Can Near-Infrared Spectroscopy (NIRS) monitoring prevent post-operative cognitive dysfunction following open- heart surgery?

OBJECTIVE: This study aimed to evaluate the relationship between Post-operative Cognitive Dysfunction (POCD) and regional Oxygen saturation (rSOs) determined by NIRS monitoring during Open-heart surgery. METHODS: This was a prospective cohort study of all patients about to undergo Open-heart surgery at Cipto Mangunkusumo National Referral Hospital, Jakarta. Subjects who fulfilled the selection criteria underwent cognitive assessment one day before the surgery. Basal rSO2 was registered prior to anaesthetic induction, and this value was reported every 10 minutes throughout the procedure as the lowest rSO2 and total desaturation (drop >20%) duration. On postoperative day 5, cognitive function was reassessed. We declared a drop in the cognitive function if the score dropped to >20% from the baseline in at least two cognitive tests. RESULTS: The incidence of POCD was 51.7%. Basal rSO2 values between POCD and non-POCD subjects were relatively similar. A significant difference was noted in the duration of total rSO2 desaturation between the two groups. Total rSO2 desaturation was longer in subjects with than without POCD. The ROC (receiver operating characteristic) curve showed a cut-off point of 20.5 minutes, with an AUC (area under curve) size of 126.5 minutes %. CONCLUSIONS: Absolute rSO2 values did not correlate with POCD. However, a drop in rSO2 value >20% from baseline may correlate with POCD. The use of NIRS in Open-heart surgery may, be beneficial for POCD prevention.

Efficacy of 0.5 mg/kg of propofol at the end of anesthesia to reduce the incidence of emergence agitation in children undergoing general anesthesia with sevoflurane.

BACKGROUND AND AIMS: Emergence agitation (EA) is a common transient behavioral disturbance after inhalational anesthesia and may cause harm to the patient. This study evaluated the efficacy of 0.5 mg/kg of propofol administered at the end of anesthesia to reduce the incidence of EA in children undergoing general inhalational anesthesia. MATERIAL AND METHODS: This double-blind randomized clinical trial was done in children aged 1-5 years undergoing general anesthesia with sevoflurane. One hundred and eight subjects were included using consecutive sampling method and randomized into two equal groups. Propofol in the dose of 0.5 mg/kg was administered at the end of anesthesia to children in the propofol group, while those in the control group did not receive any intervention at the end of anesthesia. Incidence of EA, transfer time, postoperative hypotension, desaturation, and nausea-vomiting were observed. Aono and Pediatric Anesthesia Emergence Delirium scale were used to assess EA. RESULTS: Incidence of EA was 25.9% in the propofol group compared to 51.9% in the control group (RR = 0.500; 95% CI 0.298-0.840; P = 0.006). Mean transfer time in propofol group was longer (9.5 ± 3.9 min) than control group (7.8 ± 3.6 min) (mean difference 1.71 min; 95% CI 0.28-3.14; P = 0.020). Hypotension was found in one patient (1.9%) in propofol group, while in control group there was none. Nausea-vomiting was found in five patients (9.3%) in propofol group and eight patients (14.8%) in control. There was no desaturation in both the groups. CONCLUSION: Administration of 0.5 mg/kg of propofol at the end of anesthesia effectively reduces the incidence of EA in children undergoing general inhalational anesthesia with sevoflurane.

Guyton perspective in managing peripartum cardiomyopathy patient with pulmonary edema: a case report.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-related condition characterized by left ventricular dysfunction and heart failure, typically occurring in the peripartum period. Individuals with a history of preeclampsia and hypertension are particularly prone to developing PPCM. Recent research suggests that the condition may be triggered by vascular dysfunction influenced by maternal hormones in the late stages of gestation. The onset of left heart failure results in decreased cardiac output, leading to insufficient perfusion, which in turn, contributes to pulmonary edema and exacerbates tissue hypoxia. This cardiovascular response activates the neurohumoral system, causing peripheral vasoconstriction and elevating both mean capillary filling pressure (MCFP) and central venous pressure (CVP). Early administration of furosemide reduces volume overload due to negative cumulative fluid balance gaining and vasodilation, which increases the velocity of intravascular refilling and causes interstitial edema to resolve. This will decrease interstitial fluid pressure, resulting in decreased mechanical compression to systemic capillary and systemic vein pressure, thus decreasing MCFP and CVP subsequently. Reduced CVP also contributes to increased venous return by decreasing the gradient pressure between MCFP and CVP, resulting in increased cardiac output (CO) and improved tissue oxygenation. CASE: A 33-year-old Asian woman, para 3 at full term pregnancy, admitted to the intensive care unit (ICU) after c-section and tubectomy due to shortness of breath and palpitation. Based on history taking, physical examination and echocardiography the patient fulfilled the criteria of PPCM which was also complicated by pulmonary edema. Despite impending respiratory failure, the patient rejected intubation and continuous positive airway pressure (CPAP), and was given oxygen supplementation through nasal cannula. Furosemide was given rapidly continued by maintenance dose and CVP was monitored. Antihypertensive drug, anticoagulants, and bromocriptine were also administered. After achieving negative cumulative fluid balance the patient's symptoms resolved and was discharged one week later. CONCLUSION: There is a correlation between negative cumulative fluid balance and reduced central venous pressure after early furosemide therapy. Suspicion for PPCM should not be lowered in the presence of preeclampsia, it could delay appropriate treatment and increase the mortality.

