Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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   Table of Contents - Current issue
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January-March 2017
Volume 20 | Issue 1
Page Nos. 1-122

Online since Friday, January 06, 2017

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EDITORIALS  

Annals of Cardiac Anesthesia: Beacon journey toward excellence: 2015-2017 p. 1
Poonam Malhotra Kapoor
DOI:10.4103/0971-9784.197801  PMID:28074786
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Anesthesiology and the difficult airway - Where do we currently stand? Highly accessed article p. 4
Martina Richtsfeld, Kumar G Belani
DOI:10.4103/0971-9784.197814  PMID:28074787
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ORIGINAL ARTICLES Top

Comparison of two doses of heparin on outcome in off-pump coronary artery bypass surgery patients: A prospective randomized control study Highly accessed article p. 8
Murali Chakravarthy, Dattatreya Prabhakumar, Patil Thimmannagowda, Jayaprakash Krishnamoorthy, Antony George, Vivek Jawali
DOI:10.4103/0971-9784.197818  PMID:28074788
Introduction: While off pump coronary artery bypass surgery is practiced with an intention to reduce the morbidity associated with cardiopulmonary bypass, the resultant 'hypercoagulability' needs to be addressed. Complications such as cavitary thrombus possibly due to the hyper coagulability after off pump coronary artery bypass surgery have been described. Many clinicians use higher doses of heparin - up to 5 mg/kg in order to thwart this fear. Overall, there appears to be no consensus on the dose of heparin in off pump coronary artery bypass surgeries. Aim of the Study: The aim of the study was understand the differences in outcome of such as transfusion requirement, myocardial ischemia, and morbidity when two different doses were used for systemic heparinization. Methods: Elective patients scheduled for off pump coronary artery bypass surgery were included. Ongoing anti platelet medication was not an exclusion criteria, however, anti platelet medications were ceased about a week prior to surgery when possible. Thoracic epidural anesthesia was administered as an adjunct in patients who qualified for it. By computer generated randomization chart, patients were chosen to receive either 2 or 3 mg/kg of intravenous unfractioned heparin to achieve systemic heparinization with activated clotting time targeted at >240 secs. Intraoperative blood loss, postoperative blood loss, myocardial ischemic episodes, requirement of intraaortic balloon counter pulsation and transfusion requirement were analyzed. Results: Sixty two patients participated in the study. There was one conversion to cardiopulmonary bypass. The groups had comparable ACT at baseline (138.8 vs. 146.64 seconds, P = 0.12); 3 mg/kg group had significantly higher values after heparin, as expected. But after reversal with protamine, ACT and need for additional protamine was similar among the groups. Intraoperative (685.56 ± 241.42 ml vs. 675.15 ± 251.86 ml, P = 0.82) and postoperative blood loss (1906.29 ± 611.87 ml vs 1793.65 ± 663.54 ml , p value 0.49) were similar among the groups [Table 4]. The incidence of ECG changes of ischemia, arrhythmias, conversion to CPB, or need for intra-aortic balloon counter pulsation were not different. Conclusions: Use of either 2 or 3 mg/kg heparin for systemic heparinization in patients undergoing OPCAB did not affect the outcome.
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Extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: A systematic review and meta-analysis p. 14
Shashvat Sukhal, Jaskaran Sethi, Malini Ganesh, Pedro A Villablanca, Anita K Malhotra, Harish Ramakrishna
DOI:10.4103/0971-9784.197820  PMID:28074789
Introduction: Extracorporeal membrane oxygenation (ECMO) has been extensively used for potentially reversible acute respiratory failure associated with severe influenza A (H1N1) pneumonia; however, it remains an expensive, resource-intensive therapy, with a high associated mortality. This systematic review and meta-analysis aims to summarize and pool outcomes data available in the published literature to guide clinical decision-making and further research. Methods: We conducted a systematic search of MEDLINE (1966 to April 15, 2015), EMBASE (1980 to April 15, 2015), CENTRAL, and Google Scholar for patients with severe H1N1 pneumonia and respiratory failure who received ECMO. The study validity was appraised by Newcastle-Ottawa Scale. The primary outcome was all-cause mortality. The secondary outcomes were duration of ECMO therapy, mechanical ventilation, and Intensive Care Unit (ICU) length of stay. Results: Of 698 abstracts screened and 142 full-text articles reviewed, we included 13 studies with a total of 494 patients receiving ECMO in our final review and meta-analysis. The study validity was satisfactory. The overall mortality was 37.1% (95% confidence interval: 30-45%) limited by underlying heterogeneity (I2 = 65%, P value of Q statistic = 0.006). The median duration for ECMO was 10 days, mechanical ventilation was 19 days, and ICU length of stay was 33 days. Exploratory meta-regression did not identify any statistically significant moderator of mortality (P < 0.05), except for the duration of pre-ECMO mechanical ventilation in days (coefficient 0.19, standard error: 0.09, Z = 2.01, P < 0.04, R2 = 0.16). The visual inspection of funnel plots did not suggest the presence of publication bias. Conclusions: ECMO therapy may be used as an adjunct or salvage therapy for severe H1N1 pneumonia with respiratory failure. It is associated with a prolonged duration of ventilator support, ICU length of stay, and high mortality. Initiating ECMO early once the patient has been instituted on mechanical ventilation may result in improved survival.
