently dropped during transport and after shifting in the hand-ventilated group, with significantly higher ETCO₂ excursion than in machine-ventilated patients (P < 0.05). SBP and DBP significantly decreased during transport (at 5 and 6 min intervals) and after shifting in hand-ventilated patients than in the other group (P < 0.05). Additionally, after shifting, a significant increase in Ppeak (P < 0.001), Pmean (P < 0.001), and pH (P < 0.001), and a decrease in pCO₂ (P = 0.0072) was observed in hand-ventilated patients than machine-ventilated patients. No adverse event was noted during either mode of ventilation.

Conclusion: 

Hand ventilation leads to more significant variation in ABG and hemodynamic parameters than machine ventilation in pediatric patients during transport post-cardiac surgery. Therefore, using a mechanical ventilator is the preferred method for transporting post-operative pediatric cardiac patients.

Abstract

Background: 

The emergence and spread of the coronavirus disease 2019 (COVID-19) pandemic presents an immense challenge to public health and has resulted in a dramatic loss of human life worldwide. Thus, diagnosis and identification of clinical laboratory parameters associated with the disease become crucial in critical cases, requiring intensive care management.

Aim: 

To investigate clinical laboratory parameters that may be associated with severe or critical COVID-19 disease patients, particularly those requiring intensive care management.

Materials and Methods: 

A retrospective cohort study was conducted at the U. N. Mehta Institute of Cardiology and Research Institute, Ahmedabad, Gujarat. A total of 1460 COVID-19-positive patients (aged 18 years and older) requiring admission to the intensive care unit were selected from April 3 to May 23, 2021, were enrolled, and were diagnostically monitored. Patients were evaluated based on their demographics. A Welsch t-test was used to calculate the progression in the mean difference among inflammatory and/or thromboembolic markers.

Results: 

We analyzed and examined certain laboratory parameters across the timeline and compared survival (Group 1) and nonsurvival (Group 2). All the factors were higher in Group 2 compared to Group 1, except for C-reactive protein-Q (CRP-Q), which decreased in both groups, but in Group 1, there was a further decrease in CRP-Q value as compared to Group 2 on retest day.

Conclusion: 

The results of the current study provide clinical value for prognostic factors associated with COVID-19 and establish the role of laboratory parameters in evaluating disease severity and complications.

Abstract

Background and Aims: 

Postoperative neurological dysfunction is a common noncardiac complication following cardiac surgery. Primary objective of our study was to evaluate the effects of cerebral oxygen desaturation on the neurological outcome in the postoperative period by monitoring regional cerebral oxygen saturation in off-pump coronary artery bypass grafting (OPCABG). Secondary objective was to study the correlation between regional cerebral oxygen saturation and mean arterial pressure (MAP) during grafting.

Setting and Design: 

It was a prospective observational study in 100 patients of the American Society of Anesthesiologists physical status grading II-III of either sex, having triple vessel coronary artery disease undergoing OPCABG. Patient, having left ventricular ejection fraction (LVEF) <35%, carotid artery disease, on extracorporeal membrane oxygenator or intra-aortic balloon pump, preexisting neurological disorder with standardized mini-mental state examination (SMMSE) score <23, undergoing emergency surgery, re-do surgery, and co-existing valvular diseases were excluded from the study. Surgeries were conducted under general anesthesia with midazolam 0.1 mg/kg, fentanyl 5 μg/kg, and vecuronium 0.1 mg/kg. Anesthesia was maintained with intermittent boluses of fentanyl, vecuronium, and isoflurane.

Materials and Methods: 

The SMMSE was performed preoperatively, 8 and 12 h after extubation. Patients with postoperative SMMSE score of 24–30 were allocated to Group A and patients with SMMSE score ≤ 23, were allocated to Group B. The cerebral oxygen saturation (rSO₂), heart rate, MAP, and arterial blood gas were monitored perioperatively.

Statistical Analysis: 

The Chi-square test was used to compare categorical variables and independent Samples t-test was used to compare continuous variables. Pearson bivariate correlation test was used to correlate between the continuous variables.

Results: 

The mean difference of right and left rSo₂, between baseline value, and during saphenous vein graft (SVG) to obtuse marginal grafting were 8.70 ± 3.38, 8.78 ± 3.19 in group A and 18.8 ± 2.40, 18.91 ± 1.88, respectively, in group B and were found to be statistically significant. The mean difference of right and left rSO₂, between baseline value and during SVG to posterior descending artery grafting were 6.48 ± 3.91, 7.10 ± 3.67 in group A and 18.1 ± 3.57, 17.9 ± 3.60 in group B and were found to be statistically significant. Mean difference and percentage variation from baseline of right and left rSo₂ and MAP from preinduction to grafting from left internal mammary artery to left anterior descending artery were found to be statistically insignificant.

Conclusion: 

A decrease of regional cerebral saturation value by 25% from baseline or an absolute reduction of rSO₂ value by 50% and reduction in MAP from baseline, during the period of grafting was associated with postoperative neurocognitive dysfunction.

Abstract

Background: Overinflation of cuffed endotracheal tubes and transesophageal echocardiography (TEE) probe causes increased intracuff pressure (CP) compromising tracheal perfusion pressure (TPP). Primary objective of the study was to assess CP, TPP on TEE probe insertion and examination during pediatric cardiac surgeries. Secondary objectives were to evaluate the effect of the probe on peak airway pressures (P_peak), mean airway pressures (P_mean) and to monitor CP, TPP on cardiopulmonary bypass (CPB).

Materials and methods: This prospective observational study included fifty patients, aged 1-5 years undergoing cardiac surgeries using CPB. Following induction, TEE probe was introduced. CP, TPP, P_peak, P_mean were measured before insertion of TEE probe (T₁), during probe insertion (T₂) and examination at mid-esophageal (T₃), transgastric level (T₄), and on removing probe (T₆). CP, TPP were monitored on CPB (T₅). Statistical analysis was done using paired t-test.

Results: CP, P_peak and P_mean increased significantly, while TPP decreased significantly from T₁ to T₂, T₃, T₄ (P < 0.001). CP, TPP decreased significantly at T₅ in comparison to T₆ (P < 0.001). In 48% of the patients CP increased above 30 cm H₂O at T₂.

Conclusion: TEE probe causes an increase in CP and decreases TPP. Constant monitoring and maintaining CP, TPP in optimum range is recommended.

Keywords: Cuff pressure; endotracheal tube; tracheal perfusion; transesophageal echocardiography. 

Abstract

Background: 

The emergence and spread of the coronavirus disease 2019 (COVID-19) pandemic presents an immense challenge to public health and has resulted in a dramatic loss of human life worldwide. Thus, diagnosis and identification of clinical laboratory parameters associated with the disease become crucial in critical cases, requiring intensive care management.

Aim: 

To investigate clinical laboratory parameters that may be associated with severe or critical COVID-19 disease patients, particularly those requiring intensive care management.

Materials and Methods: 

A retrospective cohort study was conducted at the U. N. Mehta Institute of Cardiology and Research Institute, Ahmedabad, Gujarat. A total of 1460 COVID-19-positive patients (aged 18 years and older) requiring admission to the intensive care unit were selected from April 3 to May 23, 2021, were enrolled, and were diagnostically monitored. Patients were evaluated based on their demographics. A Welsch t-test was used to calculate the progression in the mean difference among inflammatory and/or thromboembolic markers.

Results: 

We analyzed and examined certain laboratory parameters across the timeline and compared survival (Group 1) and nonsurvival (Group 2). All the factors were higher in Group 2 compared to Group 1, except for C-reactive protein-Q (CRP-Q), which decreased in both groups, but in Group 1, there was a further decrease in CRP-Q value as compared to Group 2 on retest day.

Conclusion: 

The results of the current study provide clinical value for prognostic factors associated with COVID-19 and establish the role of laboratory parameters in evaluating disease severity and complications.

