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   2009| January-June  | Volume 12 | Issue 1  
    Online since January 7, 2009

 
 
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REVIEW ARTICLE
Halogenated anaesthetics and cardiac protection in cardiac and non-cardiac anaesthesia
Giovanni Landoni, Elena Bignami, Fochi Oliviero, Alberto Zangrillo
January-June 2009, 12(1):4-9
DOI:10.4103/0971-9784.45006  PMID:19136748
Volatile anaesthetic agents have direct protective properties against ischemic myocardial damage. The implementation of these properties during clinical anaesthesia can provide an additional tool in the treatment or prevention, or both, of ischemic cardiac dysfunction in the perioperative period. A recent meta-analysis showed that desflurane and sevoflurane reduce postoperative mortality and incidence of myocardial infarction following cardiac surgery, with significant advantages in terms of postoperative cardiac troponin release, need for inotrope support, time on mechanical ventilation, intensive care unit and overall hospital stay. Multicentre, randomised clinical trials had previously demonstrated that the use of desflurane can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalisation following coronary artery bypass graft surgery either with and without cardiopulmonary bypass. The American College of Cardiology/American Heart Association Guidelines recommend volatile anaesthetic agents during non-cardiac surgery for the maintenance of general anaesthesia in patients at risk for myocardial infarction. Nonetheless, e vidence in non-coronary surgical settings is contradictory and will be reviewed in this paper together with the mechanisms of cardiac protection by volatile agents.
  50 13,565 2,946
ORIGINAL ARTICLES
Role of cardiac biomarkers (troponin I and CK-MB) as predictors of quality of life and long-term outcome after cardiac surgery
Elena Bignami, Giovanni Landoni, Giuseppe Crescenzi, Massimiliano Gonfalini, Giovanna Bruno, Federico Pappalardo, Giovanni Marino, Alberto Zangrillo, Ottavio Alfieri
January-June 2009, 12(1):22-26
DOI:10.4103/0971-9784.45009  PMID:19136751
Perioperative and postoperative morbidity and mortality associated with cardiac surgery affect both the outcome and quality of life. Markers such as troponin effectively predict short-term outcome. In a prospective cohort study in a University Hospital we assessed the role of cardiac biomarkers, also as predictors of long-term outcome and life quality after cardiac surgery with a three-year follow-up after conventional heart surgery. Patients were interviewed via phone calls with a structured questionnaire examining general health, functional status, activities of daily living, perception of life quality and need for hospital readmission. Descriptive statistics and multivariate analysis were performed. Out of 252 consecutive patients, 8 (3.2%) died at the three years follow up: 7 for cardiac complications and 1 for cancer. Thirty-six patients (13.5%) had hospital readmission for cardiac causes (mostly for atrial fibrillation or other arrhythmias (9.3%), but none needed cardiac surgical reintervention; 21 patients (7.9%) were hospitalised for non-cardiac causes. No limitation in function activities of daily living was reported by most patients (94%), 92% perceived their general health as excellent, very good or good and none considered it insufficient; 80% were NYHA I, 17% NYHA II, 3% NYHA III and none NYHA IV. Multivariate analysis indicated preoperative treatment with digitalis or nitrates, and postoperative cardiac biomarkers release was independently associated to death. Elevated cardiac biomarker release and length of hospital stay were the only postoperative independent predictors of death in this study.
  20 9,716 1,187
INVITED EDITORIAL
Thoracic epidural anaesthesia in cardiac surgery- the current standing
Mark A Chaney
January-June 2009, 12(1):1-3
DOI:10.4103/0971-9784.45005  PMID:19136747
  14 7,593 1,525
TUTORIAL
Adult cardiac transplantation: A review of perioperative management Part - I
Harish Ramakrishna, Dawn E Jaroszewski, Francisco A Arabia
January-June 2009, 12(1):71-78
DOI:10.4103/0971-9784.45018  PMID:19136760
Cardiac allotransplantation has, over the years, become the established therapeutic modality for patients with end-stage heart failure. Significant advances in immunosuppressive therapy have dramatically improved the outcome of heart transplantation over the past four decades. This review will focus on the anaesthetic challenges involved in the perioperative management of these complex patients as well as some of the proposed alternatives to transplantation.