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Incidence and progression of cardiac surgery-associated acute kidney injury and its relationship with bypass and cross clamp time p. 22
Habib Md Reazaul Karim, Mohd Yunus, Manuj Kumar Saikia, Jyoti Prasad Kalita, Mrinal Mandal
DOI:10.4103/0971-9784.197823  PMID:28074790
Introduction: Cardiac surgery-associated kidney injury (CSA-AKI) is common but relatively less is known about its progression. The present study is aimed at evaluating the incidence and course of CSA-AKI and its relationship with the different durations of cardiopulmonary bypass (CPB) and cross clamp times. Materials and Methods : Occurrences of CSA-AKI are evaluated as per the Akin Kidney Injury Network (AKIN) criteria over the course of 5 postoperative day (POD) in 100 patients. The relationship of different durations of CPB and aortic cross clamp time with CSA-AKI is analyzed by Chi-squared test for trend and other appropriate tests using INSTAT software. Results: One hundred (43 male, 57 female; mean age of 37.01 ± 12.28 years, and baseline mean serum creatinine 0.99 ± 0.20 mg %) patients undergone mostly valve replacement, and congenital heart disease correction was evaluated. Nearly 49% suffered CSA-AKI (81.63% AKIN Class I) with maximum numbers on 2 nd POD. Serum creatinine followed a falling trend 3 rd POD onward except in 8.16% cases of CSA-AKI. Oliguria was absent even in AKIN Class II. The CPB time >70 min and cross clamp time >60 min increase CSA-AKI risk by an OR of 4.76 and 2.84, respectively (P < 0.05). Conclusion: CSA-AKI is very prevalent; mostly of AKIN Class I and increases with increasing CPB and cross clamp time. Urine output is not a reliable indicator of CSA-AKI. The AKIN Class II on the very 1 st POD or increasing trend of serum creatinine beyond 3 rd POD should alert for early intervention.
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Selection of an appropriate left-sided double-lumen tube size for one-lung ventilation among Asians p. 28
Siti Salwani Ideris, Muhamad Rahimi Che Hassan, Mohd Ramzisham Abdul Rahman, Joanna Su Min Ooi
DOI:10.4103/0971-9784.197824  PMID:28074791
Context: Selecting an appropriate size double-lumen tube (DLT) for one-lung ventilation has always been a challenge as most choose it based on experience or using the existing guidelines based on gender and height. Aims: The aim of this study was to determine if the appropriate choice of this tube could be based on the patients' height, weight, tracheal diameter (TD), or the left main stem bronchus diameter (LMBD) and also to determine the relationship between height and depth of insertion among Asians. Subjects and Methods: This was a retrospective review of 179 patients who were intubated with a left-sided DLT and also had a posterior-anterior view of a digital chest radiograph for tracheal and left main bronchus diameter measurements. Additional data collected included patients' demographics and DLT size used. Results: There were 123 (68.7%) males and 56 (31.3%) females with an overall mean age of 33.3 ± 16.3 years. Majority of the males (48.8%) used a size 39 Fr while females (46.4%) used a 35 Fr. There were weak correlations between DLT size with height (male: R2 = 0.222; female: R2 = 0.193), DLT size with weight (male: R2 = 0.109; female: R2 = 0.211), DLT size with TD (male: R2 = 0.027); female: R2 = 0.016), and DLT size with LMBD (male: R2 = 0.222; female: R2 = 0.193). There was a good correlation between depth of DLT inserted with patient's height for both genders. Conclusion: The appropriate size of the left-sided DLT could not be predicted based on patients' height, weight, tracheal or left main bronchus diameter alone in Asians; however, the depth of insertion of the tube was dependent on the height in both genders.
