Cardiopulmonary bypass surgery-cold alert!

The term "cold agglutinin (CA)" refers to a group of disorders caused by anti-erythrocyte autoantibodies that preferentially bind RBCs at cold temperatures (4°C-18°C). CAs contribute to 10 to 15% of autoimmune hemolytic anemia. We report a case of CAs diagnosed intraoperatively during emergency mitral valve replacement.

Utility of cerebral oximetry in balloon mitral valvotomy and its correlation with post-procedure neurological complications: A pragmatic prospective observational study.

Background and Aims: Neurological complications (NCs) are significantly associated with reduced regional cerebral saturation (rSO2) in patients undergoing cardiac surgeries, as assessed with cerebral oximetry (COx). However, limited evidence is available in patients undergoing balloon mitral valvotomy (BMV). Thus, we evaluated the utility of COx in patients undergoing BMV, the incidence of BMV-related NCs and the association of >20% reduction in rSO2 with NCs. Methods: This pragmatic, prospective, observational study was performed after ethical approval, over November 2018 to August 2020, in the cardiology catherization laboratory of a tertiary care hospital. The study involved 100 adult patients undergoing BMV for symptomatic mitral stenosis. The patients were evaluated at initial presentation, pre-BMV, post-BMV and 3 months after the BMV. Results: The incidence of NCs was 7%, including transient ischaemic attack (n = 3), slurred speech (n = 2) and hemiparesis (n = 2). A significantly greater proportion of patients with NCs had a > 20% decrease in the rSO2 (P value = 0.020). At >20% cut-off, the COx had a sensitivity and specificity of 57.1% and 80%, respectively, in the prediction of NCs. Female sex (P value = 0.039), history of cerebrovascular episodes (P value < 0.001) and number of balloon attempts (P value < 0.001) were significantly associated with NCs. Patients with and without NCs had a significantly greater post-BMV mean % change in rSO2 than pre-BMV (both right and left sides), but the magnitude of mean % change was greater in those with NCs. Conclusions: COx alone has low sensitivity and specificity in the prediction of NCs and cannot reliably predict the development of post-BMV NCs.

A prospective study of various anesthetic techniques in patients with acyanotic congenital heart diseases undergoing device closure.

Background and Aims: Transcatheter device closure of congenital heart defects (CHD) has recently gained popularity. As limited literature exists regarding the ideal anesthetic technique for these procedures, we studied the perioperative anesthetic management and its effects on hemodynamics and complication rate in patients undergoing device closure. Methods: In this prospective observational study, all patients of 1 month to 50 years of age with acyanotic congenital heart diseases undergoing device closure were included. The anesthesia technique, i.e., general anesthesia with endotracheal tube (GETA)/supraglottic airway device (SGD) or conscious sedation with face mask (S-FM), and intravenous induction agent used was noted. Intraoperatively vital parameters, use of transesophageal echocardiography (TEE), and perioperative complications if any, were noted. Descriptive statistical analysis was done using a statistical package for the social sciences (SPSS) version 15. Results: GETA was used in the atrial septal defect (ASD) (62.8%), patent ductus arteriosus (PDA) (66.7%), ventricular septal defect (VSD) (65%) patients, SGD in ASD (6.3%), PDA (16.7%), and VSD (13.3%) patients. S-FM in ASD (31.3%), PDA (16.7%) and VSD (21.7%) patients. Etomidate was used as an induction agent in 30.61% of the patients and propofol in 69.39% of the patients. The mean arterial pressure (MAP) in the etomidate and propofol groups was statistically insignificant while decreased heart rate was noted in both groups. Complications like SGD dislodgement, supraventricular tachycardia, and device dislodgements were seen. Conclusion: In PDA device closure patients, GETA should be preferred. Patients for VSD device closure should receive general anesthesia as complications are common. In ASD device closure, patients without TEE use can be done under general anesthesia with SGD.

Management of ventricular storm with thoracic epidural anesthesia.

The incidence of recurrent ventricular arrhythmias is increasing these days. Ventricular electrical storm can be of three types as follows: monomorphic ventricular tachycardia (VT), polymorphic VT, and ventricular fibrillation. The mechanism of ventricular storm is complex, and its management is quite a challenge for the clinicians due to its life-threatening consequences. We report a case of ventricular storm in whom all the conventional methods for the management of arrhythmias were ineffective, and the case is managed effectively with thoracic epidural anesthesia (TEA). A 60-year-old male patient was admitted to recurrent ventricular arrhythmias. He received defibrillator shocks and other antiarrhythmic drugs, but he was not responding to the treatment. We managed to revert the ventricular arrhythmias to the sinus rhythm with TEA. Ventricular storm is a challenging complication, which can be managed effectively with timely diagnosis and effective management.