  13 17,571 3,118
ORIGINAL ARTICLES
Caudal epidural sufentanil and bupivacaine decreases stress response in paediatric cardiac surgery
Chaitali Sendasgupta, Neeti Makhija, Usha Kiran, Shiv K Choudhary, R Lakshmy, Sambhu N Das
January-June 2009, 12(1):27-33
DOI:10.4103/0971-9784.45010  PMID:19136752
Surgery and anaesthesia are known to cause stress response. Attenuation of stress response can decrease morbidity, postoperative hospital length of stay and, thus, cost. Intrathecal and epidural techniques produce reliable analgesia in patients undergoing surgery along with stress response attenuation. The present study was undertaken to evaluate the efficacy of caudal sufentanil and bupivacaine combination on perioperative stress response in paediatric patients undergoing open heart surgery. Thirty patients (ASA grade II-III) undergoing elective corrective cardiac surgery for acyanotic congenital heart disease, were randomly allocated to two groups. In group GA ( n = 15), patients received balanced general anaesthesia. In group GC ( n = 15), in addition to general anaesthesia, caudal block with bupivacaine and sufentanil combination was given after endotracheal intubation. Monitoring included electrocardiography, invasive arterial pressure, end-tidal carbon dioxide, pulse oximetry, arterial blood gases including serum electrolytes, blood glucose, serum cortisol, urine output, central venous pressure and temperature. Haemodynamic responses in both groups were statistically similar. Serum cortisol levels were significantly lower in GC group than GA group ( P < 0.05) after sternotomy (9.87.5 vs. 34.7427.35), on cardiopulmonary bypass (CPB) (12.17 6.2 vs. 35.36 24.15), after sternal closure (14.03 5.1 vs. 37.62 20.69), 4 hours (26.64 14.61 vs. 37.62 9.13) and 24 hours (14.30 8.11 vs. 28.12 16.31) after intubation. Blood glucose levels were significantly higher in GA group as compared to GC group at sternal closure (277.46 77.25 vs.197.73 42.17) and 4 hours (255.26 73.73 vs. 185.26 57.41) after intubation ( P < 0.05). To conclude, supplementation of caudal epidural bupivacaine and sufentanil could effectively attenuate the stress response in paediatric patients undergoing cardiac surgery under CPB in acyanotic congenital heart anomaly.
  11 6,450 889
Changes in near infrared spectroscopy during deep hypothermic circulatory arrest
Joseph D Tobias, Pierantonio Russo, JoAnne Russo
January-June 2009, 12(1):17-0
DOI:10.4103/0971-9784.43057  PMID:19136750
Monitoring cerebral oxygenation with near infrared spectroscopy may identify periods of cerebral desaturation and thereby the patients at risk for perioperative neurocognitive issues. Data regarding the performance of near infrared spectroscopy monitoring during deep hypothermic circulatory arrest are limited. The current study presents data regarding use of a commercially available near infrared spectroscopy monitor during deep hypothermic circulatory arrest in paediatric patients undergoing surgery for congenital heart disease. The cohort included 8 patients, 2 weeks to 6 months of age, who required deep hypothermic circulatory arrest for repair of congenital heart disease. The baseline cerebral oxygenation was 63 11% and increased to 88 7% after 15 min of cooling to a nasopharyngeal temperature of 17-18C on cardiopulmonary bypass. In 5 of 8 patients, the cerebral oxygenation value had achieved its peak value (either ≥90% or no change during the last 2-3 min of cooling on cardiopulmonary bypass). In the remaining 3 patients, additional time on cardiopulmonary bypass was required to achieve a maximum cerebral oxygenation value. The duration of deep hypothermic circulatory arrest varied from 36 to 61 min (43.4 8 min). After the onset of deep hypothermic circulatory arrest, there was an incremental decrease in cerebral oxygenation to a low value of 53 11%. The greatest decrease occurred during the initial 5 min of deep hypothermic circulatory arrest (9 3%). Over the entire period of deep hypothermic circulatory arrest, there was an average decrease in the cerebral oxygenation value of 0.9% per min (range of 0.5 to 1.6% decline per minute). During cardiopulmonary bypass, cooling and deep hypothermic circulatory arrest, near infrared spectroscopy monitoring followed the clinically expected parameters. Such monitoring may be useful to identify patients who have not achieved the highest possible cerebral oxygenation value despite 15 min of cooling on cardiopulmonary bypass. Future studies are needed to define the cerebral oxygenation value at which neurological damage occurs and if interventions to correct the decreased cerebral oxygenation will improve perioperative outcomes.
