Annals of Cardiac Anaesthesia 2018 21(4):468-468
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Cancer Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026182 & 00306932607174
Παρασκευή 19 Οκτωβρίου 2018
Surgical technique and chylothorax following coronary artery bypass grafting
Annals of Cardiac Anaesthesia 2018 21(4):468-468
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Predictors of acute kidney injury in patients undergoing adult cardiac surgery
Annals of Cardiac Anaesthesia 2018 21(4):448-454
Background: Acute kidney injury (AKI) after cardiac surgery (CS) is not uncommon and has serious effects on mortality and morbidity. A majority of patients suffer mild forms of AKI. There is a paucity of Indian data regarding this important complication after CS. Aims and Objectives: The primary objective was to study the incidence of AKI associated with CS in an Indian study population. Secondary objectives were to describe the risk factors associated with AKI-CS in our population and to generate outcome data in patients who suffer this complication. Methods: Serial patients (n = 400) presenting for adult CS (emergency/elective) at a tertiary referral care hospital in South India from August 2016 to November 2017 were included as the study individuals. The incidence of AKI-CS AKI network (AKIN criteria), risk factors associated with this condition and the outcomes following AKI-CS are described. Results: Out of 400, 37 (9.25%) patients developed AKI after CS. AKI associated with CS was associated with a mortality of 13.5% (no AKI group mortality 2.8%, P = 0.001 [P < 0.05]). When AKI was severe enough to need renal replacement therapy, the mortality increased to 75%. Patients with AKI had a mean hospital stay 16.92 ± 12.75 days which was comparatively longer than patients without AKI (14 ± 7.98 days). Recent acute coronary syndrome, postoperative atrial fibrillation, and systemic hypertension significantly predicted the onset of AKI-CS in our population. Conclusions: The overall incidence of AKI-CS was 9.25%. The incidence of AKI-CS requiring dialysis (Stage 3 AKIN) AKI-CS was lower (2%). However, mortality risks were disproportionately high in patients with AKIN Stage 3 AKI-CS (75%). There is a need for quality improvement in the care of patients with AKI-CS in its most severe forms since mortality risks posed by the development of Stage 3 AKIN AKI is higher than reported in other index populations from high resource settings.
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Facilitating noncardiac surgery for the patient with left ventricular assist device: A guide for the anesthesiologist
Annals of Cardiac Anaesthesia 2018 21(4):351-362
The introduction of left ventricular assist device (LVAD) has improved survival rates for patients with end-stage heart failure. Two categories of VADs exist: one generates pulsatile flow and the other produces nonpulsatile continuous flow. Survival is better for patients with continuous-flow LVADs. With improved survival, more of such patients now present for noncardiac surgery (NCS). This review, written for the general anesthesiologists, addresses the perioperative considerations when the patient undergoes NCS. For best outcomes, a multidisciplinary approach is essential in perioperative management of the patient.
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Unrecognized hyperlucent lesion on lateral film of chest X-Ray
Annals of Cardiac Anaesthesia 2018 21(4):440-441
We report an interesting case of bulla right lung, incidently found during CABG surgery.
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The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review
Annals of Cardiac Anaesthesia 2018 21(4):363-370
Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4–6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24–72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.
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Missing swan ganz catheter
Annals of Cardiac Anaesthesia 2018 21(4):462-463
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Tissue oximetry during cardiac surgery and in the cardiac intensive care unit: A prospective observational trial
Annals of Cardiac Anaesthesia 2018 21(4):371-375
Background: Cerebral oximetry using near-infrared spectroscopy (NIRS) has well-documented benefits during cardiac surgery. The authors tested the hypothesis that NIRS technology can be used at other sites as a tissue oximeter during cardiac surgery and in the Intensive Care Unit (ICU). Aims: To establish feasibility of monitoring tissue oximetry during and after cardiac surgery, to examine the correlations between tissue oximetry values and cerebral oximetry values, and to examine correlations between oximetry values and mean arterial pressure (MAP) in order to test whether cerebral oximetry can be used as an index organ. Settings and Designs: A large, single-center tertiary care university hospital prospective observational trial of 31 patients undergoing cardiac surgery with cardiopulmonary bypass was conducted. Materials and Methods: Oximetry stickers were applied to both sides of the forehead, the nonarterial line forearm, and the skin above one paraspinal muscle. Data were collected from before anesthesia induction until extubation or for at least 24 h in patients who remained intubated. Statistical Analysis: Categorical variables were evaluated with Chi-square or Fisher's exact tests, while Wilcoxon rank-sum tests or student's t-tests were used for continuous variables. Results: The correlation between cerebral oximetry values and back oximetry values ranged from r = 0.37 to 0.40. The correlation between cerebral oximetry values and forearm oximetry values ranged from r = 0.11 to 0.13. None of the sites correlated with MAP. Conclusions: Tissue oximetry at the paraspinal muscle correlates with cerebral oximetry values while at the arm does not. Further research is needed to evaluate the role of tissue oximetry on outcomes such as acute renal failure, prolonged need for mechanical ventilation, stroke, vascular ischemic complications, prolonged ICU and hospital length of stay, and mortality in cardiac surgery.