Abstract: Introduction: OPCAB was designed to reduce complications resulting from cardiopulmonary bypass like stroke, renal complications and myocardial ischemia and to reduce hospital stay, reduce morbidity and mortality. It includes various anatomical distortions of heart using stabilizers and suspensions which needs extensive monitoring techniques. To improve its efficiency neurological monitoring like NIRS and PA cannulation could play a significant role in further reducing such complications. Mixed venous oxygen saturation (SvO2) remains the accepted standard during anesthesia to evaluate the balance of oxygen delivery and consumption, especially during cardiac surgery. Monitoring the ScvO2-SvO2 with conventional PAC gives indirect evidence of myocardial ischemia, after excluding other causes of ischemia in lower body. Materials and Methods: In this single centred prospective interventional study, 60 patients undergoing elective off pump CABG between March 2018 to March 2020 were taken. Institutional ethical and scientific committee approval was taken (UNMICRC/ANESTH/2017/09) and written informed consent from patients was obtained. Results: Total 360 patients were enrolled in the study for comparative analysis of regional cerebral oxygen saturation (rScO2), central venous oxygen saturation (ScvO2) and mixed venous oxygen saturation (SvO2) in off pump CABG. Table 1 shows general characteristics of patients. Mean ejection fraction was 45.92 ± 9.23%. Fifty patients had triple vessel disease and 10 had double vessel disease for which 60, 53 and 49 patients had undergone Left anterior descending (LAD), Obtuse marginal (OM) or Diagonal (DG) and Posterior descending artery (PDA) or Right coronary artery (RCA) grafting respectively. Conclusion: Positioning of the heart for distal anastomoses at lateral and posterior wall was associated with more hemodynamic alteration and increased in inotropic and vasopressor requirement and significant decreased in rScO2, ScvO2 and SvO2. There was significant positive correlation on measured gradient between ScvO2 & SvO2 and rScO2 & SvO2 and rScO2 & ScvO2. ΔrScO2 was found to be highest as compared to ΔSvO2 followed by ΔScvO2. Keywords: Venous oxygen saturation, Central venous oxygen saturation, Cerebral oxygen saturation, Coronary artery bypass grafting.

Abstract

Background and Aims: 

Vasoactive-ventilation-renal (VVR) score has been validated in predicting postoperative outcomes in pediatric cardiac surgery. The aim was to evaluate its potential in predicting early postoperative outcomes in adult patients undergoing mitral valve surgery.

Material and Methods: 

A single-center prospective observational study involved 100 patients undergoing mitral valve surgery. We evaluated preoperative variables (Ambler score), VVR, and vasoactive-inotropic score (VIS) on admission to the intensive care unit (ICU) and then at 12, 24, and 48 hrs postoperatively. Outcomes assessed were length of stay in ICU (LOS-ICU), length of hospital stay (LOHS), and mortality. The data were analyzed using multivariable logistic regression model, receiver operating characteristic (ROC) curves, and areas under curve (AUC).

Conclusion: 

Our study showed the potential utility of the VVR score as a powerful tool for predicting early outcomes after mitral valve surgery, with VVR at 48 hrs having superior predictive capability.

Abstract

Background and Aims: 

Postoperative neurological dysfunction is a common noncardiac complication following cardiac surgery. Primary objective of our study was to evaluate the effects of cerebral oxygen desaturation on the neurological outcome in the postoperative period by monitoring regional cerebral oxygen saturation in off-pump coronary artery bypass grafting (OPCABG). Secondary objective was to study the correlation between regional cerebral oxygen saturation and mean arterial pressure (MAP) during grafting.

Setting and Design: 

It was a prospective observational study in 100 patients of the American Society of Anesthesiologists physical status grading II-III of either sex, having triple vessel coronary artery disease undergoing OPCABG. Patient, having left ventricular ejection fraction (LVEF) <35%, carotid artery disease, on extracorporeal membrane oxygenator or intra-aortic balloon pump, preexisting neurological disorder with standardized mini-mental state examination (SMMSE) score <23, undergoing emergency surgery, re-do surgery, and co-existing valvular diseases were excluded from the study. Surgeries were conducted under general anesthesia with midazolam 0.1 mg/kg, fentanyl 5 μg/kg, and vecuronium 0.1 mg/kg. Anesthesia was maintained with intermittent boluses of fentanyl, vecuronium, and isoflurane.

Materials and Methods: 

The SMMSE was performed preoperatively, 8 and 12 h after extubation. Patients with postoperative SMMSE score of 24–30 were allocated to Group A and patients with SMMSE score ≤ 23, were allocated to Group B. The cerebral oxygen saturation (rSO₂), heart rate, MAP, and arterial blood gas were monitored perioperatively.

Statistical Analysis: 

The Chi-square test was used to compare categorical variables and independent Samples t-test was used to compare continuous variables. Pearson bivariate correlation test was used to correlate between the continuous variables.

Results: 

The mean difference of right and left rSo₂, between baseline value, and during saphenous vein graft (SVG) to obtuse marginal grafting were 8.70 ± 3.38, 8.78 ± 3.19 in group A and 18.8 ± 2.40, 18.91 ± 1.88, respectively, in group B and were found to be statistically significant. The mean difference of right and left rSO₂, between baseline value and during SVG to posterior descending artery grafting were 6.48 ± 3.91, 7.10 ± 3.67 in group A and 18.1 ± 3.57, 17.9 ± 3.60 in group B and were found to be statistically significant. Mean difference and percentage variation from baseline of right and left rSo₂ and MAP from preinduction to grafting from left internal mammary artery to left anterior descending artery were found to be statistically insignificant.

Conclusion: 

A decrease of regional cerebral saturation value by 25% from baseline or an absolute reduction of rSO₂ value by 50% and reduction in MAP from baseline, during the period of grafting was associated with postoperative neurocognitive dysfunction.

Abstract

Background: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly leading to progressive left ventricular dysfunction and mitral regurgitation. We conducted this study to investigate various measures to optimize the outcomes of surgical correction for ALCAPA.

Materials and methods: This was a single-centre, retrospective, observational study including consecutive patients operated for ALCAPA. The main outcomes evaluated were in-hospital mortality, duration of mechanical ventilation, and duration of intensive care unit (ICU) stay. Independent sample t- test and Fisher's exact test were used for the analysis of continuous and categorical variables respectively.

Results: 31 patients underwent surgical correction for ALCAPA during the study duration. The median age was 7.3 months with a range of 21 days to 25 months. All patients underwent coronary re-implantation with the coronary button transfer technique. There was no in-hospital mortality, the mean duration of mechanical ventilation and ICU stay was 117.6 hours and 10.7 days respectively. Age at admission, development of acute kidney injury after surgery, lactate levels at 12- and 24-hours post-surgery, and heart rate at ICU admission and 12-hours post-surgery were significantly associated with mechanical ventilation duration longer than 48 hours. Use of a combination of levosimendan and milrinone and elective intermittent nasal continuous positive airway pressure ventilation after extubation in all patients with severe left ventricular dysfunction were helpful in preventing low cardiac output and need for reintubation post-surgery respectively.

Conclusion: Surgical correction for ALCAPA by coronary re-implantation has an excellent short-term outcome. Optimal postoperative management is of utmost importance for achieving the best results.

Keywords: ALCAPA; coronary reimplantation; levosimendan; milrinone; nasal continuous positive airway pressure ventilation.