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Remifentanil prevents increases of blood glucose and lactate levels during cardiopulmonary bypass in pediatric cardiac surgery p. 33
Tomohiro Chaki, Yuko Nawa, Keishi Tamashiro, Eri Mizuno, Naoyuki Hirata, Michiaki Yamakage
DOI:10.4103/0971-9784.197827  PMID:28074792
Introduction: Cardiopulmonary bypass (CPB) can cause stress response that increases levels of cytokine and catecholamine in plasma, resulting in hyperglycemia. In adults, it has been demonstrated that remifentanil infusion during CPB could prevent increases of cytokine, catecholamine, and blood glucose levels, but such effects of remifentanil in children have not been elucidated. Aim: In this study, we investigated the preventive effects of remifentanil on blood glucose and lactate levels during CPB in children. Materials and Methods: This retrospective study included children who underwent ventricular septal defect or atrial septal defect closure. Data for patients who did not receive, during CPB period, remifentanil infusion (non-Remi group) and patients who received remifentanil infusion at 0.5 μg/kg/min (Remi group) during CPB were used for analysis. Primary outcomes were lactate and blood glucose levels just before and after CPB. Data are presented as medians and interquartile ranges. Data were analyzed by the Mann-Whitney U-test and Chi-square test. A P < 0.05 was considered statistically significant. Results: During CPB, 13 and 11 patients were allocated into Remi and non-Remi groups, respectively. Pre-CPB lactate and blood glucose levels were not significantly different between the two groups, but post-CPB lactate and blood glucose levels in the Remi group were significantly lower than that in the non-Remi group. Conclusion: 0.5 μg/kg/min remifentanil infusion during CPB suppresses the increases of blood glucose and lactate levels in children.
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Assessment of limited chest x-ray technique in postcardiac surgery management p. 38
Mehrdad Salehi, Kianoush Saberi, Mehrzad Rahmanian, Ali Reza Bakhshandeh, Shahnaz Sharifi
DOI:10.4103/0971-9784.197829  PMID:28074793
Objectives: The objective of this study is to investigate the safety of elimination of chest radiography in the postcardiac surgery Intensive Care Unit (ICU). Methods and Design: We compared patients in two different groups of routine CXR (RCXR) and limited CXR (LCXR) and their diagnostic and therapeutic outcome in a University hospital-based single center from 2014 to 2016. 3 CXR in the RCXR group and 1 CXR in the limited group was performed, in addition to on-demand criteria. Measurement and Main Results: A total of 978 samples were acceptable for analysis which 55.21% of RCXR and 59.50% of LCXR were male patients. In total, 523 abnormalities in RCXR group and 154 occasions in LCXR group resulted in 26.73% diagnostic efficacy for RCXRs and 28.57% for LCXR. From 1956 CXR that was taken in RCXR group, 72 occasions required intervention (3.68%) and 84 cases out of 539 (15.58%) LCXR needed an action to therapy. This means a 14.40% in RCXRs' abnormalities and 56.00% of LCXRs' abnormalities were accompanied with some interventions. Conclusions: Abolishing routine CXR in the ICUs would not be harmful for the patients, and it can be managed based on their clinical status and other safer imaging techniques.
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Acute effect of treatment of mitral stenosis on left atrium function p. 42
Atooshe Rohani, Shahram Kargar, Afsoon Fazlinejad, Fereshte Ghaderi, Vida Vakili, Homa Falsoleiman, Ramin Khamene Bagheri
DOI:10.4103/0971-9784.197832  PMID:28074794
Aim: Peak atrial longitudinal strain (PALS) is used to evaluate left atrium (LA) function in patients with mitral stenosis (MS), before and after percutaneous transmitral commissurotomy (PTMC) and mitral valve replacement (MVR). Methods: Patients with severe symptomatic MS, who were referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery or PTMC from October of 2014 to October of 2015, were included in the study. Result: The peak systolic global LA strain improved post-PTMC (P < 0.001) and post-MVR (P = 0.012). This difference was statistically highly significant. Conclusion: PALS is impaired in patients with severe symptomatic MS and improved acutely after treatment and may be a good indicator of LA function and may predict the right time for intervention on mitral valve.
