Tricuspid Annular Plane Systolic Excursion (TAPSE) for the Assessment of Right Ventricular Function in Adult and Pediatric Cardiac Surgery: Modified Two-dimensional and M-mode TAPSE by Transesophageal Echocardiography Compared to M-mode TAPSE by Transthoracic Echocardiography.

OBJECTIVES: To compare transesophageal echocardiography-guided 2-dimensional and M-mode tricuspid annular plane systolic excursion (TAPSE) to transthoracic echocardiography (TTE)-guided M-mode TAPSE in terms of accuracy, interobserver, and intra-observer variability. DESIGN: A prospective, observational study. SETTING: Adult and pediatric operating rooms. PARTICIPANTS: Adult and pediatric patients (42 each) undergoing cardiac surgeries. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Modified midesophageal (Mod-ME), deep transgastric, and transgastric TAPSEs were analyzed for reliability and were compared to TTE TAPSE in both adult and pediatric groups. Modified ME TAPSE showed good method agreement with TTE TAPSE (bias = -0.97, p = 0.08 (adult); bias = 0.17, p = 0.71 [pediatric]), and showed a moderate correlation with right ventricular (RV) fractional area change (FAC) (r = 0.41, p = 0.006, [adult]; r = 0.57, p < 0.001, [pediatric]), with acceptable interobserver variability (percentage error =10.56 [adult]; 4.42 [pediatric]) and intraobserver variability (percentage error = 13.1 [adults]; 12.24 [pediatric]). Transgastric TAPSE poorly agreed with TTE TAPSE and had higher interobserver and intraobserver variability. Deep transgastric TAPSE had good method agreement with TTE TAPSE and had acceptable interobserver and intra-observer variability. CONCLUSIONS: Modified ME TAPSE is a reliable and reproducible measure of RV function before pericardiotomy in both adult and pediatric cardiac surgery. Right ventricular FAC values reflected the RV systolic function better than TAPSE after pericardiotomy. Deep transgastric TAPSE is reliable and reproducible but is less accurate than Mod-ME TAPSE.

Intraoperative Three-dimensional Imaging of Ventricular Septal Defects in Children Using Epicardial Echocardiography: A Novel Approach.

OBJECTIVE: To assess the feasibility and accuracy of intraoperative three-dimensional (3D) epicardial en face images of ventricular septal defects (VSD) in children using the 3D transesophageal echocardiography (TEE) probe as an epicardial probe. DESIGN: This was a prospective nonrandomized blinded observational study. SETTING: The study was conducted at a single tertiary cardiac care center. PARTICIPANTS: Fifty pediatric patients, weighing between 5.0 kg and 20 kg, who were scheduled for elective surgical closure of their VSDs, prospectively were recruited for this study. INTERVENTIONS: Epicardial 3D images were acquired using the full-volume mode. VSD location and size were determined from the 3D data sets using multiplanar reconstruction mode (QLAB 9) by a blinded investigator. The accuracy in terms of location and size was compared with surgical findings. MEASUREMENTS AND MAIN RESULTS: In 50 study subjects, 54 VSDs were located by epicardial 3D echocardiography (3DE): 12 perimembranous, 17 inlet, eight muscular, 15 malaligned, and two outlet. Average image acquisition time was 4.96 (±1.47) minutes. Average image reconstruction time was 6.18 (±1.93) minutes. Good en face views of the VSD could be rendered in all patients (100% feasibility). The highest image quality was for perimembranous and malaligned VSDs. The location of VSD by 3DE corresponded precisely with surgical findings (100% accuracy). With linear regression analysis, excellent correlation was observed between the diameters measured by surgery and that measured by 3DE from the right ventricle side (r2 = 0.97, p < 0.001). CONCLUSIONS: The authors' study demonstrated that diagnostic quality 3D en face images of VSD can be obtained intraoperatively using 3D epicardial echocardiography. The short acquisition and reconstruction times make this technique clinically applicable.

Gabapentin premedication decreases the hemodynamic response to skull pin insertion in patients undergoing craniotomy.