Abstract

Background: Coronavirus disease-2019 has rapidly spread globally and has become a global public health crisis. Obesity is the most frequent comorbidity exhibited by severe acute respiratory syndrome coronavirus-2. Many studies have highlighted the benefits of prone position (PP) with high flow nasal oxygenation (HFNC) in patients with moderate to severe acute respiratory distress syndrome (ARDS). This further delay intubation, reduce intensive care unit (ICU) stay and decreases overall morbidity.
Methods: In this study, we analyzed case record data of morbidly obese patients (body mass index >35Kg/m²) with moderate-to-severe ARDS over 3 months. We evaluated the efficacy of early application of PP with HFNO in morbidly obese patients with moderate-to-severe COVID-19 ARDS on PaO₂/FiO₂ ratio.
Results: A total of 24 morbidly obese patients were included in the study. Patients were divided into two groups: Group F (those who were intubated) and Group S (who did not require invasive mechanical ventilation). One hour of PP along with the use of HFNO, the P/F ratio was significantly higher in Group S (78.23 ± 7.16) than in Group F (63.58 ± 15.40) (P < 0.05). The ICU stay was longer in patients who required invasive mechanical ventilation, 17.33±2.52 days in Group F as compared to 8.11±1.05 days in Group S.
Conclusion: PP with HFNO seems safe in morbidly obese patients and may improve oxygenation more than in nonobese patients. It is important to stress the necessity to start out postural treatment as early because the patient's clinical condition permits. PP with HFNO might avoid tracheal intubation and its inherent risks and prove beneficial in resource-limited scenarios.

Keywords: Acute respiratory distress syndrome, COVID-19, high-flow nasal oxygenation, noninvasive ventilation, obesity, prone positioning, SARS-CoV-2, ventilation-induced lung injury

Abstract

background and Aims: Prediction of postoperative outcomes by conventional hemodynamic parameters and risk scoring systems immediately after pediatric cardiac surgery has not been found to be reliable. Trends in serum lactate value over time or serum lactate clearance were found to give better estimate. The present study aimed to find out the effect of serum lactate clearance on mortality after pediatric cardiac surgery.
Methods: Out of the 150 pediatric cardiac surgical procedures performed during the study period, 131 patients meeting inclusion criteria were enrolled in the present study. The study population was observed for lactate levels immediately postoperatively (T0) and then every 4 h for the first 24 h (T1-T6) and lactate clearance was calculated. Patient's outcomes in view of mortality, duration of mechanical ventilation, and length of intensive care unit (ICU) stay were observed.
Results: In our study, mortality was 9.23%. Median inter quartile range with Hodges-Lehmann median difference (95% confidence interval) lactate values were higher among nonsurvivors and statistically significant at T0 = (6.14 [3.43,7.34] vs. 2.50 [1.87,3.59]; 2.53 [1.02, 4.33], P ≤ 0.0001), T1 = (3.10 [2.81, 5.16] vs. 2.30 [1.73, 3.61];0.95 [0.13, 1.73], P = 0.032), T2 = (3.49 [3.03, 5.40] vs. 2.39 [1.66, 3.38];1.32 [0.48, 2.27], P = 0.004), T3 = (3.82 [2.99, 5.54] vs. 2.20 [1.58, 3.45]; 1.46 [0.50, 2.45], P = 0.003), T4 = (4.86 [3.35, 5.44] vs. 2.09 [1.42, 3.47]; 2.02 [1.09, 3.13], P ≤ 0.0001), T5 = (4.36 [3.80, 6.27] vs. 2 [1.32, 3.26]; 2.29 [1.41, 3.25], P ≤ 0.0001), and T6 = (4.12 [3.69, 5.83] vs. 1.82 [1.31, 3.15]; 2.34 [1.15, 3.21], P ≤ 0.0001). Nonsurvivors were having decreasing trend of lactate clearance which was statistically nonsignificant. Mechanical ventilation was prolonged in nonsurvivors compared to survivor (135 [202] h vs. 30 [77] h; P = 0.002); however, there was no significant difference in ICU stay (P = 0.764).
Conclusion: Poor lactate clearance and high lactate level were associated with high mortality. Serial lactate levels and decreasing trend of lactate clearance in the early postoperative period is a good predictor of postoperative outcome in pediatric cardiac surgery.

Keywords: Cardiac surgery, infants, serum lactate clearance

Background : The aim of the study was to compare the effect of two different regimens of milrinone in pediatric patients with pulmonary artery hypertension (PAH) undergoing corrective procedure.
Materials and Methods : This randomized prospective study included 100 pediatric patients undergoing corrective cardiac surgeries. Group E: Milrinone was started as infusion 0.5 μg/kg/min without a loading dose after induction of anesthesia and continued as infusion 0.5–0.75 μg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 μg/kg over 10 min before weaning from cardiopulmonary bypass (CPB) followed by infusion 0.5–0.75 μg/kg/min in the PSICU. We compared heart rate, mean arterial blood pressure, central venous pressure, cardiac index (CI), mean pulmonary arterial pressure (MPAP), serum lactate level, urine output, vasoactive inotropic score, mechanical ventilation duration, and intensive care unit (ICU)- and hospital length of stay between the groups.
Results : There was an increase in mean arterial blood pressure, CI, and urine output in Group E compared to Group L (P < 0.05). MPAP, serum lactate level, and requirement of inotropes and vasopressors were lower in Group E compared to Group L (P < 0.05). Mechanical ventilation duration, ICU, and hospital length of stay were shorter in Group E than Group L (P < 0.05).
Conclusions : Early use of milrinone in patients with PAH undergoing corrective cardiac surgeries improved CI and mean arterial pressure, decreased MPAP, improved urine output, decreased serum lactate level, and decreased requirement of inotropes and vasopressors after weaning from CPB compared to the milrinone bolus group.

Abstract

Background: 

Obstructed total anomalous pulmonary venous connection (TAPVC) typically present with severe cardiovascular decompensation and requires urgent surgical management. Pulmonary arterial hypertension (PAH) is a major risk factor affecting mortality. Perioperative management focuses on providing inotropic support and managing potential pulmonary hypertensive episodes. Milrinone and inhaled nitric oxide (iNO) efficiently reduce pulmonary artery pressure (PAP) and help to improve the outcome. The aim was to determine the outcome of patients with high PAP with milrinone alone and a combination of iNO and milrinone.

Material and Method: 

After ethical committee approval, the study was conducted over a period of 3 years in 80 patients with obstructed TAPVC repair. A total of 80 patients having severe PAH (supra systemic arterial pressure) randomly divided into two groups with 40 patients in each (M & MN). Group M (milrinone) patients received milrinone and Group MN (milrinone & iNO) patients received both milrinone (after opening aortic cross clamp) and iNO (post operative ICU). Ventilation time, hospital stay, ICU stay, complications, in hospital mortality were compared between both groups.

Result: 

Ventilation time, Intensive Care Unit (ICU) stay, hospital stay for group M was 8.02 ± 5.74 days, 11.25 ± 7.33 day, 14.92 ± 8.55 days, respectively, and for group MN was 5.02 ± 1.78 days, 8.27 ± 3.24 days, 10.3 ± 3.18 days, respectively. In hospital mortality for group M and MN was 10% and 2.5%, respectively. P value for each variable was significant < 0.05 (except mortality).

Conclusion: 

Most of the patients with obstructed TAPVC had severe PAH. Management of severe PAH with a combination of milrinone with iNO had a better outcome than milrinone alone.

Background: Procedural sedation required to improve the quality of Transthoracic Echocardiography (TTE) in infants and children. The ideal drug and route for sedation in children should have a rapid and reliable onset, atraumatic, palatable with minimal side effects, and rapid recovery. So, the aim of our study to evaluate and compare the efficacy and safety of intranasal midazolam and intranasal dexmedetomidine in pediatric patients for sedation during TTE.

Materials and Method: Hundred children under three year of age, belonging to the American Society of Anaesthesiologists class-I and II, scheduled for TTE were divided into two groups by standard randomization technique. Patients in group-M received intranasal midazolam 0.2 mg/kg, whereas patients in group-D received intranasal dexmedetomidine 2 μg/kg prior to TTE under an adequately monitored anesthesia care. Onset and duration of sedation, heart rate, oxygen saturation, sonographer's, and parent's satisfaction scores were recorded.

Results: All patients were successfully sedated for TTE. The average onset time, sedation time, awakening time and total time for Group-M were 7.3, 18.8, 29.51, 51 min and group-D were 10.1, 14.2, 24.9, 46.3 min, respectively and all were statistically significant (P < 0.001). TTE scan time of Group-M is 8.84 min and Group-D is 9.18 min and was statistically significant. Sonographer's and Parent's average satisfaction score for Group-M was 9.88, 10 and for Group-D was 7.64, 8.76, respectively, which were statistically significant (P < 0.001).