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Comparative effect of grape seed extract (Vitis vinifera) and ascorbic acid in oxidative stress induced by on-pump coronary artery bypass surgery p. 45
Naser Safaei, Hossein Babaei, Rasoul Azarfarin, Ahmad-Reza Jodati, Alireza Yaghoubi, Mohammad-Ali Sheikhalizadeh
DOI:10.4103/0971-9784.197834  PMID:28074795
Background: This study aimed to test the beneficial effect of grape seed extract (GSE) (Vitis vinifera) and Vitamin C in oxidative stress and reperfusion injury induced by cardiopulmonary bypass (CPB) in coronary artery bypass surgery. Patients and Methods: In this randomized trial, 87 patients undergoing elective and isolated coronary bypass surgery included. The patients were randomly assigned into three groups (n = 29 each): (1) Control group with no treatment, (2) GSE group who received the extract 24 h before operation, 100 mg every 6 h, orally, (3) Vitamin C group who received 25 mg/kg Vitamin C through CPB during surgery. Blood samples were taken from coronary sinus at (T1) just before aortic cross clamp; (T2) just before starting controlled aortic root reperfusion; and (T3) 10 min after root reperfusion. Some clinical parameters and biochemical markers were compared among the groups. Results: There were significant differences in tracheal intubation times, sinus rhythm return, and left ventricular function between treatment groups compared with control (P < 0.05). Total antioxidant capacity was higher (P < 0.05) in both grape seed and Vitamin C groups at T2 and T3 times. In reperfusion period, malondialdehyde level was increased in control group; however, it was significantly lower for the grape seed group (P = 0.04). The differences in the mean levels of superoxide dismutase and glutathione peroxidase among the three groups were not significant (P > 0.05 in all cases). Conclusions: In our patients, GSE and Vitamin C had antioxidative effects and reduced deleterious effects of CPB during coronary artery bypass grafting surgery.
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Low-intensity laser (660 NM) has analgesic effects on sternotomy of patients who underwent coronary artery bypass grafts p. 52
Gilderlene Alves Fernandes, Raimundo de Barros Araújo Júnior, Andréa Conceição Gomes Lima, Isabel Clarisse Albuquerque Gonzaga, Rauirys Alencar de Oliveira, Renata Amadei Nicolau
DOI:10.4103/0971-9784.197836  PMID:28074796
Background: The aim of this study was to evaluate the efficacy of low-level laser therapy for reducing the acute pain of sternotomy in patients who underwent a coronary artery bypass graft (CABG). Methods: This study was conducted with ninety volunteers who electively submitted to CABG. The volunteers were randomly allocated into three groups of equal size (n = 30): control, placebo, and laser (λ of 660 nm and spatial average energy fluency of 1.06 J/cm 2 ). Pain when coughing was assessed by a visual analog scale (VAS) and McGill Pain Questionnaire, according to sensory, affective, evaluative, and miscellaneous domains. The patients were followed for 1 month after the surgery. Results: The laser group had a greater decrease in pain with analogous results, as indicated by both the VAS and the McGill questionnaire (P ≤ 0.05) on sensory and affective scores, on days 6 and 8 postsurgery compared to the placebo and control groups. Conclusion: Laser seems to be effective promoting pain reduction after coronary-arterial bypass grafting.
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Minimally invasive compared to conventional approach for coronary artery bypass grafting improves outcome p. 57
Jitumoni Baishya, Antony George, Jayaprakash Krishnamoorthy, Geetha Muniraju, Murali Chakravarthy
DOI:10.4103/0971-9784.197837  PMID:28074797
Introduction: Minimally invasive (MI) cardiac surgery is a rapidly gaining popularity, globally as well as in India. We aimed to compare the outcome of MI to the conventional approach for coronary artery bypass graft (CABG) surgery. Methods: This prospective, comparative study was conducted at a tertiary care cardiac surgical center. All patients who underwent CABG surgery via MI approach (MI group) from July 2015 to December 2015 were enrolled and were compared against same number of EuroSCORE II matched patients undergoing CABG through conventional mid-sternotomy approach (CON group). Demographic, intra- and post-operative variables were collected. Results: In MI group, duration of the surgery was significantly longer (P = 0.029). Intraoperative blood loss lesser (P = 0.002), shorter duration of ventilation (P = 0.002), shorter Intensive Care Unit stay (P = 0.004), shorter hospital stay (P = 0.003), lesser postoperative analgesic requirements (P = 0.027), and lower visual analog scale scores on day of surgery (P = 0.032) and 1 st postoperative day (P = 0.025). No significant difference in postoperative blood loss, blood transfusion, or duration of inotrope requirement observed. There was no conversion to mid-sternotomy in any patients, 8% of patients had desaturation intraoperatively. There was no operative mortality. Conclusion: MI surgery is associated with lesser intraoperative blood loss, better analgesia, and faster recovery.