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The value of institutional protocols and focused cardiac ultrasound during a case of ultramassive transfusion
Annals of Cardiac Anaesthesia 2018 21(4):433-436
A 53-year-old female was admitted to the emergency department with an exsanguinating bleed from the rectum which was of unclear origin. In what could be considered an ultramassive transfusion, 60 units packed red blood cells, 23 units fresh frozen plasma, 20 units platelets, 6 units cryoprecipitate, 30 L of crystalloids, 2 L of colloids, and 4 g of tranexamic acid were transfused over the course of 7 h. An arterio-enteric fistula was diagnosed and treated by an interventional radiologist. The patient recovered rapidly thereafter without any major neurologic, pulmonary, cardiac, or hematologic complications.
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Preoperative predictors of poor laryngoscope views in pediatric population undergoing cardiac catheterization
Annals of Cardiac Anaesthesia 2018 21(4):376-381
Background: The primary objective of this study was to identify pre-anesthetic airway assessment parameters that would predict Cormack and Lehane grade III and IV laryngoscopy views in pediatric patients undergoing cardiac catheterization procedures. The secondary end points were to identify factors that would contribute to difficult laryngoscope views in this subset of patients. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Materials and Methods: 199 children below 5 years of age undergoing elective cardiac catheterization were included. Pre-anesthetic airway assessment was done by modified Mallampati grading, lower lip to chin distance [LCD], tragus to mouth angle [TMA], thyromental distance [TMD], neck circumference [NC], and the ratio of height to thyromental distance [RHTMD]. Demographic data including American Society of Anesthesiologists physical status [ASA PS] were recorded for each child. Receiver Operating Characteristic curves were plotted and Areas Under the Curve were measured to identify the best cut off values for each of the airway evaluation method that would predict poor laryngoscopy views as well as assess their accuracy in doing so. Results: LCD, TMD and low body mass index were found to have good sensitivity, specificity and accuracy in predicting Grade III and IV laryngoscope views. ASA PS grade III and above patients had a significantly higher incidence of poor laryngoscope visualization. Conclusions: LCD, TMA, TMD, NC, RHTMD and BMI could all be used combinedly as screening tools during pre-anesthetic airway evaluation for predicting difficult laryngoscope views in children. Among these, LCD, TMD along with low body mass index might have better accuracy.
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Abdominal compartment syndrome after surgical repair of Type A aortic dissection
Annals of Cardiac Anaesthesia 2018 21(4):444-445
Abdominal compartment syndrome is associated with severe dysfunction of intra-abdominal and intrathoracic organs. Medical therapy, with the goal of reducing intra-abdominal pressure, leads to improvement in organ perfusion.
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Usefulness of ultrasound-guided measurement of minimal transverse diameter of subglottic airway in determining the endotracheal tube size in children with congenital heart disease: A prospective observational study
Annals of Cardiac Anaesthesia 2018 21(4):382-387
Introduction: The search for an accurate and predictable method to estimate the endotracheal tube (ETT) size in pediatric population had led to derivation of many formulae. Of this, age-based formulae are the most commonly used. Studies have shown that minimal transverse diameter of subglottic airway (MTDSA) measurements using a high-frequency probe improves the success rate of predicting the airway diameter to about 90%. We did a prospective observational study using MTDSA as the criteria to select the size of ETT in children with congenital heart disease. Methods: In this prospective observational study, 51 children aged from 1 day to 5 years, scheduled for cardiac surgery, were enrolled for this study. The ETT size was guided solely based on the MTDSA. Leak test was used to determine the best-fit ETT size. Results: Data from 49 patients were analyzed. Agreement between the ETT determined by MTDSA and that predicted by Cole's age-based formulas with the best-fit ETT size was analyzed using a Bland–Altman plot. Conclusion: Age-based formula showed poor correlation (27.5%) compared to MTDSA (87.8%) in predicting the best-fit ETT. We observed that pediatric patients with congenital heart disease need a larger sized ETT as compared to what was predicted by age-based formula. Using ultrasound MTDSA measurements to guide selection of ETT size is a safe and accurate method in pediatric cardiac population.
