Bilateral Paravertebral Block versus Thoracic Epidural Analgesia for Pain Control Post-Cardiac Surgery: A Randomized Controlled Trial.

BACKGROUND: Adequate pain control after cardiac surgery is essential. Paravertebral block is a simple technique and avoids the potential complications of epidural catheters. The objective of this study is to compare the effect of ultrasound-guided bilateral thoracic paravertebral block with thoracic epidural block on pain control after cardiac surgery. MATERIALS AND METHODS: Between March 2016 and 2017, 145 patients who had cardiac surgery through median sternotomy were randomized by stratified blocked randomization into two groups. Group I (n = 70 patients) had bilateral ultrasound-guided thoracic paravertebral block and Group II (n = 75 patients) had thoracic epidural analgesia. The primary end point was the postoperative visual analogue scale (VAS). The duration of mechanical ventilation, intensive care unit (ICU), and hospital stay were the secondary end points. The study design is a randomized parallel superiority clinical trial. RESULTS: Both groups had similar preoperative and operative characteristics. No significant difference in VAS measured immediately after endotracheal extubation then after 12, 24, and 48 hours between groups (p = 0.45). Pain score significantly declined with the repeated measures (p < 0.001) and the decline was not related to the treatment group. Postoperative pain was significantly related to diabetes mellitus (p = 0.039). Six patients in group I (8.5%) required an additional dose of morphine versus three patients (4%) in group II (p = 0.30). Patients in group I had significantly shorter ICU stay (p = 0.005) and lower incidence of urinary retention (p = 0.04) and vomiting (p = 0.018). No difference was found in operative complications between groups. CONCLUSION: This randomized parallel controlled trial demonstrates that ultrasound-guided paravertebral block is safe and effective method for relieving post-cardiac surgery sternotomy pain compared with thoracic epidural analgesia but not superior to it.

Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery.

BACKGROUND: Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery. METHODS: Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7. RESULTS: There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups. CONCLUSIONS: Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.

Can enhanced external counter pulsation as a non-invasive modality be useful in patients with ischemic cardiomyopathy after coronary artery bypass grafting?

BACKGROUND: Angina symptom in patients with ischemic cardiomyopathy (ICM) after coronary artery bypass grafting (CABG) surgery is a major challenging problem in practice. The choice among different treatment modalities available can be judged by different parameters especially measuring the risk/cost ratio to achieve the benefit. Enhanced external counter pulsation (EECP) is one of safest noninvasive modality for treatment of angina as well as it has an anti-failure effect. PATIENTS AND METHOD: 42 patients with ICM after CABG were suffering from stable angina and were treated at Al-Hayat Cardiology Centre in Tanta City (ACC). 20 patients of them (group A) received 35 sessions of EECP plus their anti-ischemic and anti-failure treatment, while the other 22 patients (group B) received only medical treatment and were followed up for 3 months regarding their angina class, functional class, frequency of angina attack, frequency of sublingual nitrate and rate of rehospitalization when needed during follow up period. RESULTS: Despite both groups had nearly similar severity of symptoms regarding the CCS class and NYHA class, yet patients in group A experienced significant improvement in comparison to patients in group B (p-value = .005, p-value = .002 respectively), and this was reflected on frequency of angina and need for sublingual nitrates per week which showed significant decrease in group A (p-value = .001). CONCLUSION: As a non-invasive treatment modality EECP is very effective in improving the symptoms of angina and heart failure when combined with medical treatment in patients with ICM after CABG.

Evaluation of local intra-pleural application of tranexamic acid on postoperative blood loss in lung decortication surgery, a prospective, randomized, double-blind, placebo-controlled study.

Background: During decortication surgery, fibrous peel over the lung was removed to allow expansion of the lung and therefore, wide raw area was created with surface oozing. The phenomenon of fibrinolysis usually activated after such procedure, resulting in increasing the postoperative bleeding. Tranexamic acid is one of antifibrinolytic therapies that could be used topically and to targets directly the source of bleeding and reducing the local activation of the fibrinolytic process and consequently reducing the postoperative bleeding. Patients and Methods: A total of 70 patients underwent lung decortication surgery in Cardiothoracic Surgery Department at Tanta University Hospital from January 2015 to May 2017. Patients were randomly allocated into two groups, Group I (35 patients) receiving 3 g of tranexamic acid in 100 ml of saline solution and Group II (35 patients) receiving 100 ml of saline solution as placebo. At the end of the operation and before closing the chest, in both groups, drug or placebo solution was distributed locally all over the pleural cavity. Comparison between the groups was done regarding the amount of postoperative bleeding, postoperative hemoglobin in the first 24 and 48 h postoperatively, blood transfusion, Intensive Care Unit (ICU) stay, and hospital stay. Results: Both groups were comparable regarding demographic and surgical data. Group I patients had the significantly lesser amount of postoperative blood loss than Group II during the first postoperative 48 h, and hence, the need of postoperative blood transfusion was significantly lower in Group I with better postoperative hemoglobin level than Group II. However, there was no difference in overall ICU and hospital stay. Conclusion: The local intrapleural use of tranexamic acid after decortication surgery of the lung is safe and significantly reduces the amount of postoperative blood loss and in consequence reduces the amount of postoperative blood transfusion.