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ProSeal laryngeal mask airway as an alternative to standard endotracheal tube in securing upper airway in the patients undergoing beating-heart coronary artery bypass grafting p. 61
Kalpana Shah
DOI:10.4103/0971-9784.197838  PMID:28074798
Background: ProSeal laryngeal mask airways (PLMAs) are routinely used after failed tracheal intubation as airway rescue, facilitating tracheal intubation by acting as a conduit and to secure airway during emergencies. In long duration surgeries, use of endotracheal tube (ETT) is associated with various hemodynamic complications, which are minimally affected during PLMA use. However, except for few studies, there are no significant data available that promote the use of laryngeal mask during cardiac surgery. This prospective study was conducted with the objective of demonstrating the advantages of PLMA over ETT in the patients undergoing beating-heart coronary artery bypass graft (CABG). Methodology: This prospective, interventional study was carried out in 200 patients who underwent beating-heart CABG. Patients were randomized in equal numbers to either ETT group or PLMA group, and various hemodynamic and respiratory parameters were observed at different time points. Results: Patients in PLMA group had mean systolic blood pressure 126.10 ± 5.31 mmHg compared to the patients of ETT group 143.75 ± 6.02 mmHg. Pulse rate in the PLMA group was less (74.52 ± 10.79 per min) (P < 0.05) compared to ETT group (81.72 ± 9.8). Thus, hemodynamic changes were significantly lower (P < 0.05) in PLMA than in ETT group. Respiratory parameters such as oxygen saturation, pressure CO 2 (pCO 2 ), peak airway pressure, and lung compliance were similar to ETT group at all evaluation times. The incidence of adverse events was also lower in PLMA group. Conclusion: In experience hand, PLMA offers advantages over the ETT in airway management in the patients undergoing beating-heart CABG.
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Basic arterial blood gas biomarkers as a predictor of mortality in tetralogy of Fallot patients p. 67
Vandana Bhardwaj, Poonam Malhotra Kapoor, Kalpana Irpachi, Suruchi Ladha, Ujjwal Kumar Chowdhury
DOI:10.4103/0971-9784.197839  PMID:28074799
Background: Serum lactate and base deficit have been shown to be a predictor of morbidity and mortality in critically ill patients. Poor preoperative oxygenation appears to be one of the significant factors that affects early mortality in tetralogy of Fallot (TOF). There is little published literature evaluating the utility of serum lactate, base excess (BE), and oxygen partial pressure (PO 2 ) as simple, widely available, prognostic markers in patients undergoing surgical repair of TOF. Materials and Methods: This prospective, observational study was conducted in 150 TOF patients, undergoing elective intracardiac repair. PO 2 , BE, and lactate levels at three different time intervals were recorded. Arterial blood samples were collected after induction (T1), after cardiopulmonary bypass (T2), and 48 h (T3) after surgery in the Intensive Care Unit (ICU). To observe the changes in PO 2 , BE, and lactate levels over a period of time, repeated measures analysis was performed with Bonferroni method. The receiver operating characteristics (ROC) analysis was used to find area under curve (AUC) and cutoff values of various biomarkers for predicting mortality in ICU. Results: The patients who could not survive showed significant elevated lactate levels at baseline (T1) and postoperatively (T2) as compared to patients who survived after surgery (P < 0.001). However, in nonsurvivors, the BE value decreased significantly in the postoperative period in comparison to survivors (−2.8 ± 4.27 vs. 5.04 ± 2.06) (P < 0.001). In nonsurvivors, there was a significant fall of PO 2 to a mean value of 59.86 ± 15.09 in ICU (T3), whereas those who survived had a PO 2 of 125.86 ± 95.09 (P < 0.001). The ROC curve analysis showed that lactate levels (T3) have highest mortality predictive value (AUC: 96.9%) as compared to BE (AUC: 94.5%) and PO 2 (AUC: 81.1%). Conclusion: Serum lactate and BE may be used as prognostic markers to predict mortality in patients undergoing TOF repair. The routine analysis of these simple, fast, widely available, and cost-effective biomarkers should be encouraged to predict prognosis of TOF patients.