  11 8,525 1,129
CASE REPORTS
Anaesthetic management of a child presenting with intrapericardial teratoma compressing the airway and the heart
Indrani Hemant Kumar, V Shrote, Hemant Kumar
January-June 2009, 12(1):63-66
DOI:10.4103/0971-9784.45016  PMID:19136758
Intrapericardial tumours can cause cardiac compromise either from pericardial effusion producing cardiac tamponade or from the mass obstructing the outflow from the heart or both. Respiratory embarrassment may also be present if the mass compresses the trachea or the main stem bronchus. A 1-month-old child presented in the emergency needing prompt measures to relieve compressive symptoms. Successful anaesthetic and surgical management led to uneventful recovery. Histopathology of the mass revealed a rarely occurring intrapericardial teratoma. After surgical removal, the child had clinical follow-up for more than a year. Intrapericardial teratoma is a rare entity that presents a diagnostic and therapeutic challenge. The authors describe the case of a 1-month-old male child with this condition who was successfully managed by resection of the mass.
  8 4,119 336
Superior vena cava syndrome after pulsatile bidirectional Glenn shunt procedure: Perioperative implications
Praveen Kumar Neema, Manikandan Sethuraman, SR Krishnamanohar, Ramesh Chandra Rathod
January-June 2009, 12(1):53-56
DOI:10.4103/0971-9784.45014  PMID:19136756
Bidirectional superior cavopulmonary shunt (bidirectional Glenn shunt) is generally performed in many congenital cardiac anomalies where complete two ventricle circulations cannot be easily achieved. The advantages of BDG shunt are achieved by partially separating the pulmonary and systemic venous circuits, and include reduced ventricular preload and long-term preservation of myocardium. The benefits of additional pulsatile pulmonary blood flow include the potential growth of pulmonary arteries, possible improvement in arterial oxygen saturation, and possible prevention of development of pulmonary arteriovenous malformations. However, increase in the systemic venous pressure after BDG with additional pulsatile blood flow is known. We describe the peri-operative implications of severe flow reversal in the superior vena cava after pulsatile BDG shunt construction in a child who presented for surgical interruption of the main pulmonary artery.
  5 10,656 819
LETTERS TO EDITOR
Identical drug packaging: Heparin and midazolam-yet another instance of similar drug packaging
Satyajeet Misra, Thomas Koshy, Prabhat Sinha
January-June 2009, 12(1):88-89
DOI:10.4103/0971-9784.45024  PMID:19136766
  3 4,802 277
ORIGINAL ARTICLES
Effect of single intraoperative dose of amiodarone in patients with rheumatic valvular heart disease and atrial fibrillation undergoing valve replacement surgery
Thiruvenkadam Selvaraj, Usha Kiran, Sambhunath Das, Sandeep Chauhan, Bikash Sahu, Parag Gharde
January-June 2009, 12(1):10-16
DOI:10.4103/0971-9784.42881  PMID:19136749
Maintenance of sinus rhythm (SR) is superior to rate control in atrial fibrillation (AF). In order to achieve SR, we administered single-dose intravenous amiodarone intraoperatively and evaluated its effect on conversion of rheumatic AF to SR in patients undergoing valvular heart surgery. Patients were randomly assigned to amiodarone ( n = 42) or control ( n = 40) group in a double blind manner. The amiodarone group received amiodarone (3 mg/kg) intravenously prior to the institution of cardiopulmonary bypass and the control group received the same volume of normal saline. In the amiodarone group, the initial rhythm after the release of aortic cross clamp was noted to be AF in 14.3% ( n = 6) and remained so in 9.5% ( n = 4) of patients till the end of surgery. In the control group, the rhythm soon after the release of aortic cross clamp was AF in 37.5% ( n = 15) ( p = 0.035) and remained so in 32.5% ( n = 13) of patients till the end of surgery ( p = 0.01). At the end of first post-operative day 21.4% ( n = 9) of patients in amiodarone group and 55% ( n = 22) of patients in control group were in AF ( p = 0.002). The requirement of cardioversion/defibrillation was 1.5 (0.54) in amiodarone group and 2.26 (0.73) in the control group ( p = 0.014), and the energy needed was 22.5 (8.86) joules in the amiodarone group and 40.53 (16.5) in the control group ( p = 0.008). A single intraoperative dose of intravenous amiodarone increased the conversion rate of AF to normal sinus rhythm, reduced the need and energy required for cardioversion/defibrillation and reduced the recurrence of AF within one day.
