Comparison of standard coagulation testing with thromboelastometry tests in cardiac surgery.

Introduction: According to the several evidences, using thromboelastometry as a point of care test can be effective in reduction in blood loss and transfusion requirements in cardiac surgeries. However, there are limited data regarding to the comparison of thromboelastometry and the standard coagulation tests. In this study, we compared thromboelastometry and standard coagulation tests (PT, PTT and fibrinogen level) in patients under combined coronary-valve surgery. Methods: Forty adult patients who were under on-pump combined coronary-valve surgery were included in this study. Thromboelastometry tests Fibtem, Intem, Extem and Heptem), along with standard coagulation tests (PT, PTT and fibrinogen assay) were simultaneously performed in two time points, before and after the pump (pre-CPB and post-CPB, respectively). Results: A total of 80 blood samples were analyzed. There were no significant correlation between PT test and the CT-Extem parameter as well as PTT and CT-Intem parameter either in pre-CPB and post-CPB (P >0.05). On the contrary, fibrinogen level had high correlation with A10-Fibtem and A10-Extem in pre-PCB (P <0.05). 82% of PT and 84% of PTT measurements were outside the reference range, while abnormal CT in Extem and Intem was observed in 17.9%. Conclusion: For management of bleeding, adequate perioperative haemostatic monitoring is indispensable during cardiac surgery. Standard coagulation tests are time consuming and cannot be interchangeably used with thromboelastomety and relying on their results to decide whether blood transfusion is necessary, leads to the inappropriate transfusion.

Comparison of Bispectral Index Monitoring With the Critical-Care Pain Observation Tool in the Pain Assessment of Intubated Adult Patients After Cardiac Surgery.

BACKGROUND: Detecting pain is crucial in sedated and mechanically ventilated patients, as they are unable to communicate verbally. OBJECTIVES: This study aimed to compare Bispectral index (BIS) monitoring with the Critical-care pain observation tool (CPOT) and vital signs for pain assessment during painful procedures in intubated adult patients after cardiac surgery. MATERIALS AND METHODS: Seventy consecutive patients who underwent cardiac surgery (coronary artery bypass graft or valvular surgery) were enrolled in the study. Pain evaluations were performed early after the operation in the intubated and sedated patients by using BIS and CPOT, and also checking the vital signs. The pain assessments were done at three different times: 1) baseline (immediately before any painful procedure, including tracheal suctioning or changing the patient's position), 2) during any painful procedure, and 3) five minutes after the procedure (recovery time). RESULTS: The mean values for CPOT, BIS, and mean arterial pressure (MAP) scores were significantly different at different times; they were increased during suctioning or changing position, and decreased five minutes after these procedures (CPOT: 3.98 ± 1.65 versus 1.31 ± 1.07, respectively (P ≤ 0.0001); BIS: 84.94 ± 10.52 versus 63.48 ± 12.17, respectively (P ≤ 0.0001); MAP: 92.88 ± 15.37 versus 89.77 ± 14.72, respectively (P = 0.003)). Change in heart rate (HR) was not significant over time (95.68 ± 16.78 versus 93.61 ± 16.56, respectively; P = 0.34). CPOT scores were significantly positively correlated with BIS at baseline, during painful stimulation, and at recovery time, but were not correlated with HR or MAP, except at baseline. BIS scores were significantly correlated with MAP but not with HR. CONCLUSIONS: It appears that BIS monitoring can be used for pain assessment along with the CPOT tool in intubated patients, and it is much more sensitive than monitoring of hemodynamic changes. BIS monitoring can be used more efficiently in intubated patients under deep sedation in the ICU.

END-TO-END VERSUS END-TO-SIDE ANASTOMOSIS IN THE TREATMENT OF ESOPHAGEAL ATRESIA OR TRACHEO-ESOPHAGEAL FISTULA.