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Effectiveness of ventilation of nondependent lung for a brief period in improving arterial oxygenation during one-lung ventilation: A prospective study p. 72
Keerthi Chigurupati, Suneel Puthuvassery Raman, Unnikrishnan Koraparambil Pappu, Unnikrishnan Madathipat
DOI:10.4103/0971-9784.197840  PMID:28074800
Background: Hypoxemia is common during one-lung ventilation(OLV), predominantly due to transpulmonary shunt. None of the strategies tried showed consistent results. We evaluated the effectiveness of ventilating the operated, non-dependent lung (NDL) with small tidal volumes in improving the oxygenation during OLV. Methods: 30 ASA 1 and 2 patients undergoing elective, open thoracotomy were studied. After standard induction of anesthesia, lung seperation was acheived with left sided DLT. The ventilatory settings for two lung ventilation (TLV) were: FiO 2 of 0.5, tidal volume of 8-10ml/kg and respiratory rate of 10-12/min. After initiating OLV, the dependent lung alone was ventilated with the above settings for 15 minutes and an arterial blood gas (ABG) analysis was done. Then the NDL was ventilated with a separate ventilator, with FiO 2 of 1, tidal volume of 70 ml, I:E ratio of 1:10 and respiratory rate of 6/min for 15 minutes. The NDL ventilation was started early if the patients desaturated to <95%. ABG was done at 5 and 15 mins of NDL ventilation. We compared the PaO 2 values. Results: The mean PaO 2 decreased from 232.2 ± 67.2 mm of Hg (TLV-ABG1) to 91.2 ± 31.7 mm of Hg on OLV (OLV-ABG1). The ABG after 5 minutes and 15 minutes after institution of NDL ventilation during OLV showed a PaO2 of 145.7 ± 50.2 mm of Hg and 170.6 ± 50.4 mm of Hg which were significantly higher compared to the one lung ventilation values.
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Delirium after cardiac surgery: A pilot study from a single tertiary referral center p. 76
Ashok K Kumar, Aveek Jayant, VK Arya, Rohan Magoon, Ridhima Sharma
DOI:10.4103/0971-9784.197841  PMID:28074801
Background: Advances in cardiac surgery has shifted paradigm of management to perioperative psychological illnesses. Delirium is a state of altered consciousness with easy distraction of thoughts. The pathophysiology of this complication is not clear, but identification of risk factors is important for positive postoperative outcomes. The goal of the present study was to prospectively identify the incidence, motoric subtypes, and risk factors associated with development of delirium in cardiac surgical patients admitted to postoperative cardiac intensive care, using a validated delirium monitoring instrument. Materials and Methods: This is a prospective, observational study. This study included 120 patients of age 18-80 years, admitted to undergo cardiac surgery after applying inclusion and exclusion criteria. Specific preoperative, intraoperative, and postoperative data for possible risk factors were obtained. Once in a day, assessment of delirium was done. Continuous variables were measured as mean ± standard deviation, whereas categorical variables were described as proportions. Differences between groups were analyzed using Student's t-test, Mann-Whitney U-test, or Chi-square test. Variables with a P < 0.1 were then used to develop a predictive model using stepwise logistic regression with bootstrapping. Results: Delirium was seen in 17.5% patients. The majority of cases were of hypoactive delirium type (85.72%). Multiple risk factors were found to be associated with delirium, and when logistic regression with bootstrapping applied to these risk factors, five independent variables were detected. History of hypertension (relative risk [RR] =6.7857, P = 0.0003), carotid artery disease (RR = 4.5000, P < 0.0001) in the form of stroke or hemorrhage, noninvasive ventilation (NIV) use (RR = 5.0446, P < 0.0001), Intensive Care Unit (ICU) stay more than 10 days (RR = 3.1630, P = 0.0021), and poor postoperative pain control (RR = 2.4958, P = 0.0063) was associated with postcardiac surgical delirium. Conclusions: Patients who developed delirium had systemic disease in the form of hypertension and cerebrovascular disease. Delirium was seen in patients who had higher postoperative pain scores, longer ICU stay, and NIV use. This study can be used to develop a predictive tool for diagnosing postcardiac surgical delirium.
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Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass Highly accessed article p. 83
Poonam Malhotra Kapoor, Rohan Magoon, Rajinder Singh Rawat, Yatin Mehta, Sameer Taneja, R Ravi, Milind P Hote
DOI:10.4103/0971-9784.197842  PMID:28074802
Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2 ), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac , PreSep , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.