BACKGROUND: In patients undergoing craniotomy, skull pin insertion produces significant increases in heart rate (HR) and blood pressure. We investigated whether premedication with gabapentin would prevent or attenuate this increase. METHODS: Forty-seven ASA I and II patients, 18 to 60 years, undergoing elective craniotomy for intracranial tumor surgery were recruited prospectively and randomly divided into 3 groups; L (oral placebo plus 2% lidocaine infiltration at pin sites; n=12), G (oral gabapentin 900 mg plus normal saline infiltration; n=21) and GL (oral gabapentin 900 mg plus 2% lidocaine infiltration; n=14). The oral medications were administered 2 hours before induction of anesthesia. Measurements were made at preinduction baseline, before skull pin insertion and at every 1 minute from pin insertion till end of 10 minutes. RESULTS: Forty-three patients completed the study (L, n=11; G, n=20; GL, n=12). Premedication with gabapentin significantly attenuated the rise in systolic (SBP) and mean arterial pressure (MAP) after pin insertion when compared with placebo (for SBP, P<0.001 at 1 and 2 min and <0.05 at 3 to 5 min between L and G; P<0.001 at 1 to 4 min and <0.05 at 5 min between L and GL; for MAP, P<0.05 at 1 min, <0.001 at 2 min and <0.05 at 3 to 4 min between L and G; P<0.001 at 1 to 2 min and <0.05 at 3 to 5 min between L and GL). HR responses were also attenuated in patients premedicated with gabapentin; however, the responses were more variable in group G (P=0.03 between L and G at 4 min after pin insertion) as compared with group GL (P<0.05 at 1 min, <0.001 at 2 min and <0.05 at 3 to 10 min between L and GL). CONCLUSION: In conclusion, 900 mg of gabapentin, administered orally 2 hours before induction of anesthesia along with lidocaine scalp infiltration abolished the hemodynamic response after skull pin insertion. Premedication with gabapentin alone significantly attenuated the SBP and MAP; however, HR responses were more variable. A larger trial is required to corroborate the findings of the study before clinical recommendations would be warranted.

Oral clonidine attenuates the fall in mean arterial pressure due to scalp infiltration with epinephrine-lidocaine solution in patients undergoing craniotomy: a prospective, randomized, double-blind, and placebo controlled trial.

BACKGROUND: Scalp infiltration with epinephrine-lidocaine solution in patients undergoing neurosurgery may result in transient but significant hypotension. We investigated whether premedication with alpha2-adrenoreceptor agonist clonidine, which also exhibits alpha1-adrenoreceptor mediated vasoconstriction, would prevent or attenuate this fall in mean arterial pressure (MAP). METHODS: Sixty-six American Society of Anesthesiologists I and II adult patients, 18 to 50 years, undergoing elective tumor decompression were recruited into this prospective, randomized, double-blind, placebo controlled study, and scheduled to receive either oral pantoprazole 40 mg (placebo group) or oral clonidine 3 microg/kg (clonidine group), 90 minutes before induction of anesthesia. Primary end points studied were heart rate (HR) and MAP in both groups measured just before scalp infiltration (preinfiltration baseline) and then every 30 seconds for 5 minutes after initiation of scalp infiltration with 2.5 microg/mL epinephrine contained in 15 mL of 1% lidocaine solution. RESULTS: There was no significant change in HR in the 2 groups during the study period compared with baseline values; however, patients in clonidine group had significantly lower HR compared with placebo (*P<0.05). In both groups, MAP fell significantly below baseline 1 minute after start of infiltration. It recovered in the clonidine group after 2.5 minutes but not in the placebo group where it continued to remain low even at 5 minutes. MAP in the placebo group was also significantly lower compared with the clonidine group from 2.5 minutes to 5 minutes. CONCLUSION: In conclusion, oral clonidine 3 microg/kg administered 90 minutes before induction of anesthesia attenuates the fall in MAP due to scalp infiltration with a dilute concentration of epinephrine-lidocaine solution in patients undergoing craniotomy under isoflurane anesthesia.

Anesthesia for craniotomy in a patient with previous paralytic polio.

Poliomyelitis remains endemic in many developing nations. Patients may develop residual muscle weakness in one or more limbs after an attack of poliomyelitis in childhood. We report an adult patient who presented for right temporal cortical grid placement. He had childhood poliomyelitis and, while showing no evidence of postpolio syndrome, demonstrated excessive sensitivity to nondepolarizing muscle relaxants and developed prolonged muscle weakness during the postoperative period.