BACKGROUND: Dehiscence of esophageal anastomosis is frequent and there are still controversies which type of anastomosis is preferred to diminish its incidence . AIM: To compare end-to-end anastomosis versus end-to-side anastomosis in terms of anastomotic leakage, esophageal stricture and gastroesophageal reflux symptom. METHODS: This study was carried out for two year starting from 2012. End-to-side and end-to-side anastomosis were compared in terms of anastomotic leakage, esophageal stricture, gastroesophageal reflux symptom, length of surgery and pack cell infusion. RESULTS: Respectively to end-to-end and end-to-side anastomosis, duration of surgery was 127.63±13.393 minutes and 130.29±10.727 minutes (p=0.353); esophageal stricture was noted in two (5.9%) and eight (21.1%) cases (p=0.09); gastroesophageal reflux disease was detected in six (15.8%) and three (8.8%) cases (p=0.485); anastomotic leakage was found in five (13.2%) and one (2.9%) cases (p=0.203); duration of neonatal intensive care unit admission was significantly shorter in end-to-end (11.05±2.438 day) compared to end-to-side anastomosis (13.88±2.306 day) (p<0.0001). CONCLUSION: There were no significant differences between end-to-end and end-to-side anastomosis except for length of neonatal intensive care unit admission which was significantly shorter in end-to-end anastomosis group.

End-to-end versus end-to-side anastomosis in the treatment of esophageal atresia or tracheo-esophageal fistula / Anastomose terminoterminal versus terminolateral no tratamento da atresia ou fístula traqueoesofágica

Background: Dehiscence of esophageal anastomosis is frequent and there are still controversies which type of anastomosis is preferred to diminish its incidence . Aim: To compare end-to-end anastomosis versus end-to-side anastomosis in terms of anastomotic leakage, esophageal stricture and gastroesophageal reflux symptom. Methods: This study was carried out for two year starting from 2012. End-to-side and end-to-side anastomosis were compared in terms of anastomotic leakage, esophageal stricture, gastroesophageal reflux symptom, length of surgery and pack cell infusion. Results: Respectively to end-to-end and end-to-side anastomosis, duration of surgery was 127.63±13.393 minutes and 130.29±10.727 minutes (p=0.353); esophageal stricture was noted in two (5.9%) and eight (21.1%) cases (p=0.09); gastroesophageal reflux disease was detected in six (15.8%) and three (8.8%) cases (p=0.485); anastomotic leakage was found in five (13.2%) and one (2.9%) cases (p=0.203); duration of neonatal intensive care unit admission was significantly shorter in end-to-end (11.05±2.438 day) compared to end-to-side anastomosis (13.88±2.306 day) (p<0.0001). Conclusion: There were no significant differences between end-to-end and end-to-side anastomosis except for length of neonatal intensive care unit admission which was significantly shorter in end-to-end anastomosis group.

Racional: Deiscência de anastomose esofágica é frequente e ainda existem controvérsias qual tipo de anastomose é preferível para diminuir sua incidência. Objetivo : Comparar a anastomose terminoterminal versus a lateroterminal em termos de deiscência de anastomose, estenose de esôfago, e sintoma de refluxo gastroesofágico. Métodos : Este estudo foi realizado por dois anos a partir de 2012. Anastomoses terminoterminal e terminolateral foram comparadas em termos de deiscência de anastomose, estenose de esôfago, sintoma do refluxo gastroesofágico, duração da operação e transfusão. Resultados : Na comparação das anastomoses terminoterminal e terminolateral, respectivamente, a duração em minutos das operações foi de 127.63±13.393 e 130.29±10.727 (p=0,353); estenose esofágica foi observada em dois (5,9%) e oito (21,1%) casos (p=0,09); doença do refluxo gastroesofágico foi detectada em seis (15,8%) e três (8,8%) casos (p=0,485); deiscência de anastomose foi encontrada em cinco (13,2%) e um (2,9%) caso (p=0,203); duração do internamento na UTI neonatal foi significativamente menor na terminoterminal (11,05±2,438 dias) em comparação com terminolateral (13,88±2,306 dias, p<0,0001). Conclusão : Não houve diferença significativa entre as anastomoses terminoterminal e terminolateral, exceto para UTI neonatal que foi significativamente menor no grupo de anastomose terminoterminal.