Conclusion: Intranasal midazolam and dexmedetomidine are safe and effective for sedation in TTE. Intranasal midazolam was found to be comparatively more effective in view of onset of action, sonographers, and parental satisfaction score, while sedation time, awakening time and total duration was significantly higher as compared to intranasal dexmedetomidine.

Keywords: Intranasal dexmedetomidine, intranasal midazolam, transthoracic echocardiography

Abstract

Objective

To evaluate and compare the hemodynamic effects of intraoperative intravenous milrinone versus inhalational milrinone at two timepoints in patients with severe pulmonary hypertension undergoing mitral valve surgery.

Methods

A prospective observational study was performed in 100 patients with severe rheumatic mitral stenosis (with/without regurgitation) and right ventricular systolic pressure > 50 mm Hg. They were divided into two groups based on the strategy used to reduce pulmonary hypertension. Fifty patients had inhalational milrinone after sternotomy until initiation of cardiopulmonary bypass and after release of the aortic crossclamp until weaning off cardiopulmonary bypass. The other 50 patients received an intravenous loading dose of milrinone 50 µg·kg⁻¹ over 10 min on release of the aortic crossclamp. Both groups received intravenous milrinone 0.5 µg·kg⁻¹ during weaning from cardiopulmonary bypass. Hemodynamic data were evaluated at the 3 timepoints.

Results

Pulmonary artery pressures, central venous pressure, and pulmonary capillary wedge pressure decreased significantly in the inhalational milrinone group compared to the intravenous milrinone group. Systemic vascular resistance index and cardiac index were significantly higher and pulmonary vascular resistance index was significantly lower in the inhalational milrinone group. The mean arterial pressure-to-mean pulmonary artery pressure ratio was significantly lower in the intravenous milrinone group. Tricuspid annular plane systolic excursion and right ventricular fractional area change were increased significantly in the inhalational milrinone group.

Conclusion

Intraoperative inhalational milrinone before and after cardiopulmonary bypass is safe, easy to administer, and results in significant improvements in right ventricular hemodynamics, right ventricular function, and systemic hemodynamics.

Keywords 

Cardiopulmonary bypass, heart valve diseases, hypertension, pulmonary, hemodynamics, milrinone, mitral valve

Objective :

The aims of our prospective observational study were to evaluate the (1) reliability of clinical signs in the early detection of diaphragm palsy (DP); (2) reliability of ultrasonography using echo machine as a bedside tool for the diagnosis of DP; and (3) does early diaphragm plication result in the improved outcome? We also sought to determine the incidence and predominant risk factors for DP and diaphragm plication at our center.

Materials and Methods :

This prospective observational study included patients with suspected DP from January 2015 to December 2018. Patients with suspected DP were initially evaluated by bedside ultrasonography using echo machine and confirmed by fluoroscopy. Diaphragm plication was considered for patients having respiratory distress, difficult weaning, or failed extubation attempt without any obvious cardiac or pulmonary etiology. Patients were followed for 3 months after discharge to assess diaphragm function.

Results:

A total of 87 patients were suspected of DP based on clinical signs. DP was diagnosed in 61 patients on fluoroscopy. The median time from index operation to diagnosis was 10 (1–59) days. Diaphragm plication was done among 52 patients and not done in nine patients. Bedside ultrasonography using echo machine was 96.7% sensitive and 96.15% specific in diagnosing DP. Early plication (<14 days) significantly reduced the need for nasal continuous positive airway pressure (65% vs. 96%, P = 0.02), duration of mechanical ventilation (12 vs. 25 days, P = 0.018), intensive care unit (ICU) stay (25 days vs. 39 days, P = 0.019), and hospital stay (30 days vs. 46 days, P = 0.036).

Conclusion :

Hoover's sign and raised hemidiaphragm on chest X-ray are the most specific clinical signs to suspect unilateral DP. Bedside ultrasonography using an echo machine is a good diagnostic investigation comparable to fluoroscopy. Early plication facilitates weaning from the ventilator and thereby decreases the ICU stay and hospital stay.

Keywords: Diaphragm palsy, diaphragm plication, pediatric cardiac surgery

Background: Extra Corporeal Membrane Oxygenation (ECMO) is a well-known tool for providing life-saving support in patients developing post cardiotomy cardiogenic shock in post cardiac surgeries. The current study was designed to evaluate blood transfusion requirements and its relation to mortality in neonate and pediatric cardiac patients requiring venoarterial cardiac ECMO during post-operative period following cardiac surgery.

Materials and Methods: Overall 24 pediatric patients (including neonates) who underwent VA ECMO in post cardiac surgery at our institute from January 2016 to October 2017 were included in the study. The details of demographics, blood transfusion, ECMO, and morbidity and mortality were collected for all the patients.

Objective of the Study: The primary objective of our study was to assess the outcome of patients on ECMO in post pediatric cardiac surgery. The secondary objective of the study was to assess the effect of blood transfusion on the outcome of the patients.

Results: Overall mortality rate was 50% (n = 12). The overall transfusion rate of packed red blood cells was higher in patients who did not survive even after institution of VA ECMO. The transfusion of other blood products like platelets, cryoprecipitate, and fresh frozen plasma were also higher in this group of patients though it was statistically non-significant except for packed red cell transfusion. Though statistically non-significant, the patients who didn't survive even after institution of VA ECMO post-surgery had relatively higher mean age (703.88 ± 998.94 days) as compared to their counterparts (510.63 ± 384.36 days).

Conclusion: The use of ECMO is associated with considerable morbidity and mortality. Packed red cell transfusion is definitely higher in expired patients, indicative of deteriorated status of the patient. However, considering non-significant association of other blood components, except packed red cell it is recommended that patients' overall clinical condition should be taken into consideration for transfusion of blood products and not only targeting the transfusion triggers.

Keywords: Blood transfusion, extra corporeal membrane oxygenation, pediatric cardiac surgeries

Abstract

Background: Extra Corporeal Membrane Oxygenation (ECMO) is a well-known tool for providing life-saving support in patients developing post cardiotomy cardiogenic shock in post cardiac surgeries. The current study was designed to evaluate blood transfusion requirements and its relation to mortality in neonate and pediatric cardiac patients requiring venoarterial cardiac ECMO during post-operative period following cardiac surgery.
Materials and Methods: Overall 24 pediatric patients (including neonates) who underwent VA ECMO in post cardiac surgery at our institute from January 2016 to October 2017 were included in the study. The details of demographics, blood transfusion, ECMO, and morbidity and mortality were collected for all the patients.
Objective of the Study: The primary objective of our study was to assess the outcome of patients on ECMO in post pediatric cardiac surgery. The secondary objective of the study was to assess the effect of blood transfusion on the outcome of the patients.
Results: Overall mortality rate was 50% (n = 12). The overall transfusion rate of packed red blood cells was higher in patients who did not survive even after institution of VA ECMO. The transfusion of other blood products like platelets, cryoprecipitate, and fresh frozen plasma were also higher in this group of patients though it was statistically non-significant except for packed red cell transfusion. Though statistically non-significant, the patients who didn't survive even after institution of VA ECMO post-surgery had relatively higher mean age (703.88 ± 998.94 days) as compared to their counterparts (510.63 ± 384.36 days).
Conclusion: The use of ECMO is associated with considerable morbidity and mortality. Packed red cell transfusion is definitely higher in expired patients, indicative of deteriorated status of the patient. However, considering non-significant association of other blood components, except packed red cell it is recommended that patients' overall clinical condition should be taken into consideration for transfusion of blood products and not only targeting the transfusion triggers.

Keywords: Blood transfusion, extra corporeal membrane oxygenation, pediatric cardiac surgeries

Abstract

Objective: To evaluate and compare the hemodynamic effects of intraoperative intravenous milrinone versus inhalational milrinone at two timepoints in patients with severe pulmonary hypertension undergoing mitral valve surgery.