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Prayer sign as a marker of increased ventilatory hours, length of intensive care unit and hospital stay in patients undergoing coronary artery bypass grafting surgery p. 90
Tanveer Singh Kundra, Parminder Kaur, N Manjunatha
DOI:10.4103/0971-9784.197843  PMID:28074803
Context: Various predictors have been used to predict diabetic patients who are likely to have increased ventilatory hours and an increased length of stay (LOS) in the Intensive Care Unit (ICU) as well as in the hospital after undergoing coronary artery bypass grafting (CABG) surgery, for example, glycosylated hemoglobin (HbA1c). The authors propose a simple bed-side test, i.e., the prayer sign to predict increased ventilatory hours and increased length of ICU and hospital stay. Aims: The aim of the present study was to assess whether any association exists between a positive prayer sign and increased ventilatory hours, length of ICU and hospital stay after CABG surgery in diabetic patients. Settings and Design: This prospective observational study was conducted in a 650-bedded tertiary cardiac center. Subjects and Methods: A total of 501 diabetic patients were recruited in the study over a period of 1 year. Group P consisted of 121 patients with prayer sign positive, whereas Group N consisted of 380 patients with prayer sign negative. HbA1c levels, ventilatory hours, LOS in the postoperative ICU and hospital were compared. Statistical Analysis Used: Unpaired Student's t-test was used to compare the data. Results: The mean HbA1c levels in Group P were 8.01 ± 2.28% as compared to 6.52 ± 2.46% in Group N (P < 0.0001). The mean ventilatory hours in Group P were 9.52 ± 6.46 h, and in Group N were 7.42 ± 8.01 h (P = 0.013). Whereas, the mean length of ICU stay and hospital stay in Group P was 156.42 ± 32.66 h (6.51 ± 1.36 days) and 197.36 ± 32.46 h (8.22 ± 1.35 days), respectively, it was 121.12 ± 29.48 h (5.04 ± 1.22 days) and 178.52 ± 28.52 h (7.43 ± 1.18 days) in Group N (P < 0.0001). Conclusions: A positive prayer sign is a useful bedside test for predicting increased ventilatory hours and increased length of ICU and hospital stay after CABG surgery.
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Outcome of four pretreatment regimes on hemodynamics during electroconvulsive therapy: A double-blind randomized controlled crossover trial p. 93
Devangi Ashutosh Parikh, Sanchita Nitin Garg, Naina Parag Dalvi, Priyanka Pradip Surana, Deepa Sannakki, Bharati Anil Tendolkar
DOI:10.4103/0971-9784.197844  PMID:28074804
Context: Electroconvulsive therapy (ECT) is associated with tachycardia and hypertension. Aims: The aim of this study was to compare two doses of dexmedetomidine, esmolol, and lignocaine with respect to hemodynamics, seizure duration, emergence agitation (EA), and recovery profile. Methodology: Thirty patients undergoing ECT were assigned to each of the following pretreatment regimes over the course of five ECT sessions in a randomized crossover design: Group D1 (dexmedetomidine 1 μg/kg), Group D0.5 (dexmedetomidine0.5 μg/kg), Group E (esmolol 1 mg/kg), Group L (lignocaine 1 mg/kg), and Group C (saline as placebo) before induction. Heart rate (HR), mean arterial pressure (MAP), seizure duration, EA, and time to discharge were evaluated. Results: Groups D1, D0.5, and esmolol had significantly reduced response of HR, MAP compared to lignocaine and control groups at 1, 3, 5 min after ECT (P < 0.05). Motor seizure duration was comparable in all groups except Group L (P = 0.000). Peak HR was significantly decreased in all groups compared to control. Total propofol requirement was reduced in D1 (P = 0.000) and D0.5 (P = 0.001) when compared to control. Time to spontaneous breathing was comparable in all the groups (P > 0.05). Time to eye opening and time to discharge were comparable in all groups (P > 0.05) except Group D1 (P = 0.001). EA score was least in Group D1 (P = 0.000). Conclusion: Dexmedetomidine 1 μg/kg, 0.5 μg/kg, and esmolol produced significant amelioration of cardiovascular response to ECT without affecting seizure duration, results being best with dexmedetomidine 1 μg/kg. However, the latter has the shortcoming of delayed recovery.
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INTERESTING IMAGES Top

Misdirected minitracheostomy tube p. 100
Ajmer Singh, Chinmaya Nanda, Yatin Mehta
DOI:10.4103/0971-9784.197845  PMID:28074805
We report a patient who after an uneventful coronary artery bypass graft surgery and left ventricular aneurysmorrhaphy developed intracerebral hemorrhage and subsequently required minitracheostomy. Chest X-ray showed misdirected minitracheostomy tube facing upward toward the laryngeal opening which was repositioned using bronchoscope.