  3 7,722 1,111
CASE REPORTS
Induced mild hypothermia in post-cardiopulmonary bypass vasoplegia syndrome
Mukesh Tripathi, Prabhat Kumar Singh, Naresh Kumar, Kailash Chandra Pant
January-June 2009, 12(1):49-52
DOI:10.4103/0971-9784.45013  PMID:19136755
The state of vasoplegia in immediate post-cardiopulmonary bypass period is characterized by severe hypotension, supranormal cardiac output, low systemic vascular resistance (SVR), and resistance to vasoconstrictors. We could successfully use induced mild hypothermia to increase SVR, and could avoid very high doses of nor-epinephrine (>0.3 mcg/kg/min) in the background of severe pulmonary hypertension (systolic pulmonary pressure >90mmHg). Its effects such as decreased oxygen demand, positive inotropy and better right ventricle performance probably helped to improve oxygenation in presence of pulmonary oedema.
  2 5,727 542
INTERESTING IMAGES
Large rhabdomyosarcoma of the right ventricle obstructing tricuspid valve, pulmonary valve and left ventricular outflow tract
Thiruvenkadam Selvaraj, Poonam M Kapoor, Usha Kiran
January-June 2009, 12(1):81-82
DOI:10.4103/0971-9784.45020  PMID:19136762
  2 3,307 349
LETTERS TO EDITOR
Intraoperative coronary vein graft thrombosis: Should we blame the use of aprotinin?
S Sivasubramaniam, B Murali, CJ Smallpiece, BAC Smith, M Kalkat
January-June 2009, 12(1):84-86
DOI:10.4103/0971-9784.45022  PMID:19136764
  2 2,854 234
CASE CONFERENCE
Surgical retrieval of embolised atrial septal occluder device from pulmonary artery: Pathophysiology and role of the intraoperative transoesophageal echocardiography
Shrinivas Gadhinglajkar, KP Unnikrishnan, Rupa Sreedhar, Mukul Chandra Kapoor, Praveen Kumar Neema
January-June 2009, 12(1):40-48
DOI:10.4103/0971-9784.45012  PMID:19136754
Atrial septal defect is usually closed in the cardiac catheterisation laboratory using atrial septal occluder (ASO) device. One of the complications associated with the procedure is embolisation of the device into the pulmonary artery. We are reporting two cases wherein the pulmonary embolisation of ASO device occurred during the procedure in one patient and in the early post-procedure period in another; both were retrieved surgically. We are also describing the haemodynamic consequences of this complication and the role of intraoperative transoesophageal echocardiography during surgical retrieval of the device.
  1 6,973 467
CASE REPORTS
Intraoperative myocardial ischemia during renal transplantation caused by anomalous origin of the right coronary artery
Virendra K Arya, Ashish Bangaari, Subramanyam Rajeev, Ashish Sharma, Mukat Minz, Manoj K Rohit
January-June 2009, 12(1):57-62
DOI:10.4103/0971-9784.45015  PMID:19136757
Anomalous origin of the right coronary artery (AORCA) is a rare congenital anomaly with an incidence of 0.92% during routine cardiac catheterization. Its presence raises an important concern to the anaesthesiologist because it can lead on to myocardial ischaemia manifesting as either angina pectoris or myocardial infarction, or sudden death in young patients with minimal exertion, even in the absence of atherosclerosis. Patients with AORCA may be intolerant to stress and the high cardiac output condition owing to volume loading. Such a therapeutic manoeuvre may be desirable during renal transplantation to enable better perfusion of the renal graft immediately after grafting the kidney, in order to improve its function. Hence, haemodynamic goals in renal transplant recipient with AORCA can be contradictory during surgery, thereby rendering anaesthetic management challenging. We report a case of acute myocardial ischemia precipitated by fluid loading conditions in a patient with AORCA during renal transplant that was successfully treated with emergent intra-aortic balloon pump therapy intraoperatively. Judicious intraoperative fluid replacement is recommended, and volume overload must be avoided in AORCA patients undergoing surgery.