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Is routine preoperative chest X-ray: An underutilized tool in asymptomatic patients!
Annals of Cardiac Anaesthesia 2018 21(4):460-461
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Dreams content and emotional load in cardiac rehabilitation patients and their relation to anxiety and depression
Annals of Cardiac Anaesthesia 2018 21(4):388-392
Background: The assessment of a dream and its mechanisms and functions may help us to percept cognitions, emotions, and complex behaviors of patients. Hence, the present study aimed to assess (i) the rate of perceived dream and its emotional load and content and (ii) the relationship between functions of dream with anxiety and depression. Methods: In this cross-sectional study, 167 cardiac patients who had undergone rehabilitation in the western part of Iran were assessed during May–October 2016. Research instrument included Beck depression inventory, Beck anxiety inventory, Schredl's dream emotions manual, and content analysis of dreams manual. The findings were analyzed through Pearson's correlative coefficient and multiple regression analysis. Results: The mean age of participants (66.5% men) was 59.1 ± 9 years. The results indicated that the emotional content of patients' dreams included happiness (49.1%), distress (43.1%), sad (13.8%), fear (13.2%), and anger (3%). Although women report more sad dreams than men (P = 0.026), there was no difference between them in terms of other components of dreams, anxiety, and depression. Regression models showed that anxiety and depression were significantly able to predict perceived dream rates (P = 0.030) and emotionally negative dreams (P = 0.019). Conclusion: The increased rates of depression, especially anxiety, are related to increasing perceived dreams with negative and harmful emotional load. Regarding severity and negative content of dreams are reflexes of stressful emotional daily experiences, the management of experienced psychological symptoms such as depression and anxiety is concerned as an undeniable necessity.
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Anesthesia considerations in neonate with tetralogy of fallot posted for laparotomy
Annals of Cardiac Anaesthesia 2018 21(4):465-466
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Is elevated blood glucose a marker of occult tissue hypoperfusion in off-pump coronary artery bypass grafting?
Annals of Cardiac Anaesthesia 2018 21(4):393-401
Context: Hyperglycemia has been found to occur during myocardial infarction and cardiac surgery even in nondiabetic patients. These being essentially stressful processes associated with hypoperfusion, we decided to find a possible relationship between the occurrence of global tissue hypoperfusion (GTH) and elevated blood glucose level in adult nondiabetic patients undergoing elective off-pump coronary artery bypass grafting (CABG). Aims: This study aims to observe for the occurrence of global tissue hypoperfusion and its effect on blood glucose level and whether raised blood glucose level can be used as a marker for GTH. Design: Prospective, observational study. Settings: Cardiothoracic operation theater and intensive care unit of a tertiary care teaching hospital. Materials and Methods: The occurrence of global tissue hypoperfusion were detected with the help of combined markers of mixed venous oxygen saturation and arterial lactate level at various perioperative study points together with arterial blood glucose level. Blood glucose level compared between the patients with and without GTH. Statistical Analysis Used: Numerical variables were compared between groups by Student's t-test and categorical variables by Fisher's exact test. Two-tailed P ≤ 0.05 was considered for statistically significant. Results: The incidence of GTH was 67%. Blood glucose level was raised in patients with GTH at some study time points but with poor sensitivity and specificity values. Conclusions: Global tissue hypoperfusion is a common occurrence in even nondiabetic patients undergoing elective off-pump CABG. A relationship exists between rise in blood glucose level and global tissue hypoperfusion in such patients, although it cannot be viewed as marker of the same.
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Statistical literacy for healthcare professionals: Why is it important?