Effect of octopus tissue stabilizer on cardiac output during off-pump coronary artery bypass graft surgery.

INTRODUCTION: Significant hemodynamic derangements can occur during off-pump coronary artery bypass graft (OPCAB) surgery resulting from the displacement of the beating heart, which may necessitate conversion to on-pump surgery. AIM: We proposed to evaluate the alterations in hemodynamic parameters in patients during the course of anastomosis in OPCAB surgery using the Octopus tissue stabilizer. MATERIAL AND METHODS: In 100 consecutive patients undergoing OPCAB surgery, hemodynamic variables including cardiac output (CO), heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) were recorded at baseline, during each coronary artery anastomosis at 2 min, 10 min and after release of the Octopus tissue stabilizer. RESULTS: CO decreased significantly after target stabilization and during all coronary anastomoses (5.42 ±1.1 l/min at baseline, 4.26 ±1.02 l/min at 2 min and 3.92 ±0.98 l/min at 10 min; p < 0.001), with the greatest decrease noted during obtuse marginal (OM) branch of left circumflex artery anastomosis (3.67 ±0.86 l/min at 2 min and 3.38 ±0.78 l/min at 10 min). Inotropic drugs were required to maintain mean arterial pressure (MAP) > 60 mm Hg in 43 patients, which was most frequently noted during OM anastomosis (p < 0.001). The incidence of bradycardia requiring inotropes was noted to be the highest during left anterior descending (LAD) artery anastomosis (p = 0.002). CONCLUSIONS: During OPCAB surgery using the Octopus for coronary target stabilization, CO decreased the most during OM anastomosis requiring inotropes, while bradycardia was most frequent during LAD anastomosis. Careful monitoring and management of hemodynamic variables are therefore of utmost importance to avoid conversion to on-pump surgery.

Effect of dexmedetomidine infusion on hemodynamic responses in microsurgery of larynx.

BACKGROUND AND AIMS: Microlaryngeal surgery is a frequently performed ear, nose, and throat procedure used to diagnose and treat laryngeal disorders. Suspension laryngoscopy causes prolonged stimulation of the deep pressure receptors of the larynx leading to adverse circulatory responses and consequently cardiac complications. In this study, dexmedetomidine infusion was used to assess its effectiveness for attenuation of this hemodynamic stress response. MATERIAL AND METHODS: Sixty patients undergoing elective microlaryngeal surgery randomly received either dexmedetomidine 1 µg/kg over 10 min followed by continuous infusion of 0.5 µg/kg (Group D) or normal saline infusion at the same rate (Group P) till the end of surgery. Anesthesia in all patients was induced with propofol, succinylcholine to facilitate endotracheal intubation after premedication with fentanyl 2 µg/kg and glycopyrrolate. Intraoperative, vital parameters were maintained within 20% of baseline with rescue analgesic fentanyl 1 µg/kg and subsequently with propofol boluses up to 1 mg/kg. The percentage of patients and the total amount of intraoperative fentanyl and propofol required in each group were recorded. Sedation score at 10 minutes postextubation was assessed by Ramsay sedation score. RESULTS: Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group P (P > 0.05). The percentage of patients requiring rescue fentanyl and propofol was higher in Group P than Group D (36.6% and 30% vs. 6.6% and 3.3% P = 0.01). Recovery scores were better in dexmedetomidine group. CONCLUSION: Dexmedetomidine infusion attenuates the hemodynamic stress response during laryngoscopy, intubation, and microlaryngeal surgery and is associated better recovery profile.

Anesthetic management of patent ductus arteriosus in adults.

Patent ductus arteriosus (PDA) is an extracardiac left to right shunt. It should be corrected at an early age, but some patients may survive into adult life even without repair. Anesthetic management for adult patients with PDA poses many challenges for the anesthesiologist due to alterations in the cardiopulmonary physiology. We report successful anesthesia management of a case of an adult patient of PDA with moderate pulmonary artery hypertension with infective endarteritis (two large mobile vegetations at the pulmonary end of the duct).