Methods: A prospective observational study was performed in 100 patients with severe rheumatic mitral stenosis (with/without regurgitation) and right ventricular systolic pressure > 50 mm Hg. They were divided into two groups based on the strategy used to reduce pulmonary hypertension. Fifty patients had inhalational milrinone after sternotomy until initiation of cardiopulmonary bypass and after release of the aortic crossclamp until weaning off cardiopulmonary bypass. The other 50 patients received an intravenous loading dose of milrinone 50 µg·kg^-1 over 10 min on release of the aortic crossclamp. Both groups received intravenous milrinone 0.5 µg·kg^-1 during weaning from cardiopulmonary bypass. Hemodynamic data were evaluated at the 3 timepoints.

Results: Pulmonary artery pressures, central venous pressure, and pulmonary capillary wedge pressure decreased significantly in the inhalational milrinone group compared to the intravenous milrinone group. Systemic vascular resistance index and cardiac index were significantly higher and pulmonary vascular resistance index was significantly lower in the inhalational milrinone group. The mean arterial pressure-to-mean pulmonary artery pressure ratio was significantly lower in the intravenous milrinone group. Tricuspid annular plane systolic excursion and right ventricular fractional area change were increased significantly in the inhalational milrinone group.

Conclusion: Intraoperative inhalational milrinone before and after cardiopulmonary bypass is safe, easy to administer, and results in significant improvements in right ventricular hemodynamics, right ventricular function, and systemic hemodynamics.

Keywords: Cardiopulmonary bypass; heart valve diseases; hemodynamics; hypertension; milrinone; mitral valve; pulmonary.

Abstract

Background: Procedural sedation required to improve the quality of Transthoracic Echocardiography (TTE) in infants and children. The ideal drug and route for sedation in children should have a rapid and reliable onset, atraumatic, palatable with minimal side effects, and rapid recovery. So, the aim of our study to evaluate and compare the efficacy and safety of intranasal midazolam and intranasal dexmedetomidine in pediatric patients for sedation during TTE.

Materials and method: Hundred children under three year of age, belonging to the American Society of Anaesthesiologists class-I and II, scheduled for TTE were divided into two groups by standard randomization technique. Patients in group-M received intranasal midazolam 0.2 mg/kg, whereas patients in group-D received intranasal dexmedetomidine 2 μg/kg prior to TTE under an adequately monitored anesthesia care. Onset and duration of sedation, heart rate, oxygen saturation, sonographer's, and parent's satisfaction scores were recorded.

Results: All patients were successfully sedated for TTE. The average onset time, sedation time, awakening time and total time for Group-M were 7.3, 18.8, 29.51, 51 min and group-D were 10.1, 14.2, 24.9, 46.3 min, respectively and all were statistically significant (P < 0.001). TTE scan time of Group-M is 8.84 min and Group-D is 9.18 min and was statistically significant. Sonographer's and Parent's average satisfaction score for Group-M was 9.88, 10 and for Group-D was 7.64, 8.76, respectively, which were statistically significant (P < 0.001).

Conclusion: Intranasal midazolam and dexmedetomidine are safe and effective for sedation in TTE. Intranasal midazolam was found to be comparatively more effective in view of onset of action, sonographers, and parental satisfaction score, while sedation time, awakening time and total duration was significantly higher as compared to intranasal dexmedetomidine.

Keywords: Intranasal dexmedetomidine; intranasal midazolam; transthoracic echocardiography.

ABSTRACT

Objective : The aims of our prospective observational study were to evaluate the (1) reliability of clinical signs in the early detection of diaphragm palsy (DP); (2) reliability of ultrasonography using echo machine as a bedside tool for the diagnosis of DP; and (3) does early diaphragm plication result in the improved outcome? We also sought to determine the incidence and predominant risk factors for DP and diaphragm plication at our center.

Materials and Methods : This prospective observational study included patients with suspected DP from January 2015 to December 2018. Patients with suspected DP were initially evaluated by bedside ultrasonography using echo machine and confirmed by fluoroscopy. Diaphragm plication was considered for patients having respiratory distress, difficult weaning, or failed extubation attempt without any obvious cardiac or pulmonary etiology. Patients were followed for 3 months after discharge to assess diaphragm function.

Results : A total of 87 patients were suspected of DP based on clinical signs. DP was diagnosed in 61 patients on fluoroscopy. The median time from index operation to diagnosis was 10 (1–59) days. Diaphragm plication was done among 52 patients and not done in nine patients. Bedside ultrasonography using echo machine was 96.7% sensitive and 96.15% specific in diagnosing DP. Early plication (<14 days) significantly reduced the need for nasal continuous positive airway pressure (65% vs. 96%, P = 0.02), duration of mechanical ventilation (12 vs. 25 days, P = 0.018), intensive care unit (ICU) stay (25 days vs. 39 days, P = 0.019), and hospital stay (30 days vs. 46 days, P = 0.036).

Conclusion : Hoover’s sign and raised hemidiaphragm on chest X‑ray are the most specific clinical signs to suspect unilateral DP. Bedside ultrasonography using an echo machine is a good diagnostic investigation comparable to fluoroscopy. Early plication facilitates weaning from the ventilator and thereby decreases the ICU stay and hospital stay.

Keywords : Diaphragm palsy, diaphragm plication, pediatric cardiac surgery

ntroduction Revascularization of coronary artery increases the blood flow in the coronary sinus (CS) too. The study aimed to measure the CS blood flow using transesophageal echocardiography (TEE) to estimate the adequacy of revascularization in patients undergoing off-pump coronary artery bypass grafting. Patients and methods After ethical committee approval, 100 patients scheduled for elective coronary artery bypass grafting were included in this study. After induction of balanced anesthesia according to institutional protocol, a 5-Hz multiplane phased-array TEE probe was inserted into patients’ esophagus, and the following parameters were calculated at pre-revascularization and post-revascularization periods: velocity time integral of CS, coronary sinus diameter, coronary sinus cross-section area, and coronary sinus blood flow (CSBF) per beat and per minute. Results Our study showed a statistically significant increase in velocity time integral in the post-revascularization period as compared with the pre-revascularization period (P<0.001). There was significant increment in mean CS diameter in the post-revascularization period as compared with the pre-revascularization period (0.79 vs.0.68 cm) (P<0.001). There was a significant increase in CSBF per minute in the post-revascularization period (363.8±80.55 ml) as compared with the pre-revascularization period (218.9±46.61 ml) (P<0.001). Conclusion TEE is a superior modality to evaluate CSBF before and after coronary artery bypass revascularization to determine the adequacy of surgical revascularization in real time during off-pump coronary artery bypass revascularization.

Abstracrt

Background and Aims

Ultrasound guidance of central venous catheter (CVC) insertion improves the safety and efficacy of its placement, but still it may not ensure correct placement of catheter tip. In our study, we aimed to identify the correct placement of CVC tip and to detect mechanical complications, by visualizing it in real time with the help of sonography and comparing this to the chest X-ray findings.

Patients and Methods

This was a cross-sectional observational study conducted on 80 patients with American Society of Anesthesiologists grades 1 and 2, in the age group of 18 to 65 years, who required central venous catheterization in intensive care unit. The CVC tip placement was identified with ultrasound and then the finding was compared with postinsertion chest X-ray.

Results

In only 9 out of the 80 patients (11.3%) malposition was detected on ultrasound and was corrected immediately, whereas in remaining 71 patients (88.8%) no intervention was required. It was observed that all the patients had correct position of CVC tip on postprocedural chest X-ray. Accidental arterial cannulation occurred in two (2.5%) patients in whom right internal jugular vein was cannulated and in two (2.5%) patients who had arrhythmia.

Conclusion

Ultrasonography (USG) examination can be used as a diagnostic tool method for confirmation of CVC tip and identification of cannulation-related complications. Thus, we can say that USG might obviate the need for post-CVC insertion chest X-ray.

Abstract

Background:

Cardiac surgery is frequently associated with macro and microcirculatory hypoperfusion. Patients with normal central venous oxygen saturation (Scvo2) also suffer from hypoperfusion. We hypothesized that monitoring central venous‑arterial pco2 difference (dCO2 ) could also serve as additional marker in detecting hypoperfusion in cardiac surgery patient.