Annals of Cardiac Anaesthesia 2018 21(4):349-350
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Predictors and outcome of early extubation in infants postcardiac surgery: A single-center observational study
Annals of Cardiac Anaesthesia 2018 21(4):402-406
Objective: The objective of the current study was to evaluate the timing of first extubation and compare the outcome of patient extubated early with others; we also evaluated the predictors of early extubation in our cohort. Materials and Methods: This prospective cohort study included children <1 year of age undergoing surgery for congenital heart disease. Timing of first extubation was noted, and patients were dichotomized in the group taking 6 h after completion of surgery as cutoff for early extubation. The outcome of the patients extubated early was compared with those who required prolonged ventilation. Variables were compared between the groups, and predictors of early extubation were evaluated using multivariate logistic regression analysis. Results: One hundred and ninety-four (33.8%) patients were extubated early including 2 extubation in operating room and 406 (70.7%) were extubated within 24 h. Four (0.7%) patients died without extubation. No significant difference in mortality and reintubation was observed between groups. Patient extubated early had a significant lower incidence of sepsis (P = 0.003) and duration of Intensive Care Unit (ICU) stay (P = 0.000). Age <6 months, risk adjustment for congenital heart surgery category ≥3, cardiopulmonary bypass time ≥80 min, aortic cross-clamp time ≥ 60 min, and vasoactive-inotropic score >10 were independently associated with prolonged ventilation. Conclusion: Early extubation in infants postcardiac surgery lowers pediatric ICU stay and sepsis without increasing the risk of mortality or reintubation. Age more than 6 months, less complex of procedure, shorter surgery time, and lower inotropic requirement are independent predictors of early extubation.
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Right atrial myxoma: Unusual location; uncommon association
Annals of Cardiac Anaesthesia 2018 21(4):437-439
We are presenting a case of the right atrial myxoma found in a case of rheumatic heart disease. During transthoracic echocardiography for the evaluation of a suspected rheumatic valvular heart disease, a diagnosis of severe mitral stenosis with severe mitral regurgitation with the right atrial thrombus was made. On transesophageal echocardiography, a pedunculated mass in the right atrium was confirmed. In the course of surgery, it was found that there is a tumor originating from the right atrial appendage (RAA) which was confused with clot on echocardiography. Rheumatic heart disease and myxomas have different etiopathogenesis, and this coexistence has not been reported. Further, right atrial myxoma arising out of RAA is also being reported for the first time.
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Predictors and outcome of early extubation in infants postcardiac surgery: A single-center observational study
Annals of Cardiac Anaesthesia 2018 21(4):407-408
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Aortic regurgitation after chemoport catheter insertion: Diagnostic dilemma
Annals of Cardiac Anaesthesia 2018 21(4):442-443
Catheter insertion in central vein can potentially cause accidental arterial injury. However it is very unusual to see such catheter in aorta causing aortic regurgitation. Pressure monitoring and Ultrasound guidance can reliably prevent accidental arterial puncture.
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Protecting the Beans: Perioperative Acute Kidney injury
No abstract availablehttps://ift.tt/2CUYdZ5
Preoperative Intravenous Iron to Enhance a Blood Management Program: Is It All in “Vein”?
No abstract availablehttps://ift.tt/2CT0i7F
Multimodal General Anesthesia: A Principled Approach to Producing the Drug-Induced, Reversible Coma of Anesthesia
No abstract availablehttps://ift.tt/2CU6dt7
Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial
BACKGROUND: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHODS: We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULTS: MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55–4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26–3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89–6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. CONCLUSIONS: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability.https://ift.tt/2CV1JT4
Postoperative Hypotension and Surgical Site Infections After Colorectal Surgery: A Retrospective Cohort Study
BACKGROUND: Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection. Hypotension on surgical wards, while usually less severe than intraoperative hypotension, is common and often prolonged. In this retrospective cohort study, we tested the hypotheses that there is an association between surgical site infections and low postoperative time-weighted average mean arterial pressure and/or postoperative minimum mean arterial pressure. METHODS: We considered patients who had colorectal surgery lasting ≥1 hour at the Cleveland Clinic between 2009 and 2013. We defined blood pressure exposures as time-weighted average (primary) and minimum mean arterial pressure (secondary) within 72 hours after surgery. We assessed associations between continuous blood pressure exposures with a composite of deep and superficial surgical site infection using separate severity-weighted average relative effect generalized estimating equations models, each using an unstructured correlation structure and adjusting for potentially confounding variables. RESULTS: A total of 5896 patients were eligible for analysis. Time-weighted mean arterial pressure and surgical site infection were not significantly associated, with an estimated odds ratio (95% CI) of 1.03 (0.99–1.08) for a 5-mm Hg decrease (P = .16). However, there was a significant inverse association between minimum postoperative mean arterial pressure and infection, with an estimated odds ratio of 1.08 (1.03–1.12) per 5-mm Hg decrease (P = .001). CONCLUSIONS: Postoperative time-weighted mean arterial pressure was not associated with surgical site infection, but lowest postoperative mean arterial pressure was. Whether the relationship is causal remains to be determined.https://ift.tt/2CU1ojD
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