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An unusual cause of postpartum heart failure p. 102
Ibrahim Khaddash, Amer Hawatmeh, Zaid Altheeb, Aiman Hamdan, Fayez Shamoon
DOI:10.4103/0971-9784.197846  PMID:28074806
Peripartum cardiomyopathy is a weakness of the heart muscle. It is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic dysfunction toward the end of pregnancy or in the months after delivery, in the absence of any other cause of heart failure. It is a rare condition that can carry mild or severe symptoms.
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Isolated persistent left superior vena cava: A case report and its clinical implications p. 104
Samarjit Bisoyi, Usha Jagannathan, Anjan Kumar Dash, Sabyasachi Tripathy, Raghunath Mohapatra, Naba Kumar Pattnaik, Satyajit Sahu, Debashish Nayak
DOI:10.4103/0971-9784.197847  PMID:28074807
The venous anomaly of a persistent left superior vena cava (PLSVC) affects 0.3%-0.5% of the general population. PLSVC with absent right superior vena cava, also termed as "isolated PLSVC," is an extremely rare venous anomaly. Almost half of the patients with isolated PLSVC have cardiac anomalies in the form of atrial septal defect, endocardial cushion defects, or tetralogy of Fallot. Isolated PLSVC is usually innocuous. Its discovery, however, has important clinical implications. It can pose clinical difficulties with central venous access, cardiothoracic surgeries, and pacemaker implantation. When it drains to the left atrium, it may create a right to left shunt. In this case report, we present the incidental finding of isolated PLSVC in a patient who underwent aortic valve replacement. Awareness about this condition and its variations is important to avoid complications.
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Demonstration of blood flow by color doppler in the femoral artery distal to arterial cannula during peripheral venoarterial-extracorporeal membrane oxygenation p. 108
KG Suresh Rao, T Muralikrishna, KR Balakrishnan
DOI:10.4103/0971-9784.197848  PMID:28074808
In spite of distal perfusion of the limb using a cannula, the limb can have ischemic events if there is an undetected kink or clot anywhere in the line or thrombus in the artery. There are several ways to monitor and assess the limb ischemia. Monitoring for clinical signs of limb ischemia like temperature change and pallor is reliable and mandatory. We report a method where we used color Doppler to document the blood flow. Curvilinear vascular probe of an echo machine is used to identify the flow in the distal femoral artery of the lower limb. . As we have demonstrated in the video attached, once flow to the distal limb perfusion system is shut off by closing the three way stop cock, we can appreciate the immediate cessation of flow in the artery by Doppler.
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BRIEF COMMUNICATION Top

Holt-Oram syndrome: Anesthetic challenges and safe outcome p. 110
Meenal Rana, Sohan Lal Solanki, Vandana Agarwal, Jigeeshu V Divatia
DOI:10.4103/0971-9784.197849  PMID:28074809
Holt-Oram syndrome (HOS) is an autosomal dominant disease with skeletal and cardiac manifestations. We here are presenting a 31-year-old man and a diagnosed case of HOS, with an ulceroproliferative lesion on lateral border of the tongue, was posted for wide excision of lesion with primary closure and left side radical neck dissection.
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LETTERS TO EDITOR Top

Nucleic acid-based methods for early detection of sepsis p. 112
Sarvesh Pal Singh
DOI:10.4103/0971-9784.197850  PMID:28074810
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Reliability and validity of perceived heart risk factors scale p. 114
Mozhgan Saeidi, Saeid Komasi
DOI:10.4103/0971-9784.197851  PMID:28074811
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Iatrogenic vocal cord paralysis after cardiac surgery: evocative note for surgeon and anesthesiologist p. 117
Monish S Raut, Sumir Dubey, Arun Maheshwari
DOI:10.4103/0971-9784.197852  PMID:28074812
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Anesthetic management of a patient with Yamaguchi syndrome for laparoscopic radical nephroureterectomy p. 119
Gaurav Sindwani, Sandeep Sahu, Uday Pratap Singh, Roopali Khanna
DOI:10.4103/0971-9784.197853  PMID:28074813
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VIDEO COMMENTARIES Top

Percutaneous tracheostomy p. 121
Yatin Mehta, Chitra Mehta
DOI:10.4103/0971-9784.197854  PMID:28074814
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Effect of heparin and Bivalirudin on the kinetics of clot formation: Viscoelastic coagulation testing p. 122
Suruchi Hasija, Poonam Malhotra Kapoor
DOI:10.4103/0971-9784.197855  PMID:28074815
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