Microleakage of Three Types of Glass Ionomer Cement Restorations: Effect of CPP-ACP Paste Tooth Pretreatment.

STATEMENT OF THE PROBLEM: Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) increases the mineral content of tooth structure. This may enhance the chemical bonding of glass ionomer cements (GIC) and marginal sealing of their restorations. PURPOSE: The aim of this study was to evaluate the effect of CPP-ACP paste pretreatment on the microleakage of three types of GIC. MATERIALS AND METHOD: In this study, 72 Class V cavities were prepared on the buccal and lingual surfaces of molars with occlusal margins in enamel and gingival margins in root. The cavities were divided into 6 groups. Cavities in group 1 and 2 were restored with Fuji II, group 3 and 4 with Fuji II LC, and group 5 and 6 with Ketac N100 with respect to the manufacturers' instructions. In groups 2, 4 and 6, CPP-ACP containing paste (MI paste) was placed into the cavities for 3 minutes before being filled with GIC. The teeth were thermocycled, stained with dye, sectioned, and scored for microleakage under stereomicroscope. Kruskall-Wallis and Chi-Square tests were used to analyze the data. RESULT: There were no statistically significant differences between the control and the CPP-ACP pretreatment groups in enamel and dentin margins. In pairwise comparisons, there were no significant differences between the control and the experimental groups in enamel margin, and in dentin margins of G1 and 2, G5 and 6; however, a significant differences was detected in dentin margins between G3 and 4 (p= 0.041). CONCLUSION: CPP-ACP paste pretreatment did not affect the microleakage of Fuji II and Ketac N100 in enamel or dentin, but decreased the microleakage in dentine margins of Fuji II LC when cavity conditioner was applied before surface treatment.

The Effects of Positive Airway Pressure Ventilation during Cardiopulmonary Bypass on Pulmonary Function Following Open Heart Surgery.

BACKGROUND: Intrapulmonary shunt as a result of atelectasis following cardiac surgeries is an important and common postoperative complication that results into pulmonary dysfunction typically lasting more than a week following surgery. Different methods have been provided to prevent these complications. OBJECTIVES: In order to prevent postoperative pulmonary complications, investigation of the effectiveness of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV) during cardiopulmonary bypass (CPB) in patients undergoing coronary artery bypass grafting (CABG). MATERIALS AND METHODS: In this prospective interventional study, 300 patients, candidate for elective CABG (On-Pump), were randomly allocated to 3 groups: A, B, C. Group A (CPAP) patients received CPAP at 10 cm H2O during CPB. Group B (IMV) patients received IMV with a tidal volume of 2 cc/kg and respiratory rate of 15/min and group C (control) patients did not receive any type of ventilation during CPB. Other procedures were similar between groups. Arterial blood samples were taken at 8 moments and arterial blood gas (ABG) analysis were compared between groups. Chest x-rays after CABG were also evaluated with respect to atelectasis. RESULTS: The demographic data were similar in between three groups. Graft number, pump time and preoperative ABGs were not significantly different. Postoperative PaO2 were significantly higher in the CPAP and IMV groups and (A-a) DO2 were significantly lower in these two groups, compared to the control group. CONCLUSIONS: In the present study, applying positive airway pressure methods (CPAP or IMV) during CPB was associated with better postoperative ABG measurements and (A-a) DO2.

Deep sedation in patients undergoing atrioventricular nodal reentry tachycardia ablation.