  1 4,604 406
INTERESTING IMAGES
Intramyocardial dissecting haematoma causing cardiac tamponade: An unusual complication after mitral valve replacement surgery
Panduranga Prashanth, Mohammed Mukhaini, Madan Mohan Maddali
January-June 2009, 12(1):79-80
DOI:10.4103/0971-9784.45019  PMID:19136761
  1 4,263 338
LETTERS TO EDITOR
Selective lung separation with Fogarty catheter guided by an adult fiberoptic bronchoscope in a paediatric patient with situs inversus
Mahesh Kodivalasa, Gopinath Ramachandran
January-June 2009, 12(1):83-84
DOI:10.4103/0971-9784.45021  PMID:19136763
  1 3,203 243
Diagnostic fiberoptic bronchoscope aided double lumen tube insertion
Umesh Goneppanavar, Manjunath Prabhu, Ellango Appuswamy, Jasvinder Kaur
January-June 2009, 12(1):89-91
DOI:10.4103/0971-9784.45025  PMID:19136767
  1 7,046 427
ORIGINAL ARTICLES
Butorphanol premedication to facilitate invasive monitoring in cardiac surgery patients before induction of anaesthesia
Mukesh Tripathi, Soumya Shanker Nath, Sudipto Banerjee, Mamta Tripathi
January-June 2009, 12(1):34-39
DOI:10.4103/0971-9784.45011  PMID:19136753
Cannulations (peripheral vein, radial artery and jugular vein) performed for invasive monitoring before induction of anaesthesia in cardiac surgery patients may be associated with stress and anxiety. The efficacy and safety of butorphanol premedication was assessed in setting up of invasive monitoring. The study was a prospective, randomized, double blind, placebo controlled one with 70 patients undergoing elective cardiac surgery. In group-1 patients ( n = 35) (placebo) intramuscular saline was administered 1-2 hours before the surgery in equivalent volume to butorphanol. In group-2 ( n = 35) butorphanol (1, 1.5 and 2 mg for three body weight groups <40 kg, 41-60 kg and >60 kg, respectively) was administered 1-2 hours before surgery. Observer blinded for medication recorded the sedation score, pupil size and pain after each cannulation using visual analogue score (VAS). Student's ' t ' test and Chi-square test for proportions, Mann-Whitney test for non-parametric data was carried out. The median pain score of cannulation in group-2 (butorphanol) in the hand (10 mm) and neck (20 mm) were significantly ( P < 0.05) lower than group-1 (placebo) patients (hand = 30 mm and neck = 40 mm). Pain during neck cannulation was significantly ( P < 0.05) reduced (VAS < 30 mm) in patients with the pupil size of <2.5 mm. Since the pain during neck cannulation was more than pain during hand cannulations in both the groups, we conclude that the intensity of pain depends also upon the site of cannulation. Besides the analgesic effect of butorphanol, its sedative effect helped to effectively decrease the pain during neck cannulation in conscious patients.
  1 4,961 423
CASE REPORTS
Milrinone infusion: A therapeutic option in coronary vasospasm after primary percutaneous transluminal coronary angioplasty
Amarpal Singh, Rajesh Chand Arya, Bishav Mohan
January-June 2009, 12(1):67-70
DOI:10.4103/0971-9784.45017  PMID:19136759
A 42-year-old male presented to the emergency department with acute chest pain. The electrocardiogram revealed inferior wall myocardial infarction. Emergency coronary angiography revealed total occlusion of the distal right coronary artery with thrombus. Patient was taken up for primary percutaneous coronary angioplasty with stenting of distal right coronary artery. Six hours following the procedure, the patient developed re-elevation of ST-segment in inferior leads of electrocardiogram and subsequent haemodynamic instability. Repeat coronary angiography revealed patent stent and coronary artery spasm in proximal part, which was relieved by intracoronary injection of nitroglycerine. After an hour, the patient re-developed symptoms of chest pain along with bradycardia, hypotension and ST segment elevation. Intravenous infusion of nitroglycerine did not improve the condition but produced persistent hypotension. Infusion of milrinone was then started. Over time, normalisation of electrocardiogram occurred. The patient was discharged in stable condition. This case suggests that milrinone may be effective in alleviating coronary artery spasm when the use of other agents fails
  - 5,785 413
LETTERS TO EDITOR
The value of postoperative troponin levels in predicting long-term mortality after coronary artery bypass surgery
Petros Tzimas, Haralampos J Milionis, Helen Arnaoutoglou, Kallirroi Kalantzi, Elias Karfis, Panagiotis Korantzopoulos, Kostantinos Pappas, Georgios Drossos, Georgios Papadopoulos
January-June 2009, 12(1):86-88
DOI:10.4103/0971-9784.45023  PMID:19136765
  - 3,709 345
MEDICOLEGAL CASE
Sedated, unconscious patients - Hot water bags

January-June 2009, 12(1):92-93
  - 2,913 228