Methods: This is a prospective observational study. Patients undergoing off‑pump coronary artery bypass grafting included in this study. The dCO2 was measured postoperatively. The patients with a ScvO2 ≥70% were divided in to 2 groups, the high‑dCO2 group (≥8 mmHg) and the low‑dCO2 group (8 mmHg)

Results: The 65 patient had scvO2 ≥70%. Out of these, 20 patients were assigned to the high dCO2 group and 45 patients to the low dCO2 group. Patients with high dco2 had higher lactate levels after ICU admission. They also had significantly prolonged need for mechanical ventilation (14.90 ± 10.33 vs 10 ± 9.65, P = 0.0402), ICU stay (5.05 ± 2.52 d vs 3.75 ± 2.36 d, P = 0.049) and hospital stay (12.25 ± 5.90 d vs 8.57 ± 5.55 d P = 0.018). The overall rate of post‑operative complications was similar in both the group.

Conclusion: The present study demonstrates dCO2 as an easy to assess and routinely available tool to detect global and microcirculatory hypoperfusion in off‑pump CABG patients, with assumed adequate fluid status and ScvO2 as a hemodynamic goal. We observed that high dCO2 (>8 mmHg) was associated with decreased DO2 I, increased oxygen extraction ratio, the longer need for mechanical ventilation and longer ICU stay.

Keywords: Central venous-arterial pco2 difference, microcirculatory hypoperfusion, off-pump coronary artery bypass

Abstract

Background: Spinal Anesthesia is the regional anesthesia obtained by blocking spinal nerves in subarachnoid space, the aesthetic agents are deposited in the subarachnoid space and act on spinal nerve roots and not on substance of cord. Intrathecal opioids are synergistic with local aesthetic and intensity of sensory block without increasing motor block and offer Hemodynamic stability. Intrathecal opioids like fentanyl citrate is combined with local anesthetics which has milder side effects, also fentanyl citrate is lipophilic drugs. It has rapid onset compared lyophobic morphine. This property may affect onset of sensory block. When fentanyl citrate is added to bupivacaine hydrochloride for subarachnoid block. An intrathecal Clonidine has substantial antinociceptive effect by its action on 2 Receptor in dorsal Horn of spinal cord and by adding Clonidine with Bupivacaine hydrochloride improves intraoperative analgesia and might prolong the duration of spinal Analgesia. We compared the effects of fentanyl and Clonidine as an adjuvant to Bupivacaine for spinal Anesthesia.

Methods: The study was carried out by selecting the patients presenting for surgery of lower limb, perineal surgery, lower abdominal surgery etc. Study was done in 50 patients belonging to ASA 1 and 2 selected for the study. Group - BF: Inj. Bupivacaine Hydrochloride (20 mg) (0.5%) + inj. Fentanyl citrate 25 µg. Group - BC: Inj. Bupivacaine Hydrochloride (20 mg) (0.5%) + inj. Clonidine Hydrochloride 50 µg. Time at which sensory and motor blockade reached highest dermatome level & stabilized at highest level. Recording of vital signs was started from the point of injection of drug in CSF. Heart Rate, Blood Pressure, SpO2, were noted every 1 min for first 10 min, then every 5 min till 30 min and then every 15 min till 60 min. Duration of total sensory and Motor Blockade is noted. Hypotension was defined as Systolic - Blood Pressure less than 90 mm HG or 30% decrease in Systolic Blood Pressure from Base line and Brady cardia was defined as Heart Rate less than 50 min. Patients were observed for following complication during procedure Hypotension, Bradycardia, Sedation, Respiratory depression, Nausea, Vomiting, Rigors, Pruritus. Duration of Motor & Sensory Blockade was noted. Results: We studied that mean time for onset of sensory block (sec) and motor block (sec) was shorter in Group - BF as compared to Group - BC. Total duration of motor and sensory block was longer in Group - BC as compared Group - BF. Changes in pulse rate, systolic BP and diastolic BP shows statistical significance in both Group. First analgesic requirement was more prolonged in Group - BC. Group - BF shows some complications like Nausea, Pruritus, and Hypotension. Group - BC shows complications like sedation, Hypotension + Bradycardia.

Conclusion: Clonidine Hydrocloride caused intense sensory and motor blockade when injected with bupivacaine. Clonidine also didn’t show side effects like respiratory depression, pruritus, urinary retention. Which were noted with the use of fentanyl. But onset of action was delayed with use of clonidine and increased chances of more bradycardia, hypotension and sedation compared to fentanyl which required more supportive care.

Keywords: Fentanyl; Clonidine; Bupivacaine; Spinal Anesthesia; Hemodynamic; Sensory and Motor blockade.

Abstract 

Background and Aim: Various studies have been done on addition of various adjuncts to spinal local anaesthetics to improve as well as to increase the time of spinal anesthesia and analgesia, so that the total dose of local anaesthetics could be decreased. Present study was done with an aim to evaluate the relative efficacy of dexmedetomidine and
fentanyl with 0.5% hyperbaric bupivacaine intrathecally in Endo-urological procedures.

Material and Methods: Total 80 patients of ASA grade I and II, between 18 to 70 years were scheduled for different Endo-urological surgeries including Turp, Turbt, End To End Urethroplasy,Suprapubic Cystolithotrity/Suprapubic Cystolithotomy And Urs (Lower ureteric stone) and RIRS were included in the study. Patients were allocated into 2 groups, each of 40 patients, each received a total volume of 3.5ml which contained dose of 15mg (i.e. 3ml) 0.5% hyperbaric bupivacaine
combined either Dexmedetomidinne or Fentanyl. After noting baseline parameters the patients were monitored using continuous electrocardiography (lead II), heart rate, non-invasive blood pressure, and continuous pulse oximetry.

Results: The changes in mean heart rate between two groups were significant statistically after 60 minutes of spinal anaesthesia, which showed more fall in heart rate in patients of group-D than group-F. The changes in mean arterial pressure were also statistically significant between the two groups after 75 minutes of spinal anaesthesia, which showed more fall in patients of group-D. Intra–operative hypotension requiring treatment was also observed more in group-D patients (12.5%) compared to group-F (2.5%).

Conclusion: Dexmedetomidine is a good option to fentanyl in spinal anesthesia as it significantly prolongs duration of sensory and motor block and increase the duration of analgesia, it causes hypotension and bradycardia which are easily reversible and without any untoward adverse events.
Key words: Bradycardia, Dexmedetomidine, Fentanyl, Hypotension

Corresponding Author : Jigar Panchal

Background and aims

Early goal-directed therapy (EGDT) provides preset goals to be achieved by intravenous fluid therapy and inotropic therapy with earliest detection of change in the hemodynamic profile. Improved outcome in cardiac surgery patients has been shown by perioperative volume optimization, while postoperative intensive care unit (ICU) stay can be decreased by improving oxygen delivery. Our aim of this study was to study the outcome of EGDT in patients undergoing elective cardiac surgery.

Materials and methods

This is a prospective single institute study involving a total of 478 patients. Patients were divided into group I, who received standard hospital care, and group II, who received EGDT. Postoperatively, patients were observed in ICU for 72 hours. Hemodynamics, laboratory data, fluid bolus, inotrope score, complication, ventilatory time, and mortality data were collected.

Results

Postoperative ventilatory period (11.12 ± 10.11 vs 9.45 ± 8.87, p = 0.0719) and frequency of change in inotropes (1.900 ± 0.9 vs 1.19 ± 0.61, p = 0.0717) were lower in group II. Frequency of crystalloid boluses (1.33 ± 0.65 vs 1.75 ± 1.09, p = 0.0126), and quantity of packed cell volume (PCV) used (1.63 ± 1.03 vs 2.04 ± 1.42, p = 0.0364) were highly significant in group II. Use of colloids was higher in group II and was statistically significant (1.98 ± 1.99 vs 3.05 ± 2.17, p = 0.0012). The acute kidney injury (AKI) rate was (58 (23.10%) vs 30 (13.21%), p = 0.007) lower and statistically significant (p = 0.007) in group II.