BACKGROUND: General anesthesia and deep sedation can be used during cardiac EPS to relief pain and provide comfort and immobility, but many electrophysiologists avoid sedation for better arrhythmia induction. OBJECTIVE: To determine anesthesia effects in ablation procedures in adults, we used intravenous anesthetic agents in patients who underwent slow pathway ablation. PATIENTS AND METHODS: One hundred patients who were to undergo radiofrequency catheter ablation were randomly assigned to with and without intravenous anesthesia groups. All patients had palpitation with a documented electrocardiography (ECG) compatible with atrio-ventricular nodal reentrant tachycardia (AVNRT). We used propofol, fentanyl and midazolam for intravenous sedation. Electrophysiological parameters were checked for the two groups and compared before and after the ablation. RESULTS: Electrophysiological parameters were not significantly different in the two groups. In the anesthetic group, patients were more satisfied with the procedure (P value < 0. 001). CONCLUSIONS: Intravenous anesthesia could be done safely in patients who underwent electrophysiological procedures. It had no effect on arrhythmia induction or slow pathway ablation in patients with documented AVNRT.

Methanol poisoning in Iran, from 2000 to 2009.

Methanol poisoning continues to be a serious problem in Iran; however, there is not yet any report of the prevalence of methanol intoxication. This report is a descriptive study of methanol intoxication in Iran. We performed a cross-sectional analysis of 51 patients with methanol intoxication who were admitted to Noor Hospital affiliated with Isfahan University of Medical Science (Isfahan, Iran) from January 2000 to December 2009. Characteristics of the participants, including age, sex, amount of methanol ingestion, exposure type, time from ingestion to presentation, and patient outcome, were recorded. There were 51 patients (84.3% male and 15.7% female; mean age: 32.5 ± 15.2 and 20.1 ± 7.5 years, respectively). Of the patients, 13.7% were under 20 years in age, 51% were from 20 to 29, 11.8% were from 30 to 39, and 23.5% were above 40. Four patients died, 15 survived with late complications, and 32 survived without any complications. There are a growing number of patients presenting with acute poisonings in Iran. Early diagnosis and treatment is necessary to prevent long-term complications.

Relationship between gender and in-hospital morbidity and mortality after coronary artery bypass grafting surgery in an Iranian population.

BACKGROUND: Many previous studies have investigated the influence of gender on coronary artery bypass grafting surgery (CABG) outcomes. Despite the great volume of reports on this issue, it is still not clear whether it is the gender of the patient or pre-existing comorbid conditions that is the best predictor for the different outcomes seen between men and women. Multiple studies have shown that women are at higher risk of postoperative complications than men, particularly in the perioperative period. OBJECTIVES: The goal of this study was to determine whether sex differences exist in preoperative variables between men and women, and to evaluate the effect of gender on short-term mortality and morbidity after CABG in an Iranian population. PATIENTS AND METHODS: Data were collected prospectively from 690 consecutive patients (495 men and 195 women) who underwent isolated CABG. Preoperative, intraoperative, and postoperative variables, major complications and death were compared between the male and female patients until hospital discharge using multivariate analysis. RESULTS: Women were older (P = 0.020), had more diabetes (P = 0.0001), more obesity (P = 0.010), a higher New York Heart Association functional class (P = 0.030), and there was less use of arterial grafts (P = 0.016). Men had more tobacco smokers (P = 0.0001) and lower preoperative ejection fractions (EF) (P = 0.030). After surgery, women had a higher incidence of respiratory complications (P = 0.003), higher creatine kinase (CK) - MB levels (P = 0.0001), and higher inotropic support requirements (P = 0.030). They also had a higher incidence of decreased postoperative EF versus preoperative values (P = 0.020). The length of ICU stay, incidence of return to ICU and postoperative death, were similar between men and women. Nevertheless, after adjusting for age and diabetes, female gender was still independently associated with higher morbidity in patients over 50 years of age. CONCLUSIONS: Women had more risk factors, comorbidities, and postoperative complications. Women older than 50 years of age were at a higher risk of postoperative complications than men. This difference decreased with younger age. In-hospital mortality rates were not influenced by sex, as there was no difference found between the two groups (2.5% women vs. 2.2% men; P > 0.05).