Analgesic Effect and Sleep Quality of Low-Dose Dexmedetomidine in Cardiac Surgical Patients After Ultrafast-Track Extubation: A Randomized Clinical Trial.

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.

A Comparison of Perioperative Complications and Outcomes in Patients Undergoing Cerebral Aneurysm Clipping Performed Ultra-Early (≤ 24 hours) versus Late (> 24 hours): A 7-Year Retrospective Study of 302 Patients.

Objectives The intracerebral aneurysm with subarachnoid hemorrhage (SAH) has a high morbidity and mortality rate. This study aimed to compare the incidences of perioperative complications in ultra-early surgery (within 24 hours) with those in late surgery (> 24 hours). Methods Retrospective data were reviewed for 302 patients who underwent craniotomies with aneurysm clipping between January 2014 and December 2020. Perioperative data were obtained from the medical records and reviewed by the investigators. The complications were compared between ultra-early and late operations. We were interested in major complications such as delayed ischemic neurologic deficit (DIND), intraoperative aneurysm rupture (IAR), and anesthesia-related complications. The short-term (in hospital) and long-term (1 year) outcomes in patients with or without DIND and IAR were compared. The collected data was statistically analyzed. Results Three hundred and two patients were analyzed, and 264 patients had completed follow-up. The ultra-early cases (150 patients) had a higher American Society of Anesthesiologists physical status, a lower Glasgow Coma Scale, and higher Hunt and Hess scales. The surgeons operated on more cases of the anterior cerebral artery as ultra-early operations. The incidence rates of DIND, IAR, severe hemodynamic instability, and cardiac arrest were 5.6, 8.3, 6.3, and 0.3%, respectively, which were not different between groups. However, the reintubation rate was higher in the ultra-early surgery cases (0 vs. 3.3%, p = 0.023). The DIND and IAR patients had poorer short-term (in hospital) outcomes. Conclusions There were no differences in major complications between ultra-early and late craniotomy with aneurysm clipping. However, the reintubation rate was strikingly higher in the ultra-early group. Patients with major complications had early, unfavorable outcomes.

Learning curve for the acquisition of 20 standard two-dimensional images in advanced perioperative transesophageal echocardiography: a prospective observational study.

BACKGROUND: Learning to perform intraoperative transesophageal echocardiography takes time and practice. We aimed to determine the cumulative success rate in the first 20 intraoperative transesophageal echocardiography cases performed by trainee anesthesiologists with no transesophageal echocardiography experience. METHODS: This prospective observational study included nine anesthesiologists (four cardiovascular and thoracic anesthesia fellows and five short-course perioperative intraoperative transesophageal echocardiography trainees). Overall, 180 studies self-performed by the trainees were reviewed by certified reviewers. A study was considered successful when at least 15 qualified images were collected within 30 min. The cumulative success of each trainee was used as a surrogate of a basic two-dimensional intraoperative transesophageal echocardiography learning curve. RESULTS: The participants comprised three male and six female anesthesiologists aged 29-43 years with 2-13 years of work experience. Most studies (146/180, 81.11%) were completed within 30 min, and the cumulative success rate was 70-90% (average 82.78 ± 6.71%). The average cumulative success rate in the short-course group (85 ± 7.07%) was higher than that in the official cardiovascular and thoracic fellow trainee group (80 ± 7.07%). The recommended caseload for a 80-100% success rate was 18-20 cases (95% confidence interval, 0.652-0.973). The CUSUM method analysis confirmed that the lower decision limit was crossed after 20 TEE studies among those achieved competence. CONCLUSIONS: We recommended a 18-20 caseload for a target success rate of 80-100% in studies performed by trainees with no previous experience. Our findings will enable the development of programs to train anesthesiologists in intraoperative transesophageal echocardiography.

Comparison of age-based and height-based formula for tracheal tube size in cardiac children.

OBJECTIVE: To compare the effectiveness of age-based formula (ABF) and height-based formula (HBF) for pediatric cardiac patients, including patients with failure to thrive (FTT). MATERIAL AND METHOD: In a retrospective study of 260 cardiac patients that included those with failure to thrive, aged 2 to 7 years was done. The actual uncuffed endotracheal tube (ETT) size was compared with the predicted one, using both the ABF [ID (mm) = age (years)/4 + 4] and the HBF [ID (mm) = height (cm)/30 + 2]. RESULTS: ABF and HBF correctly predicted 50.8% and 50.4% of ETT sizes (p = 1.0), whereas three sizes of tubes (one above and one below the predicted size) cover 95.8% and 93.5% of the patients, respectively (p = 0.24). In patients with FTT, both the ABF and HBF correctly predicted 56.6% of ETT sizes. CONCLUSION: Age- and height-based formula for estimating tube size in cardio-surgical children is equivalent and independent of physical development. Age-based formula as the simple method can be recommended. The availability of three tube sizes (one smaller one larger than estimated) should be ensured.

