Perioperative Management of Parturient Women With Severe Pulmonary Arterial Hypertension Secondary to Atrial Septal Defect.

At our institution, we occasionally see pregnant patients in the later stages of pregnancy who present with severe pulmonary arterial hypertension caused by congenital heart disease. The physiological changes in pregnancy may worsen the cardiovascular status leading to heart failure which is associated with a high incidence of morbidity and mortality. A scheduled caesarean section in such patients ensures delivery in a controlled environment, avoiding prolonged labour, which is detrimental. Perioperative complications that may worsen pulmonary arterial hypertension should be prevented. The perioperative management, in particular, the anaesthesia technique used and the clinical outcome of this population, is discussed through five interesting cases. Despite a multidisciplinary team and intensive care management, two patients with existing cor pulmonale, one of whom received general and the other central neural blockade anaesthesia, succumbed to their illness immediately after lower segment caesarean section. The management of severe pulmonary arterial hypertension in pregnant patients remains a multidisciplinary challenge among participating physicians. Thorough perioperative preparation encompassing monitoring, medical therapy, timing and mode of delivery, and risk consultation is vital in avoiding circumstances that could exacerbate pulmonary arterial hypertension, with physicians readily equipped to promptly detect and manage any untoward event.

Performance of Point-of-Care Ultrasonography in Confirming Feeding Tube Placement in Mechanically Ventilated Patients.

BACKGROUND: A feeding tube (FT) is routinely placed in critically ill patients, and its correct placement is confirmed with a chest X-ray (CXR), which is considered the gold standard. This study evaluated the diagnostic accuracy of ultrasonography (USG) in verifying FT placement compared to a CXR in an intensive care unit (ICU). METHOD: This was a prospective single-blind study conducted on patients admitted to the ICU of a tertiary hospital in Malaysia. The FT placements were verified through a fogging test and USG at the neck and subxiphoid points. The results of confirmation of FT placement through USG were compared with those obtained using CXRs. RESULTS: A total of 80 patients were included in this study. The FT positions were accurately confirmed by overall USG assessments in 71 patients. The percentage of FT placements correctly identified by neck USG was 97.5%, while the percentage of those identified by epigastric USG was 75%. The corresponding patients' CXRs confirmed correct FT placement in 76 patients. The overall USG assessment had a sensitivity of 92.11% and specificity of 75%, a positive predictive value of 98.59%, and a negative predictive value of 33.33%. The USG findings also showed a significant association between FT size and BMI. FTs with a size of 14Fr were better visualized (p = 0.008), and negative USG findings had a significantly higher BMI (p < 0.001). CONCLUSION: USG is a simple, safe, and reliable bedside assessment that offers relatively high sensitivity in confirming correct FT placement in critically ill patients.

Intraoperative phenylephrine infusion to reduce perioperative shivering in lower segment caesarean section: A randomised controlled study.

BACKGROUND: Shivering is described as an involuntary, repetitive activity of the skeletal muscles that can have deleterious effects on anaesthetized patients. This study aimed to evaluate the effectiveness of phenylephrine infusion in preventing perioperative shivering in patients undergoing lower segment cesarean section under spinal anesthesia and to observe the change in the patient's core temperature between the study and control groups. METHODS: A total of 118 patients scheduled for elective lower segment cesarean section under spinal anesthesia were recruited for this prospective, double-blind, randomized controlled study. The patients were randomized into 2 groups with 59 patients per group. The phenylephrine Group received phenylephrine infusion at a rate of 0.5 mcg/kg/minutes, while the Control Group received normal saline at an equivalent rate. Systolic and diastolic blood pressure, heart rate, core temperature, and the presence and intensity of shivering were recorded before induction and every 15 minutes intraoperatively and postoperatively. RESULTS: The incidence of intraoperative shivering was significantly lower in the Phenylephrine Group compared to control group (29.1% vs 47.5% respectively; P = .044). Postoperatively, the Phenylephrine Group also had a lower incidence of shivering (34.5% vs 42.4%), but the difference was not statistically significant (P value = 0.391). There were no significant differences in the intensity of shivering between the 2 groups perioperatively, as well as in the systolic and diastolic blood pressure and core temperature. The phenylephrine Group showed a significantly lower heart rate at 15, 30, and 45 minutes after spinal block (P value = .005, .000, and .008, respectively), and at 0 and 30 minutes (P value = .004 and .020 respectively) in the recovery room. There were no significant differences in perioperative adverse events such as hypotension, hypertension, and bradycardia. CONCLUSION: Phenylephrine infusion reduces the incidence of perioperative shivering in lower segment cesarean sections under spinal anesthesia.

Analgesic efficacy of the superficial versus deep serratus plane blocks for mastectomy with axillary clearance: A randomized controlled trial.

BACKGROUND: The serratus plane block is an effective technique for providing analgesia to patients undergoing breast surgery. METHODS: This prospective, double-blind, randomized study enrolled 60 female patients scheduled for unilateral mastectomy and axillary clearance. The patients received either a superficial serratus plane block or deep serratus plane block. Dermatomal spread was recorded 30 minutes after block administration. Postoperatively, pain visual analog scale (VAS) scores were documented at recovery (time 0), at 30 minutes; and in the ward hourly for 4 hours, and 4-hourly until 24 hours postoperatively. The time to first analgesic rescue and cumulative morphine consumption using patient-controlled analgesia morphine (PCAM) were recorded. RESULTS: The results showed lower VAS scores at rest (at 1, 2, 3, and 4 hours postoperatively), and during movement (at 1, 2, 3, 4, 8, and 24 hours postoperatively) in the superficial serratus plane block group, P < .005. Similarly, cumulative morphine usage was lower in the superficial serratus plane group, P < .005. The time to the first rescue analgesic was also significantly longer in the superficial group, P < .001. More patients in the superficial serratus plane group achieved greater dermatomal spread at T2 and T7 than those in the deep group. CONCLUSIONS: Superficial serratus plane block provides better analgesic efficacy than deep serratus plane block in mastectomy and axillary clearance.