Preoperative Fasting of Eight Hours Provide Better Gastric Emptying: Ultrasound Assessment of Gastric Volume.

BACKGROUND: Preoperative fasting is a common practice to decrease perioperative aspiration risk. The American Society of Anesthesiologists (ASA) recommends preoperative fasting of 8 hours after a full meal. ASA preoperative fasting recommendation is based on the Western diet. A typical Western diet has a higher fat content than Asian standard solid meals. This study aimed to analyze intragastric volume with ultrasound after 6-hour and 8-hour fasting after an Asian traditional solid meal. METHODS: This cohort study recruited 37 subjects from January to February 2019. Subjects were patients scheduled for elective non-digestive surgery and planned for preoperative fasting of 8 hours. Before preoperative fasting, all subjects consumed standard Asian meals. We performed an ultrasound of the gastric antrum during the relaxation phase after two contractions. After a good image was acquired, the cross-sectional area and gastric volume (GV) were calculated. GV was grouped based on a border value of 1.5 mL/kg. RESULTS: GV 6 hours after solid intake was 30.93 (1.60-205.25) mL, and GV 8 hours after solid intake was 16.34 (0.73-62.49) mL (P = 0.002). After 6 hours, 5.4% of the subjects had a GV above 1.5 mL/ kg, while after fasting for 8 hours, the GV of all subjects was below 1.5 mL/kg. Age was correlated moderately and negatively with the GV of 6 hours and 8 hours fasting (P < 0.001, correlation coefficient = -0.610, and P < 0.001, correlation coefficient = -0.580). CONCLUSION: Intragastric volume 8 hours after a standard Asian meal intake was lower than 6 hours after a traditional Asian meal.

Comparison of Bioimpedance Versus Pulse Contour Analysis for Intraoperative Cardiac Index Monitoring in Patients Undergoing Kidney Transplantation.

BACKGROUND: Cardiac index (CI; cardiac output indexed to body surface area) is routinely measured during kidney transplant surgery. Bioimpedance cardiometry is a transthoracic impedance as the non-invasive alternative for hemodynamic monitoring, using semi-invasive uncalibrated pulse wave or contour (UPC) analysis. OBJECTIVES: We performed a cross-sectional observational study on 50 kidney transplant patients to compare the CI measurement agreement, concordance rate, and trending ability between bioimpedance and UPC analysis. METHODS: For each patient, CI was measured by bioimpedance analysis (ICONTM) and UPC analysis (EV1000TM) devices at three time points: after induction, during incision, and at reperfusion. The device measurement accuracy was assessed by the bias value, limit of agreement (LoA), and percentage error (PE) using Bland-Altman analyses. Trending ability was assessed by angular bias and polar concordance through four-quadrant and polar plot analyses. RESULTS: From each time point and pooled measurement, the correlation coefficients were 0.267, 0.327, 0.321, and 0.348. Bland-Altman analyses showed mean bias values of 1.18, 1.06, 1.48, and 1.30, LoA of -1.35 to 3.72, -1.39 to 3.51, -1.07 to 4.04, and -1.17 to 3.78, and PE of 82.21, 78.50, 68.74, and 74.58%, respectively. Polar plot analyses revealed angular bias values of -10.37º, -15.01º, -18.68º, and -12.62º, with radial LoA of 89.79º, 85.86º, 83.38º, and 87.82º, respectively. The four-quadrant plot concordance rates were 70.77, 67.35, 65.90, and 69.79%. These analyses showed poor agreement, weak concordance, and low trending ability of bioimpedance cardiometry to UPC analysis. CONCLUSIONS: Bioimpedance and UPC analysis for CI measurements were not interchangeable in patients undergoing kidney transplant surgery. Cardiac index monitoring using bioimpedance cardiometry during kidney transplantation should be interpreted cautiously because it showed poor reliability due to low accuracy, precision, and trending ability for CI measurement.