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OBJECTIVE: To compare the analgesic and sleep quality effects of dexmedetomidine infusion versus placebo in patients undergoing cardiac surgery with ultra-fast track extubation. DESIGN: The randomized, double-blind clinical trial study. SETTING: At a single academic center hospital. PARTICIPANTS: We included patients aged 25 to 65 scheduled for elective cardiac surgery under general anesthesia with cardiopulmonary bypass from October 2021 to December 2022. INTERVENTION: After immediate extubation in the operating room, the patients who were allocated at first after providing their consent to either the dexmedetomidine group (Dex) or the placebo group (Placebo) received continuous infusion of dexmedetomidine (0.2 µg/kg/h) or saline for 12 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: The groups' demographic and perioperative variables were not statistically significant. Total morphine consumption in milligrams at 12 and 24 hours after administered study drug, total sleep time in hours by BIS value ≤85, and sleep quality with the Richard-Campbell Sleep Questionnaire were compared. The analysis included 22 Dex and 23 Placebo patients. The consumption of morphine was not statistically different between the Dex and Placebo groups at 12 and 24 hours (p = 0.707 and p = 0.502, respectively). The Dex group had significantly longer sleep time (8.7 h [7.8, 9.5]) than the Placebo group (5.8 h [2.9, 8.5]; p = 0.007). The Dex group also exhibited better sleep quality (7.9 [6.7, 8.7] vs 6.6 [5.2, 8.0]; p = 0.038). CONCLUSIONS: Sedation with low-dose dexmedetomidine infusion for ultra-fast track extubation following cardiac surgery enhances sleep duration and quality.
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Maternal cardiac arrest is a rare occurrence. In this case report, we present a detailed account of a 37-year-old pregnant woman with preeclampsia with severe features who underwent cesarean delivery. The patient experienced dyspnea and hypoxia at 12 hours postpartum, leading to cardiac arrest in the maternity ward. Advanced cardiac life support measures, including 15 minutes of chest compressions, were performed until spontaneous circulation was restored. This study explores the underlying factors contributing to maternal cardiac arrest during the postpartum period. Additionally, it highlights the effective strategies employed by our multidisciplinary team in managing and resolving this critical medical event.
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BACKGROUND: Pulmonary hypertension in pregnancy is rare and leads to high maternal morbidity and mortality. CASE: A 27-year-old parturient woman with a 31-week gestational age underwent cesarean delivery under combined spinal-epidural anesthesia. She had systemic lupus erythematosus associated with severe pulmonary arterial hypertension. The operation was done in the cardiac theatre along with meticulous invasive monitoring. Insertion of femoral artery and femoral vein catheters for veno-arterial extracorporeal membrane oxygenation was done before delivery as preparation for the potential emergency of a life-threatening form of decompensated cardiac failure. During the delivery, the patient suddenly developed increased pulmonary arterial pressure. This was controlled by the continuous infusion of intravenous milrinone. CONCLUSIONS: We report the successful management of this patient in the perioperative period. For cases such as that reported here, we recommend multidisciplinary team collaboration coupled with invasive cardiovascular monitoring and scrupulous anesthetic management.
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BACKGROUND: Polypharmacy, which is defined as the use of 5 or more medications, can exert significant adverse impact on older adult patients. The objective of this study was to determine the prevalence of polypharmacy, and to investigate its association with postoperative cognitive dysfunction (POCD) in older adult patients who underwent elective major surgery at Siriraj Hospital-Thailand's largest national tertiary referral center. METHODS: This prospective study included older adult patients aged ≥65 years who were scheduled for elective major surgery during December, 2017 to December, 2019 study period. Patient demographic, sociodemographic, anthropometric, clinical, comorbidity, anesthetic, surgical, and medication data were collected and compared between the polypharmacy and non-polypharmacy groups. Postoperative cognitive dysfunction (POCD) was diagnosed in patients with at least a 2-point decrease in their Montreal Cognitive Assessment score after surgery. Multivariate logistic regression analysis was used to identify independent predictors of POCD. RESULTS: A total of 250 patients (141 males, 109 females) with an average age of 72.88 ± 6.93 years were included. The prevalence of polypharmacy was 74%. Preoperative data showed the polypharmacy group to be more likely to be receiving potentially inappropriate medications, to be scheduled for cardiovascular thoracic surgery, and to have more comorbidities. There was a non-significant trend in the association of polypharmacy and POCD (crude odds ratio (OR): 2.11, 95% confidence interval [CI]: 0.90-4.94; p = 0.08). Benzodiazepine, desflurane, or isoflurane administration during surgery were all significantly associated with POCD in univariate analysis. Multivariate analysis revealed intraoperative benzodiazepine (adjusted OR [aOR]: 2.24, 95% CI: 1.10-4.68; p = 0.026) and isoflurane (aOR: 2.80, 95% CI: 1.35-5.81; p = 0.006) as two independent variables associated with the development of POCD. Desflurane was found to be a protective factor for POCD with a crude OR of 0.17 (95% CI: 0.03-0.74, p = 0.019); however, independent association was not found in multivariate analysis. CONCLUSION: There was a high prevalence of polypharmacy in this study; however, although close (p = 0.08), significant association was not found between polypharmacy and POCD. Benzodiazepine and isoflurane were both identified as independent predictors of the development of POCD among older adult patients undergoing elective major surgery, especially among those classified as polypharmacy.