Tranexamic acid as a means of reducing the need for blood and blood component therapy in children undergoing open heart surgery for congenital cyanotic heart disease.

Children undergoing cardiac operations using cardiopulmonary bypass (CPB) are at risk of significant postoperative bleeding and the need for transfusion. The antifibrinolytic drug, tranexamic acid, decreases blood loss in adult patients undergoing cardiac surgery. However, its efficacy has not been extensively studied in patients with cyanotic congenital heart defects (CHD). Using a prospective, randomized, double-blind study design, we examined 67 children undergoing repair of cyanotic CHD. After induction of anesthesia and prior to skin incision, patients received 15 mg/kg of tranexamic acid intravenously. At the end of CPB, a second bolus of tranexamic acid (15 mg/kg) or saline placebo was administered. Postoperative blood loss and transfusion requirements from the period after protamine administration until 24 hours after admission to the intensive care unit were recorded. In addition, the hematocrit, platelet count and other indices of coagulation were recorded every 6 hours. There was no significant difference in postoperative blood loss between the treated and the placebo group (12.51 +/- 13.20 ml/kg per 24 hours, in the tranexamic acid group, vs 10.68 + 6.38 ml/kg per 24 hours, in the placebo group). Also there was no significant difference in the amounts of blood and blood products administered between the two groups. No adverse effects of tranexamic acid were found in this study. In conclusion, there was no significant difference in postoperative blood loss or blood and blood product requirement between those children with cyanotic CHD undergoing open heart surgery who received a single dose of tranexamic acid compared with those who received two doses.

Awareness under general anesthesia.

OBJECTIVE: To determine the occurrence and associated factors of awareness in the patients undergoing elective surgery under general anesthesia. METHODS: A prospective cohort study of 802 patients, scheduled for elective general and gynecological surgery under endotracheal anesthesia was performed at Siriraj Hospital. Balanced general endotracheal anesthesia was performed as routine practice. Standard monitoring and clinical observation for movement, tear, sweat, and eye-lid opening were obtained. They were interviewed during the first 12 hours after a surgical completion. If the patient was suspected to have awareness, then a second interview was performed on postoperative day 3. RESULTS: The ages of the study population were 16-84 years. There were 659 females and 143 males. Awareness was found in 5 patients (3 females, 2 males) as an occurrence of 0.62 per cent. The only positive clinical observation found was hand movement. The cause of awareness should be inadequate anesthesia. Apart from that, data gathered from interviews with the group who had no awareness (797 patients), the last thing they could remember before unconsciousness was auditory perception. Also hearing someone calling was the first thing upon awakening. Most of the patients did not dream during anesthesia. No serious psychological disorder occurred. CONCLUSION: The occurrence of awareness was 0.62 per cent in the patients undergoing surgery under anesthesia. Inadequate anesthesia was the most likely cause of awareness. No postoperative sequelae of awareness occurred.

Perioperative cardiac arrest at Siriraj Hospital between 1999-2001.

Cardiac arrest during the perioperative period is a good indicator of the quality of anesthetic management. The incidence of perioperative cardiac arrest in Siriraj Hospital hasn't been reported before. Our objectives were to determine the incidence of perioperative anesthesia-related cardiac arrest and the results of cardiopulmonary resuscitation in these cases in order to find out how to improve our anesthetic care. This prospective study was undertaken between 1999-2001 by sending a questionnaire to those witnessing a cardiac arrest. The incidence of perioperative cardiac arrest was 8.2:10,000 instances of anesthesia with a mortality of 5.6:10,000 within 48 hours of the arrest. The incidence of perioperative cardiac arrest that was related to anesthesia was 0.7:10,000 instances of anesthesia and the anesthesia related mortality was 0.19: 10,000 within 48 hours of arrest. Failed cardiopulmonary resuscitation occurred in of occasions 41.7 per cent. There was no difference between intraoperative and postoperative cardiopulmonary resuscitation. Twenty-one per cent of patients experiencing a cardiac arrest were discharged from hospital. Seventy-three per cent of events occurred in patients with an ASA rating 3-5 and most often the cause of arrest was massive or uncontrolled bleeding. In those patients with an ASA rating 1-2 there were no outstanding cause of arrest.