Conclusion

Early goal-directed therapy reduces the postoperative ventilatory period, frequency of changes in inotropes, and incidence of AKI, and decreases ventilation hours, number of times inotropes changed, and AKI.

Abstract:

Background: Laryngoscopy and intubation in the lightly anaesthetised patient is associated with significant increase in blood pressure and heart rate. These changes occur from reflex sympathetic discharge resulting from pharyngeal and laryngotracheal stimulation with increases in plasma concentration of epinephrine and nor-epinephrine. This reaction is not prevented by regular pre-medication. This study was designed to compare the two different doses of fentanyl citrate that is 2 mcg/kg and 4 mcg/kg in attenuation of haemodynamic effects during laryngoscopy and intubation.

Methods: 80 adult patients 40 in each group ranging from 18-60 years of age and from both sexes undergoing modified radical mastectomy and total and subtotal thyroidectomy and surgeries which include oral intubation were selected for the study. Only patients belonging to ASA 1 and 2 were selected for the study. Group 1: Receives Inj. Fentanyl Citrate 2 mcg/kg. Group 2: Receives Inj, Fentanyl Citrate 4 mc/kg. All the parameters including heart rate, systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure were recorded at the time of intubation and sequencially 1 min, 3min, 5 min, and 10 minutes after intubation.

Results: We studied all 4 parameters in both the groups in all the patients and found out that the heart rate slightly increased during intubation in the group 1 patients while it was either remained stable or decreased in group 2 patients. There is consistent decrease in S.B.P., D.B.P. and M.B.P.  in both the groups from the baseline throughout the study period. And maximum decrease in all the pressures found at 10 minutes interval in group 2 patients.

Conclusion: Fentanyl citrate given 5 minutes before intubation produces most attenuation of the haemodynamic effects of stress response.Pre-treatment with fentanyl citrate in every normal case would cause attenuation of haemodynamic effects of laryngoscopy and intubation. It will cause minimal change in heart rate, S.B.P., D.B.P., M.A.P., R.P.P. during the first 10 minutes after intubation. Fentanyl citrate in 2 mcg/kg significantly attenuate but fentanyl 4 mcg/kg completely attenuates the haemodynamic responses during laryngoscopy and intubation

Abstract

BACKGROUND: Spinal Anesthesia is the regional anaesthesia obtained by blocking spinal nerves in subarachnoid space .the aesthetic agents are deposited in the subarachnoid space and act on spinal nerve roots and not on substance of cord. Intrathecal opioids are synergistic with local aesthetic and intensity of sensory block without increasing motor block and offer Hemodynamic stability. Intrathecal opioids like fentanyl citrate is combined with local anaesthetics which has milder side effects, also fentanyl citrate is lipophilic drugs. It has rapid onset compared lyophobic morphine.  This property may affect onset of sensory block. When   fentanyl citrate is added to bupivacaine hydrochloride for subarachnoid block. An   intrathecal Clonidine has substantial antinociceptive effect by its action on ∝2 Receptor in dorsal Horn of spinal cord and by adding Clonidine with Bupivacaine hydrochloride improves intraoperative analgesia and might prolong the duration of spinal Analgesia. We compared the effects of fentanyl and Clonidine as an adjuvant to Bupivacaine for spinal Anesthesia.

Method: The study was carried out by selecting the patients presenting for surgery of lower limb, perineal surgery, lower abdominal surgery etc. Study was done in   50 patients belonging to ASA 1 AND 2 selected for the study. Group – BF:  Inj Bupivacaine Hydrochloride (20mg) (0.5%) + inj Fentanyl citrate 25µg. Group – BC:  Inj Bupivacaine Hydrochloride (20mg) (0.5%) + inj. Clonidine Hydrochloride 50µg.  Time at which sensory and motor blockade reached highest dermatome level & stabilized at highest level. Recording of vital signs was started from the point of injection of drug in CSF.  Heart Rate, Blood Pressure, SPO2,  were noted  every 1 min for first 10 min, then every 5 min till 30 min and then  every  15min till 60 min.  Duration of total sensory and Motor Blockade is noted.  Hypotension  was  defined  as  Systolic – Blood  Pressure  less  than 90 mmHG or 30% decrease in Systolic Blood Pressure from Base line  and  Brady cardia was defined as Heart-Rate less than 50/min. Patients   were   observed   for   following   complication   during    procedure Hypotension, Bradycardia,   Sedation, Respiratory depression, Nausea, Vomiting,  Rigors, Pruritus .  Duration of Motor   & Sensory Blockade was noted.

RESULTS: We studied that mean time for onset of sensory block (sec) and motor block (sec) was shorter in GROUP-BF as compared to GROUP-BC. Total   duration of motor and sensory block was longer in GROUP- BC as compared GROUP-BF. Changes in pulse rate, systolic BP and diastolic BP shows statistical significance in both group. First analgesic requirement was more prolonged in GROUP-BC. GROUP-BF shows some complications like Nausea, Pruritus, and Hypotension.  GROUP-BC shows complications like sedation, Hypotension + Bradycardia.

CONCLUSION:  Clonidine Hydrocloride caused intense sensory and motor blockade when injected with bupivacaine.  Clonidine also didn’t show side effects like respiratory depression, pruritus, urinary retention.  Which were noted with the use of fentanyl.  But onset of action was delayed with use of clonidine and increased chances of more bradycardia, hypotension and sedation compared to fentanyl which required more supportive care.   

Key words: fentanyl, clonidine. Bupivacaine, spinal Anaesthesia, haemodynamic, Sensory and motor blockade.    

Abstract

BackgroundandAim: Variousstudieshavebeendoneonadditionofvariousadjunctstospinallocalanaestheticsto improveaswellastoincreasethetimeofspinalanesthesiaandanalgesia,sothatthetotaldoseoflocalanaesthetics couldbedecreased.Presentstudywasdonewithanaimtoevaluatetherelativeefficacyofdexmedetomidineand fentanylwith0.5%hyperbaricbupivacaineintrathecallyinEndo-urologicalprocedures. MaterialandMethods:Total 80patientsofASAgradeIandII,between18to70yearswerescheduledfordifferentEndo-urologicalsurgeries includingTurp,Turbt,EndToEndUrethroplasy,SuprapubicCystolithotrity/SuprapubicCystolithotomyAndUrs (Lower ureteric stone) and RIRSwere includedin the study. Patients were allocatedinto 2 groups, each of 40 patients,eachreceivedatotalvolumeof3.5mlwhichcontaineddoseof15mg(i.e.3ml)0.5%hyperbaricbupivacaine combinedeitherDexmedetomidinne orFentanyl.Afternotingbaselineparameters thepatientsweremonitored using continuous electrocardiography (lead II), heart rate, non-invasive blood pressure, and continuous pulse oximetry.Results:Thechangesinmeanheartratebetweentwogroupsweresignificantstatisticallyafter60minutes of spinal anaesthesia,which showed more fall in heart ratein patients of group-D than group-F. The changes inmean arterial pressurewere also statistically significant between the two groups after 75 minutes of spinal anaesthesia,whichshowedmorefallinpatientsofgroup-D.Intra–operativehypotensionrequiringtreatmentwas alsoobservedmoreingroup-Dpatients (12.5%)compared togroup-F (2.5%).Conclusion:Dexmedetomidineisa goodoptiontofentanylinspinalanesthesiaasitsignificantlyprolongsdurationofsensoryandmotorblockand increasethedurationofanalgesia,itcauseshypotensionandbradycardiawhichareeasilyreversibleandwithout anyuntowardadverseevents. Keywords:Bradycardia,Dexmedetomidine,Fentanyl,Hypotension

Abstract

Background and aims

Early goal-directed therapy (EGDT) provides preset goals to be achieved by intravenous fluid therapy and inotropic therapy with earliest detection of change in the hemodynamic profile. Improved outcome in cardiac surgery patients has been shown by perioperative volume optimization, while postoperative intensive care unit (ICU) stay can be decreased by improving oxygen delivery. Our aim of this study was to study the outcome of EGDT in patients undergoing elective cardiac surgery.

