Authentication of Radial Versus Femoral Arterial Pressure Waveform-Derived Cardiac Output With Transesophageal Echocardiography-Derived Cardiac Output Measurements in Patients Undergoing On-Pump Coronary Bypass Surgery.

OBJECTIVE: The aim of this study was to ascertain if arterial waveform-derived cardiac output measurements from radial and femoral cannulation sites were reliable as compared with transesophageal echocardiography (TEE)-derived cardiac output (CO) values, and which of the CO measurements derived from radial and the femoral arterial pressure waveforms closely tracked simultaneously measured TEE-derived CO values. This study also aimed to ascertain if cardiopulmonary bypass (CPB) would impact the accuracy of arterial pressure-derived CO values from either of the 2 sites. DESIGN: A prospective observational study. SETTING: Tertiary care cardiac center. PARTICIPANTS: Cardiac surgical patients undergoing on-pump primary coronary artery bypass surgery. INTERVENTIONS: Waveform-derived CO monitoring through radial and femoral artery cannulation using a FloTrac/Vigileo system. MEASUREMENTS AND MAIN RESULTS: Twenty-seven consecutive cardiac surgical patients undergoing on-pump primary coronary artery bypass surgery were included in the study. Cardiac output was measured sequentially by the arterial pressure waveform analysis method from radial and femoral arterial sites and compared with simultaneously measured TEE-derived CO. Cardiac output data were obtained in triplicate at 6 predefined time intervals: before and after sternotomy, 5, 15, and 30 minutes after separation from CPB and prior to shifting the patient out of the operating room. The overall bias of the study was 0.11 and 0.27, the percentage error was 19.31 and 18.45, respectively, for radial and femoral arterial waveform-derived CO values as compared with TEE-derived CO measurements. The overall precision as compared with the TEE-derived CO values was 16.94 and 15.95 for the radial and femoral cannulation sites, respectively. The bias calculated by the Bland-Altman method suggested that CO measurements from the radial arterial site were in closer agreement with TEE-derived CO values at all time periods, and the relation was not affected by CPB. However, percentage error and precision calculations showed that CO values derived from the femoral arterial waveform were in closer agreement, albeit marginally, with the TEE values at all time points. CONCLUSIONS: Both the radial and femoral arterial pressure waveform-derived CO measurements were comparable with the TEE measurements during the various stages of the cardiac surgery. Although the femoral cannulation site provided marginally better correlation with the reference TEE-derived CO values based on the precision and percentage error analysis; this may not be significant clinically and either of the arterial cannulation sites can be used reliably for CO measurements in clinical practice. Cardiopulmonary bypass had no impact on the radial and femoral artery pressure waveform-derived CO measurements.

Anaesthetic Challenges and Transesophageal Echocardiography-Guided Perioperative Management in a Patient with Uncorrected Adult Congenital Heart Disease Presenting for Emergency Laparoscopic Hysterectomy.

Anaesthetic management of a patient with adult congenital heart disease with a single ventricle physiology presenting for an emergency laparoscopic surgery is challenging. The importance of a multidisciplinary approach, astute understanding of the pathophysiology and optimisation of intraoperative hemodynamic goals cannot be overemphasised. The present report describes the anaesthetic challenges and the role of transoesophageal echocardiography in perioperative management of a patient with uncorrected tetralogy of Fallot with pulmonary atresia, who successfully underwent an emergency laparoscopic hysterectomy under general anaesthesia.

Effect of low-dose dexamethasone on extra vascular lung water in patients following on-pump elective primary coronary artery bypass graft surgery.

Background: The primary objective was to compare the effect of a low-dose dexamethasone as against a saline placebo on extravascular lung water index (EVLWI) in patients undergoing elective primary coronary artery bypass surgery. The secondary endpoints were to assess the effect of dexamethasone on other volumetric parameters (pulmonary vascular permeability index, global end diastolic volume index, and intrathoracic blood volume index), Vasoactive Inotrope Scores, hemodynamic parameters and serum osmolality in both groups. Settings and Design: Prospective observational study performed at a single tertiary cardiac care center. Materials and Methods: Twenty patients were randomized to receive either dexamethasone (steroid group, n = 10) or placebo (nonsteroid group, n = 10) twice before the institution of cardiopulmonary bypass (CPB). EVLWI and other volumetric parameters were obtained with the help of VolumeView™ Combo Kit connected to EV 1000 clinical platform at predetermined intervals. Hemodynamic parameters, vasoactive-inotropic Scores, hematocrit values were recorded at the predetermined time intervals. Baseline and 1st postoperative day serum osmolality values were also obtained. Results: The two groups were evenly matched in terms of demographic and CPB data. Intra- and inter-group comparison of the baseline EVLWI including other volumetric and hemodynamic parameters with those recorded at subsequent intervals revealed no statistical difference and was similar. Generalized estimating equation model was obtained to compare the changes between the groups over the entire study period which showed that on an average the changes between the steroid and nonsteroid group in terms of all volumetric parameters were not statistically significant. Conclusions: There were no beneficial effects of low-dose dexamethasone on EVLWI or other volumetric parameters in patients subjected to on-pump primary coronary bypass surgery. Hemodynamic parameters were also not affected. Probably, the advanced hemodynamic monitoring aided in optimal fluid management in the nonsteroidal group impacting EVLW accumulation.

Elephant Trunk-Like Teratoma of the Face with Compromised Airway in an Infant with Complex Congenital Cardiac Defects: An Anesthetic Challenge.

Large head and neck teratomas are very rare. Depending on their site of origin, they can produce varying degrees of airway compromise and can interfere with the conduct of general anesthesia. Large space-occupying lesions of the face may even interfere with the simple task of mask ventilation rendering inhaled induction of general anesthesia and maintenance of spontaneous ventilation difficult. If these neoplasms coexist with cardiac lesions necessitating corrective or palliative procedures, the task of oxygenation, ventilation, and securing a definitive airway becomes challenging especially in the presence of underlying unstable hemodynamics. We report on the anesthetic management of a female infant with a facial teratoma and single-ventricle physiology undergoing a cardiac palliative procedure where securing a definitive airway with minimal hemodynamic instability was the immediate requirement.