Materials and methods

This is a prospective single institute study involving a total of 478 patients. Patients were divided into group I, who received standard hospital care, and group II, who received EGDT. Postoperatively, patients were observed in ICU for 72 hours. Hemodynamics, laboratory data, fluid bolus, inotrope score, complication, ventilatory time, and mortality data were collected.

Results

Postoperative ventilatory period (11.12 ± 10.11 vs 9.45 ± 8.87, p = 0.0719) and frequency of change in inotropes (1.900 ± 0.9 vs 1.19 ± 0.61, p = 0.0717) were lower in group II. Frequency of crystalloid boluses (1.33 ± 0.65 vs 1.75 ± 1.09, p = 0.0126), and quantity of packed cell volume (PCV) used (1.63 ± 1.03 vs 2.04 ± 1.42, p = 0.0364) were highly significant in group II. Use of colloids was higher in group II and was statistically significant (1.98 ± 1.99 vs 3.05 ± 2.17, p = 0.0012). The acute kidney injury (AKI) rate was (58 (23.10%) vs 30 (13.21%), p = 0.007) lower and statistically significant (p = 0.007) in group II.

Conclusion

Early goal-directed therapy reduces the postoperative ventilatory period, frequency of changes in inotropes, and incidence of AKI, and decreases ventilation hours, number of times inotropes changed, and AKI.

Keywords: Acute kidney injury, Cardiopulmonary bypass, Early goal-directed therapy

Abstract

Background: Intranasal midazolam is a novel technique for administering premedication in children. It has been shown to be more effective than parental presence or placebo in reducing anxiety and improving patient’s compliance at induction of anesthesia. Dexmedetomidine is selective 2 agonist with sedative, anxiolytic and analgesic properties with favorable pharmacokinetics. We designed this prospective randomized double-blinded study to compare the safety and efficacy of midazolam and dexmedetomidine administered intranasally as premedication in children undergoing cardiac surgery for CHD. Method: Sixty-two children belonging to the American Society of Anaesthesiologists (ASA) class I and II, scheduled for elective cardiac surgery were divided into two groups by standard randomization technique. Patients belonging to group M received intranasal midazolam 0.2 mg/kg whereas patients in group D received intranasal dexmedetomidine 1 µgm/kg 30 min prior to surgery in an adequately monitored condition. Patient’s sedation score, behaviour scores, attitude, heart rate, respiratory rate, oxygen saturation, intravenous cannula acceptance and face mask acceptance at the time of induction were studied by an observer till induction of anesthesia. Results: There was no significant difference in sedation score in both the groups except at 20 minutes, when it was significantly lower in patients belonging to Group D as compared to those of Group M. There was no significant difference inheart rate, respiratory rate, SpO2 , behavior score, parental separation acceptance, behavior at separation and level of sedation atinduction of anaesthesia between the two groups. There was a significant difference in the number of patients with a change of behaviour (6.4% v/s 34.4%) and change of sedation (7.1% v/s 37.5%) in Group M and Group D respectively. Patients inGroup M were calmer and allowed face mask application at the time of induction of anesthesia. Conclusion: Intranasal route is safe and effective for administering both, midazolam and dexmedetomidine as premedication in children undergoing corrective surgery for congenital heart disease. However, we observed better behaviour with midazolam at induction of anesthesia. Keywords: Intranasal midazolam; Intranasal Dexmedetomidine; Cardiac Surgery

Abstract

Background: Conventional cardiac surgery involving cardiac arrest and cardiopulmonary bypass (CPB) is well known to be associated with postoperative myocardial dysfunction and low cardiac output syndrome (LCOS). The aim of this study is to compare the effect of prophylactically administered levosimendan and milrinone on postoperative parameters and outcomes in neonates and infants after corrective open-heart surgery and comparing postoperative parameters like heart rate, mean arterial pressure, arterial and venous blood gasses at certain particular points of time. Method: We performed a prospective observational study at our institute. Total 100 pediatric patients undergoing complex congenital cardiac surgeries to evaluate the efficacy of milrinone and levosimendan on intraoperative and postoperative outcomes. Result: In the postoperative period heart rate and mean arterial pressure at three different time periods (T1, T2 and T3) did not show any statistically significant difference in both the groups. The VIS score after 48 hours was less in Group L (p = 0.0005). Serum creatinine estimated at T2 and T3 showed a statistically significant difference. (p value at T2 = <0.001, p value at T3 = 0.002). Duration of ventilation was less in Group L (p = 0.0297). Conclusion: In our prospective observational study of 100 infants undergoing surgery for complex congenital cardiac conditions, postoperative hemodynamic parameters and markers of tissue perfusion overtime were similar in infants with administration of either levosimendan or milrinone. Our results might be the basis of future controlled trials of levosimendan in children with a special focus on duration of mechanical ventilation and the incidence of renal complications. Keywords: Levosimendan; Milrinone; Cardiopulmonary bypass (CPB); Low cardiac output syndrome (LCOS)

Abstract

Background: Pulmonary artery catheter and central venous catheter are an important and integral part of hemodynamic monitoring during coronary artery bypass grafting. Methods: In our prospective randomized survey, 180 patients received either pulmonary artery or central venous catheter after induction of anesthesia. Patients between 35 and 75 years with ejection fraction between 35 and 60% undergoing elective off pump coronary artery bypass grafting surgery were included. Both groups were compared regarding heart rate, mean arterial pressures, serum lactate and central venous saturation, need for inotropes, fluid challenge, blood and blood products use, postoperative complications and ICU stay. Results: There is no statistical difference in heart rate and mean arterial pressure in intra- and postoperative period in both CVC and PA group except in PA group where heart rate was significantly lower after grafting and mean arterial pressure was higher at T6 and T12 hrs. After 48 hours blood lactate level was significant lower in PA catheter groups. Both groups were similar in terms of central venous saturation, intraoperative fluid bolus use, blood, blood products use and output both intraoperative and postoperatively. Use of inotropes particularly noradrenaline and levosemandan was more in PA group. There was no statistically significant difference in respiratory, CNS and Renal complications (p value >0.05), ICU stays >48 hr and mortality in both groups. Conclusion: We can conclude from our study that PAC definitely provides additional information regarding cardiac output and cardiac index in comparisons with CVC but clearly it does not result in significant difference in postoperative ICU stay and outcome of patient in form of morbidity and mortality in coronary artery bypass patients with preserved LV function. Keywords: Central venous catheter; Pulmonary artery catheter; Coronary artery bypass graft; Peripheral vascular disease.

Abstract

Background: Present study was conducted to compare various anaesthetic techniques for laparoscopic tubal ligation using general anaesthesia with intubation, general anaesthesia with mask ventilation and total intravenous anaesthesia.Subjects and Methods: Sixty female patients having age between 20-40 years belonging to ASA grade I undergoing laparoscopic tubal ligation were randomly divided into three groups- Group I (GA with ET intubation), Group II (GA with mask ventilation) and Group III (TIVA with Inj. Propofol). General anaesthesia in group I was induced with Inj. Sodium Pentothal 4-6 mg/kg and Inj. Suxamethonium Chloride 1-2 mg/kg followed by ET intubation. In group II, GA was induced with Inj. Sodium Pentothal 4-6 mg/kg and Group III patients were induced with Inj. Propofol 2mg/kg.Results: There were no significant difference found between 3 groups with regards to age, weight and duration of anaesthesia. The incidence of increase in Heart rate (>20/min) and increase in blood pressure (>11-20 mm Hg) were significantly less in group III. The incidence of PONV was also found less in group III as compared to group I and II.Conclusion: Rapid and smooth induction with good intraoperative hemodynamic stability and decrease in incidence of post-operative nausea and vomiting makes TIVA with Inj. Propofol a better choice.